Substance Abuse Treatment Flashcards
buprenorphine (Buprenex)
Indication: Opioid Dependence (induction and maintenance); Moderate to Severe Pain
Dose: Varies; SL and buccal tablets more bioavailable; monthly injection and implants available
Monitoring: No routine monitoring required. Check levels with “buprenorphine plus metabolite.” If taking appropriately, the norbuprenorphine level will be higher than the buprenorphine level; if just took it, then buprenorphine level > norbuprenorphine.
Mechanism: delta and mu receptor agonist; kappa receptor antagonist
Advantages: Lower rates of diversion than methadone
Disadvantages: Prescribers need to have met qualifications for prescription (now 100-275 patients); Schedule III; metabolites do accumulate; still has street value.
ADEs: headache; pain; insomnia; nausea; anxiety; surgical site pain (+itching and redness); liver function abnormalities (from simple elevations in transaminases to fulminant hepatitis – usually in preexisting hepatic impairment patients); QT prolongations with higher doses of transdermal
buprenorphine/naloxone (Suboxone)
Indication: Opioid Dependence (induction and maintenance)
Dose: Varies; SL and buccal tablets more bioavailable
Monitoring: No routine monitoring required
Mechanism: delta and mu receptor agonist; kappa receptor antagonist; (naloxone) opioid receptor antagonist
Advantages: No IV use because naloxone is bioavailable when injected
Disadvantages: Prescribers need to have met qualifications for prescription; Schedule III; metabolites do accumulate; still has street value
ADEs: headache; pain; vomiting; sweating; liver function abnormalities (from simple elevations in transaminases to fulminant hepatitis – usually in preexisting hepatic impairment patients)
Fun Facts: Maker of Suboxone also make Durex condoms and Lysol products
Smoking Cessation Plans
Nicotine Replacement Therapy (NRT): 1ppd=21mg patch, less 14mg; Start above the heart and then rotate around the body; use 0.5% cortisone for rash; First patch for 8 weeks, then taper by 7mg every two months
Combination NRT: Add gum, inhaler, or spray for in-between use
Varenicline: 0.5mg for three days, increase to BID for ten days, THEN QUIT SMOKING; follow with 1mg BID for three months
Zyban: 150mg daily is as effective as BID for smoking cessation
Hints: 1) Normalize failure; 2) First week is hardest; 3) Cravings last only 10-20 minutes, so distract yourself with a drink of water or others; 4) Cough after quitting is normal and it is just the lung healing; 5) 1-800-QUIT NOW
disulfiram (Antabuse)
Indication: Alcohol Dependence
Dose: Begin after abstinence of > 12 hours; Start 125mg QPM, increasing to 250mg QPM after a week; maintenance is between 250-500mg QPM
Monitoring: liver function tests
Mechanism: aldehyde dehydrogenase inhibitor; produces flushing, vomiting, chest pain, and vertigo
Advantages: None.
Disadvantages: must avoid any alcohol containing products (including antiperspirants, vinegar, ciders, or extracts) otherwise the serious reaction will occur (“You will wish you were dead, but it will probably not kill you”); need to wear medical alert bracelet to alert medical responders
ADEs: skin eruptions, drowsiness, fatigue, impotence, headache, metallic taste; SERIOUS: hepatic failure (usually in those with already compromised hepatic function), rare psychotic episodes, rare peripheral neuropathy; rare optic neuritis; rare CV collapse (when taken with alcohol); rare death (when taken with alcohol)
Off-Label: Giardia and Trichomonas infections
lofexidine (Lucemyra)
Indication: Opioid Withdrawal (not effective for alcohol withdrawal, though studied)
Dose: Start at (3) 0.18mg tablets QID—adjust to withdrawal symptoms; MAX=2.88mg (16 tablets) daily, no single dose>0.72mg (4 tablets); taper over at least a 2-4d period (based on COWS)
Monitoring: BP and pulse; EKG in patients with CHF, bradyarrhythmia, or at risk of QTc prolongation
Mechanism: alpha-2 receptor antagonist
Advantages: more effective than clonidine
Disadvantages: cost; rebound hypertension
ADEs: orthostatic hypotension; bradycardia; dizziness; somnolence; sedationl dry mouth; syncope; QTC prolongation
Off-Label: Hot flashes of menopause
methadone
Indication: Opioid Dependence; Severe Pain
Dose: Start 15-30mg, then 5-10mg every four hours; Max (d1) = 40mg; 80-120mg is a common maintenance dose
Monitoring: EKG for cardiac disease
Mechanism: opioid agonist
Advantages: most successful harm reduction model for opioid dependence because it reduces transmission of infection diseases associated with injection (hepatitis and HIV)
Disadvantages: accumulation effects that can lead to toxicity; interindividual difference is pharmacokinetic parameters; limited availability only to treatment programs; DDI; Schedule II
ADEs: constipation; dizziness; sedation; nausea; sweating; increased QTc; respiratory depression (which can be prolonged in cases of overdose)
varenicline (Chantix)
Indication: Smoking cessation
Dose: Set a quit date for 35d out; Start 0.5mg daily for 3d, then increase to 0.5mg BID for 4d, then 1mg BID x 11 weeks. Quit at D35 or one week after. Take with food AND water; If successful with quitting, continue for 12 more weeks (o/w discontinue)
Monitoring: No routine monitoring required.
Mechanism: nicotine receptor partial agonist: Dual action: a) mimics nicotine effects on the brain thereby reducing withdrawal symptoms; and b) blocks nicotine from binding to these receptors, decreasing the reinforcing effects of smoking
Advantages: may be the most effective form of smoking cessation; may be combined with bupropion (but combination with NRT increases nausea and headache side effects)
Disadvantages: NP events; produces lower tolerance to alcohol; stopping smoking impacts psychokinetic properties of antipsychotics, theophylline, warfarin, and insulin
ADEs: nausea; insomnia; abnormal dreams; headache; constipation; flatulence; SERIOUS: NP events (depression, suicidal thoughts, psychosis, hostility, suicide) – risk may be lower than previously suspected
naltrexone (ReVia (oral); Vivitrol (IM))
Indication: Alcohol Dependence (more frequent); Opioid Dependence (relapse prevention)
Dose: 50mg daily; 380mg IM q4 weeks
Monitoring: LFTs
Mechanism: opioid antagonist
Advantages: promotes self-control
Disadvantages: emergency pain management requires alternatives to opioids; narrow therapeutic window before hepatocellular injury
ADEs: nausea, headache, somnolence; black box warning for hepatic injury
Off-Label: Self-injurious behavior
Fun Facts: naltrexone good for alcohol cravings (minimize severity of drinking); acamprosate better to prevent relapse
acamprosate (Campral)
Indication: alcohol dependence
Dose: 666mg TID (or 333mg TID for patients with renal impairment)
Mechanism: promotes a balance between glutamate and GABA, but mechanism not fully developed)
Advantages: good for patients with hepatic impairment; may be used in combination with naltrexone or disulfram; contains calcium
Disadvantages: suicidal ideations and completions rare, but higher than placebo
ADEs: diarrhea (transient, dose-related); weakness; peripheral edema; insomnia; SI (rare)
