substance abuse pt 2 Flashcards
MC preventable cause of mortality
smoking
smoking increases the risks of?
ASHD, COPD, stroke, cancer (especially lung)
who are the at-risk populations of smoking?
Divorced/widowed, lower income or education, AI/AN or multiracial, LGBTQ
risk factors for smoking?
- Relationships -
- Parents, friends, housemate who smokes
- Strained relationship with parent - Psychiatric -
- Low self-esteem
- Comorbid psychiatric disorders - Female - Preoccupation with weight and body image
- Male - Aggression and rebelliousness
other forms of tobacco?
-
Cigars/Pipes - typically not inhaled as deeply into lungs
- Slightly lower risk of lung cancer -
Hookahs - varying amounts of nicotine and toxins
- Vapor/smoke from burning product (such as tobacco) is passed through a water chamber before being inhaled
- Still linked to cancer, COPD -
Smokeless Tobacco - varying amounts of toxins
- 3% of US adults -
E-Cigarettes/Vaping - aerosolized nicotine - similar vapor to cigarettes, fewer traditional toxins
- Significantly increasing rates of use among adults and children/adolescents
who is the most likely to use smokeless tobacco?
white males of low socioeconomic status in southern US
Linked to nicotine addiction, cancer of oral cavity
what is EVALI?
acute lung injury associated specifically with the use of vaping products
Acute eosinophilic pneumonia reported after vape use
MOA of nicotine
stimulates nicotinic cholinergic receptors in the brain
Triggers dopamine release
Triggers epinephrine release
nicotine reaches the brain how fast?
15 sec; t½ about 1-2 hours
Some genetic variants - metabolize more slowly
what are the positive effects after nicotine intake
- Dopamine:
- Decreased anxiety
- Improved mood - Epinephrine:
- Increased alertness and memory
- Decreased appetite
- Improved problem solving skills
- Improved reaction time
due to upregulation of nicotinic (acetylcholine) receptors → develops rapidly
tolerance
as early as 2 hrs after last cigarette, peaks in first 72 hrs, fades gradually over 3-4 weeks
withdrawal
what happens when you receive less dopamine than before (when smoking)? epinephrine?
- Less dopamine - irritable, hostile, anxious, restlessness, cravings
- Less epinephrine - decreased HR, insomnia, increased appetite, weight gain
- Craving may persist for years even after withdrawal ends
what are the acute toxic effects from tobacco
Nausea, salivation, pallor
Tachycardia, poor concentration
Decreased REM sleep
harmful effects of smoking
- Increased all-cause mortality - die on average 10 years earlier
- Cancer
-↑ risk - head and neck, lung, gastric, pancreatic, renal, ovarian, bladder, cervical, penile, anal - Pulmonary
-↑ risk - COPD
- Worse clinical course for COPD, asthma, bronchiolitis - Periodontal
- ↑ risk - periodontal disease (gingivitis, periodontitis) - Immunologic
↑ risk - several types of infections
- TB, Pneumococcal pneumonia, meningococcal disease, Legionnaires
disease, influenza, common cold - Endocrine
-↑ risk - type 2 DM
- Nicotine causes impaired insulin sensitivity
- May worsen course of type 2 DM - Musculoskeletal
-↑ risk - osteoporosis
- Accelerates bone loss - increased risk of hip fractures in females - Reproductive
-↑ risk - pregnancy complications
- Spontaneous abortion, ectopic pregnancy, low birth weight, fetal harm
-↑ risk - premature menopause, erectile dysfunction, infertility - Gastrointestinal
-↑ risk - gastric and duodenal ulcers
- Slower healing of gastric and duodenal ulcers
- Increased failure rates of H. pylori treatment - Postoperative
↑ risk - delayed wound healing, pulmonary complications, admission
to ICU, post-operative infection
what is present in tobacco and most vapes, not nicotine replacement and is not usually picked up from secondhand smoke
Anabasine
what nicotine metabolite is in serum - 16 hrs, urine - several weeks and can pick up from secondhand smoke exposure
continine
routes for nicotine replacement therapy
transdermal patch, gum, lozenge, inhaler, nasal spray
Different absorption than cigarettes
what is the recommended combo for nicotine replacement therapy
long-acting (patch) and short-acting (oral)
T/F: E-cigarettes are not FDA approved for tobacco cessation
T
what nicotine replacement therapy has good patient compliance - simplest method
No chance to adjust nicotine dose - continuous
transdermal patch
what is the dosing for transdermal patch
- Apply one patch each morning to any non-hairy skin
- Rotate site of application and do not leave on overnight
- If >10 cigarettes/day: 21 mg x 6 wks, 14 mg x 2 wks, 7 mg x 2 wks
- If 10 or less cigarettes/day: 14 mg x 6 wks, 7 mg x 2 wks
SE of transdermal patch
skin irritation (most common), insomnia, vivid dreams
Will also see SE of nicotine administration
which nicotine replacement therapy diminishes rather than stops withdrawal
oral nicotine gum
4 mg of nicotine gum is for pt who smoke ?
