Substance dependence & Wernickes encephalopathy Flashcards
What treatments are used for Nicotine dependence?
Nicotine replacement therapy (NRT), bupropion & varenicline
- Combination therapy like transdermal & opral preps
- NOT RECOMMENDED: Combination of NRT + Varenicline or bupropion
What are the choices for NRT?
- Nicotine patches, slow release 16hrs (remove patch overnight)
- Nicotine patches 24hrs slow release (for patients who have strong craving on waking)
- Immediate release preps like gum, lozenges, sublingual tabs, inhalator, nasal spray & oral spray.
These are used whenever urge occurs or to prevent cravings
What are the side effects of NRT?
- Irritation of throat (inhalation cartridges
- Increased salivation (spray, gums, lozenges)
- Minor skin irritation (patches)
- Coughing
- Nasal irritation
- Sneezing
- Watery eyes
- G.I disturbances
What side effect can NRT oral spray have?
Paraethesia - burning sensation in arms or feet. The feeling of tingling, numbness or “pins and needles.”.
And rash & hot flushes
- Sweating & myalgia
- Arthralgia
What side effect can NRT patches have?
Abnormal dreams - so removing patch before bed may help
Sweating & myalgia
- Arthralgia (joint pain)
What side effect can NRT lozenges have?
Rash and hot flushes
What needs to be known about Opioid substitution therapy?
Methadone & Buprenorphine is used as substitution therapy.
Start with short period of stabilisation, followed either by withdrawal or maintenance.
Must be reviewed regularly and monitor signs of toxicity
How long does complete withdrawal from opioids take?
Inpatient - 4 weeks
Community - up to 12 weeks
What should be done for missed doses of strong Opioids?
- Patients who miss 3 or more doses are at risk of overdose because of loss of tolerance.
- Consider reducing the dose in these patients
- If patient misses 5 or more days, then assess for illicit drug use before starting substitution therapy (esp for patients on buprenorphine because of risk of precipitated withdrawal)
Why is Buprenorphine usually preferred than methadone?
- It is less sedating than methadone
- Suitable for employed patients
- Safer when used with other sedating drugs or less interactions
- Milder withdrawal symptoms
- Dose reduction easier
- Lower risk of overdose
What needs to be known about Methadone?
- It is a long acting opioid agonist
- Usually administered in a single daily dose 1mg/ml oral solution
- Used for patients with long history of opioid misuse, drug dependence, alcohol dependence etc
What needs to be known for Opioid substitution during pregnancy?
- Acute withdrawal of opioids should be avoided in pregnancy, because it can cause fetal death
- Withdrawal during 1st trimester can cause spontaneous miscarriage.
- Buprenorphine is not license for use in pregnancy
What should be given in adjunction to Opioids to the side effects and withdrawal symptoms?
- Diarrhoea = Loperamide
- Stomach cramps = Mebeverine
- Muscular pain & headaches = NSAIDs
- Nausea & Vomiting = Metoclopramide or Prochloperazine
- Insomnia = Benzodiazepines/zopiclone (short courses for a few days only)
- Physical symptoms of opioid withdrawal = Lofexidine
- For accidental overdose = Naloxone
- To prevent relapse = Naltrexone
What can the abrupt stopping of alcohol cause?
Can cause alcohol withdrawal syndrome, which leads to seizures, delirium tremens & death
What medications are used for Alcohol dependence?
- Long acting benzodiazepines (chlordiazepoxide or diazepam): reduce effects of alcohol withdrawal symptoms.
- Carbamazepine: alternative treatment in acute alcohol withdrawal
- Clomethiazole: alternative to carbamazepine or benzodiazepine
- Fasting acting benzodiazepines (Lorazepam): reduce seizures