25+ cigarettes per day
what must you avoid when chewing nicotine gum
Avoid acidic beverages before and during gum use
TMJ, poor dentition, dental appliances
SE of nicotine gum
N/V/D, HA, excess salivation, mouth irritation
what nicotine replacement therapy Does not need to be chewed and has most nicotine content
Oral Nicotine Lozenge
SE of nicotine lozenge
mouth irritation, N/V/D, palpitations, HA, insomnia
what nicotine replacement therapy is absorbed through oral mucosa, like lozenge and gum
Helps satisfy sensory and behavioral cravings
nicotine inhaler
SE of nicotine inhaler
oropharynx irritation, bronchospasm
who should avoid using nicotine inhalers?
reactive airway disease (asthma)
which nicotine therapy is absorbed through nasal mucosa - more rapid peak than oral? SE?
nicotine nasal spray
SE - nasal and throat irritation, sneezing, tearing
what nicotine replacement therapy is not available in the US
Nicotine Mouth Spray and Nicotine Sublingual
which tobacco tx blocks dopamine and norepinephrine reuptake (DNRI), antagonizes nicotinic cholinergic receptors
Bupropion (Wellbutrin, Zyban)
SE of bupropion
MC are insomnia, agitation, dry mouth, headache
Rarer - seizure (dose-dependent)
CI for bupropion
epilepsy; high seizure risk; hx of anorexia or bulimia
partial agonist of nicotinic cholinergic receptors
Partial stimulation of receptor to decrease withdrawal
Blocks nicotine from binding to receptor, interfering with “reward”
Varenicline (Chantix)
SE of Varenicline (Chantix)
-
MC vivid dreams, nausea, insomnia, syncope
- When first released - concern over neuropsychiatric SE (mood, behavior, suicidal thoughts)
- Not as common as once thought - FDA has removed black box warning
- Potential adverse events in CV disease (controversial - not as common as once thought)
CI for Varenicline (Chantix)
hypersensitivity or skin reactions to rx
antibodies bind nicotine and stop it from crossing the blood-brain barrier
Blocks nicotine from binding to CNS receptor, interfering with “reward”
Nicotine Vaccine
several ongoing trials, but so far inadequate antibody responses or no improvement over placebo therapy
nonpharmacologic tx for tobacco
- Behavioral counseling (including 5 A’s)
- Acupuncture (questionable benefit)
- Financial incentives
what are the types of opiates
- Natural - derived from poppy plant
- codeine, morphine - Semi-synthetic - derived from opium (extract of poppy plant)
- heroin, oxycodone, buprenorphine, oxymorphone, hydrocodone, hydromorphone - Synthetic
- meperidine, fentanyl, methadone - Endogenous Opioids
- endorphins, enkephalins, dynorphins, endomorphins - Other
tramadol → acts on mu and noradrenergic/serotonin receptors
acts on mu, kappa and delta opioid receptors in brain, digestive tract, spinal cord
opioids
receptor that mediates pain, respiratory depression, constipation and physical dependence
Mu
what pain receptor is responsible for analgesia, diuresis, sedation , psychological dependence
kappa
what receptor is responsible for analgesia, dependence, antidepressant
delta
effects of opioids in the body
- Positive Effects
- Pain
↓ perception
↓ reaction
↑ tolerance
↓ cough
- Psychiatric: Euphoria, Anxiolysis - Mild intoxication
- Pupillary constriction
- Constipation - Severe intoxication
- Respiratory depression
- Pinpoint pupils
tx that is a short-acting opioid antagonist used for Cardiorespiratory arrest and Spontaneous ventilations
naloxone (narcan)
long term effects from use of opioids
-
desensitization and down-regulation of opioid receptors
- Causes development of tolerance
- Earlier onset and more pronounced in short-acting opiates like morphine, heroin
- Physical and psychological dependence
what is the grading for opioid withdrawal symptoms
- Grade 0 - craving, anxiety
- Grade 1 - Grade 0 + yawning, lacrimation, rhinorrhea, perspiration
- Grade 2 - Grade 0, 1 + mydriasis, piloerection, anorexia, tremors, hot and cold flashes, generalized aching
- Grade 3 - Grade 0, 1, 2 + increased temperature, blood pressure, pulse, and respiratory rate and depth
- Grade 4 - Grade 0, 1, 2, 3, + vomiting, diarrhea, weight loss, hemoconcentration, spontaneous ejaculation or orgasm
- Treat - if grade 2 or higher
what is Rebound Hyperactivity
restlessness, irritability and poor concentration → lasts 3-6 months
tx for acute opioid withdrawal
- Methadone
- buprenorphine
- Symptomatic treatment PRN
- Alpha-2 Agonists – ↓ autonomic withdrawal s/s
- Clonidine
- Lofexidine
opioid antagonist
Indicated for maintenance treatment
Naltrexone (Revia, Vivitrol)
long acting opioid agonist
Helps decrease withdrawal s/s and block “high” from acute opioid use
Methadone
if Naltrexone is used for acute tx what will happen?
cause withdrawal
SE and BBW for naltrexone
- Nausea (mc), V/D, dizziness, abdominal pain, HA, anxiety, syncope, arthralgia
- Black-Box Warning - hepatocellular injury
- Risk of opioid overdose if resumed use
SE of methadone
- constipation, drowsiness, sweating, peripheral edema, reduced libido, erectile dysfunction
- Cardiac arrhythmias (QT prolongation)
- Hyperalgesia
- Overdose (greater chance for lethal OD than buprenorphine)
To qualify for methadone tx, patient must meet one of the following criteria:
- One yr of continuous/intermittent use for > 1 year
- Have been on methadone maintenance within the past 2 yrs and show signs of imminent return to opioid dependence
- recently released from hospital/prison + hx of dependence and signs of return to opioid dependence
- Pregnant and opioid dependent
partial opioid agonist also available as long-acting implant
Sublingual tablet - often combo with naloxone (Suboxone)
Discourages abuse of therapy
Buprenorphine (Buprenex, Subutex)
how to taper buprenorphine?
reduce dose by 2 mg every 1-2 weeks
what is able to give as take-home therapy due to lower abuse potential
Buprenorphine
SE of buprenorphine
headache, nausea, pain, insomnia, withdrawal syndrome
Rare - liver disease and necrosis, anaphylaxis
non-pharm tx for opioid use
- Individual and group counseling
- Cognitive Behavioral Therapy
- Insight-Oriented Therapy - Drug-free residential programs
- Peer support groups
what type of tx has best long-term outcomes for opioid tx?
Combination with medication (MAT) and non-pharm tx
cause release and block reuptake of dopamine, norepinephrine, serotonin
Methamphetamines, MDMA (ecstasy), ephedrine
ADHD medications
Most often smoked or snorted
Psychostimulants
Psychostimulants can accumulate how much more in the brain than in plasma
10 x
how to tx amphetamine intoxication?
- Largely symptomatic
- Sedation/Seizure control - IV benzodiazepines
antipsychotics as adjunct treatment
- Airway management - intubation if needed
- Antihypertensives - IV medication
- Hyperthermia - cooling blankets, ice packs, evaporative cooling techniques, benzodiazepines
– no antipyretics (acetaminophen, ibuprofen, etc.)
- Fluid resuscitation
increased hyperactivity even when doses are spread out over weeks
Can have cross-sensitization with cocaine
Sensitization
chronic use of amphetamine can cause?
- chronic insomnia, anxiety, appetite suppression, weight loss, HTN, hypersexuality
- Increased all-cause mortality risk
- decrease in dopamine receptors in basal ganglia → motor deficit
- decrease in metabolic rate in prefrontal cortex → cognitive deficit
- verbal/working memory, perceptual speed, attention and fluency
- can develop long-term psychosis
s/s of amphetamine withdrawals? (what types)
- develops in a few hours, peak in 1-2 days, and resolve in about 2 weeks
- Acute - dysphoria, anhedonia, fatigue, vivid dreams, insomnia or hypersomnia, agitation, anxiety, drug craving, increased appetite
- Subacute - insomnia/hypersomnia, appetite changes, depression, possible suicidal thoughts
tx for Amphetamine Withdrawal
No proven medication treatment regimen
- Benzodiazepines, antidepressants, antipsychotics, behavioral therapy
first-line tx for chronic amphetamine use?
Bupropion and naltrexone
what is recommended if patients do not tolerate or respond to bupropion and naltrexone combo
Mirtazapine
alternatives for chronic amphetamine use
methylphenidate (stimulant)
topiramate (anticonvulsant)
MC abused anxiolytic
Benzodiazepines (BZDs)
- enhances effect of GABA
- Indications - sedation, sleep-induction, anticonvulsant, anxiolytic, muscle relaxant, alcohol withdrawal
- For anxiety - short term, panic attacks
Benzodiazepines
what happens with chronic use of benzodiazepines
structural GABA receptor changes - ↓ affinity for BZD
overdose of benzodiazepines alone causes ?
CNS depression with normal vital signs
Usually overdosed with other substances (especially alcohol)
tx for anxiolytic overdose?
- Airway, breathing, and circulation
- Flumazenil - competitive antagonist of GABA receptor
why is flumazenil controversial for anxiolytic overdose?
can precipitate withdrawal seizures
tx for anxiolytic withdrawal?
- Long-acting BZD given IV and titrated to effect
- Goal - eliminate withdrawal s/s, avoid oversedation or respiratory depression
- Taper gradually over a period of months
Adjunct Medications for anxiolytic withdrawal
Beta blockers, antipsychotics, SSRIs, antihistamines
All have been shown to be inferior to BZDs for tx of acute withdrawal
Treatment for any underlying anxiety
Counseling and therapy
Antidepressants
how must you taper with chronic anxiolytic use?
Gradual (6-12 mo) taper to avoid inducing withdrawal
Long-acting BZD - diazepam, chlordiazepoxide
what drugs may help reduce anxiolytic cravings (4)
anticonvulsants
valproic acid, gabapentin, topiramate, lamotrigine
what is the primary effect/MOA of cocaine
blocks dopamine reuptake
Use with ___ can produce more intense and longer-lasting effects of cocaine
alcohol
what can be used for tx of cocaine
- Acute withdrawal - dopamine agonist
- Bromocriptine - Psychosis - antipsychotic medications
- Symptomatic support
- Social services and psychological consult
- Support groups and counseling
long term tx for cocaine
-
Topiramate - first-line treatment
- Anticonvulsant - acts on GABA - Dopamine Agonists/Stimulants
- dextroamphetamine, methamphetamine
- modafinil - less abuse potential but not as strong evidence - Disulfiram
- Emerging - TA-CD vaccine - no good
Mimics anandamide and increases dopamine levels
marijuana
long-term use of marijuana
- Pulmonary
- Many of the same combusted particles as tobacco smoke, but nearly always unfiltered - 3x the amount of tar and 50% more carcinogens
- Acute and chronic inflammatory changes - Exacerbations of pulmonary disease; Increased risk of lung cancer - Cardiovascular
- EKG changes (typically transient)
- May cause exacerbation of underlying CV disease - Reproductive
- Males - Decreased testosterone, decreased sperm count
- Females - Abnormal menstruation, infertility, appears in breastmilk
- During pregnancy - increased stillbirth risk, poorer visual/motor coordination, increased behavioral problems - Neuro/Psych
- Cognition - mixed - some studies show no long-term deficits, others do
- Atrophy - most studies note accelerated brain volume loss
- Psychosis - most studies note significantly higher risk of long-term psychosis, schizophrenia - Gastrointestinal
- Gastroparesis - early satiety, N/V, postprandial fullness/heaviness
- Liver - can accelerate course of pre-existing liver disease
- Cannabis hyperemesis syndrome - N/V/D and abdominal pain
– Hx of chronic cannabis use (usually daily)
– Relieved by hot showers/bath
– Normal labs/GI work-up
– Tx - abstinence from cannabinoids, especially THC
goal of tx for marijuana
sustained abstinence rather than a controlled low level of continued use
what is the preferred tx for marijuana over meds
Psychosocial interventions
- Cognitive-behavioral therapy
- Motivational interviewing
- Peer support
what are the possible meds for marijuana
acetylcysteine, gabapentin, topiramate, varenicline have some/mixed evidence
Antidepressants, synthetic THC - no evidence
Drugs, substances, and certain chemicals used to make drugs split into five categories (“schedules”), depending on:
Drug’s acceptable medical use
Drug’s abuse or dependence potential
which schedule of drugs are most abused and has dependence potential? least abuse and dependence potential?
I
V
no accepted medical use; high potential for abuse
Most dangerous of all - potentially severe psychological/physical dependence
what schedule
I
illicit drugs - Heroin, LSD, marijuana, ecstasy, peyote
high potential for abuse (less than Schedule I)
Potentially severe psychological or physical dependence
what schedule
II
1. Most ADHD medications (Adderall, Ritalin, methamphetamines)
2. Most opioid medications
- methadone, hydromorphone, meperidine, oxycodone, fentanyl
- Hydrocodone products with <15 mg of hydrocodone per dose
3. cocaine
moderate-low potential for dependence
what schedule
III
- Codeine products with <90 mg of codeine per dose (Tylenol #3)
- Ketamine, anabolic steroids including testosterone
low potential for abuse, low risk of dependence
what schedule
IV
- BZDs (alprazolam, lorazepam)
- Tramadol (Ultram), carisoprodol (Soma), insomnia meds (zolpidem (Ambien), eszopiclone (Lunesta))
medications with limited quantities of certain opiates
what schedule
V
- Lower potential for abuse than Schedule IV
- Often used for antidiarrheal, antitussive, analgesic needs
- Cough preparations with <200 mg of codeine per 100 mL
- diphenoxylate/atropine (Lomotil), pregabalin (Lyrica)
- gabapentin (Neurontin) - in some states
Require a written or electronically prescribed prescription signed by the practitioner
May vary by state and facility
No refills allowed
what schedule
II
- May be allowed to prescribe multiple prescriptions that would total a 90 day supply under special circumstances
- Physician Assistants often cannot prescribe
Written script or e-prescribed
Refills generally allowed
what schedule
III, IV, V
what do the written treatment agreements of controlled substances include?
- Clarify boundaries regarding pain tx with controlled substances
- Describe patient and provider responsibilities
- Describe possible consequences of violation of agreement
- Obtain agreement to:
- Future drug testing as requested
- Use of one pharmacy and one prescriber
- Bringing in pill bottle for pill counts as requested - Describe reasons and strategies for ending opioid treatment
- Include criteria for ending opioid treatment
- Include strategies for how to taper opioids humanely
cons of treatment agreements
- Very limited evidence supporting effectiveness
- No guidelines or consensus
- Wide variation in content, tone, and implementation - Negative impact on the provider-patient relationship
- Too much focus on prohibited behaviors, risks, and abuse monitoring
- Discriminatory implementation - May bias providers and patients against opioid therapy
- Potential for undertreatment of pain or improper discontinuation
- Stigmatization of opioid therapy - May have overly demanding stipulations
