SUBSTANCE MISUSE Flashcards
Describe the cycle of change model.
- Pre-Contemplation
- No intention of changing behavior - Contemplation
- Is aware a problem exists
- BUT has no commitment to action - Preparation/Determination
- has an INTENTION on taking action to address the problem - Action
- They are ACTIVELY modifying their behavior - Maintenance
- New behavior replaces the old one - Relapse
- Back to old behavior
What are the three types of therapies to aid in stopping smoking?
- NRT
- Bupropion (Zyban)
- Varencicline (Champix)
Which drugs may be effected when someone stops smoking?
- Theophylline
- Smoking decreases theophylline concentration - Cinacalcet
- Ropinorole
- Clozapine
- Olanzapine
- Chlorpromazine
- Haloperidol
Need dose reductions
Champix MOA
Nicotine receptor blockers. Won’t feel anything from smoking and the receptors are blocked
What is the MHRA warning of champix?
Discontinue treatment and seek prompt medical advice if they develop:
1. Agitation
2. Depressed mood
3. Suicidal thought
So caution in those with a history of psychiatric illness (should be monitored closely)
Champix - avoid in
epilepsy, CVD and psychiatric illness
Bupropion - avoid in
- Acute alcohol withdrawal
- Acute benzo withdrawal
- Bipolar
- HISTORY OF SEIZURES
- Can cause seizures
Bupropion - SE
- SS
- depression = refer
NRT
- Patch (16H patch if pregnant/ experience nightmares)
+ - short term reliever (lozenges, gum, sublingual tabs, inhalator, nasal spray, and oral spray)
Best effects when use together
NRT patch and reliever
Patch acts as long term basal fix and short term acts as quick fix
Which drugs are used as opioid substitution therapy?
- Buprenorphine
- Methadone
What are the advantages of
Buprenorphine over methadone?
- Less sedating than methadone
- so preferred in employed patients or people who perform skilled tasks e.g. drive - Fewer drug-drug interactions
- Dose reduction is easier with buprenorphine than with methadone
- Milder withdrawal symptoms
- Lower risk of overdose
What are the
disadvantages of Buprenorphine?
- Increased risk of precipitating withdrawal
- especially if taken with opioid
- reduce the risk by starting the dose 6-12 hours after the last use of heroin
OR 24 - 48 hours after the last use of Methadone
What are the advantages of Methadone over buprenorphine?
More sedative effect:
* Probably preferable for those who typically abuse a variety of sedative drugs and alcohol
* And those who suffer from increased anxiety during withdrawal periods from opioids
Opioid dependence - Rx
- FP10MDA
- Maximum supply of 14 days
- SUPERVISED consumption is not a LEGAL requirement. It’s GOOD PRACTICE
Methadone - SE
QT
Methadone SF vs S
o If its prescribed as SF must give SF
o S can cause more local irritation if pt decides to inject it. Injecting with substance high in sugar would hurt
o SF won’t hurt
o If pt is at high risk of abusing it, then go for S so it hurts them
When should methadone be first initiated after the last heroin use?
Initiated at least 8 hours after last heroin use
- provided there is objective evidence of withdrawal symptoms
What should you be aware of with regard to titrating the dose of methadone?
A dose on the first day may be toxic on the third day
- because of long-half life, plasma concentrations progressively rise during initiation
- It may take 3-10 days for the plasma concentration to reach a steady state
- titration to a stable dose may take several weeks
How do you manage opioid substitution in pregnancy?
- Continue Methadone or
Buprenorphine (unlicensed) - Safer than acute withdrawal of opioids
- Safer than illicit drugs
Neonate should be monitored for
respiratory depression
- high-pitch,
- rapid breathing
- hungry but ineffective suckling
- excessive wakefulness
Can you give opioids during breastfeeding?
- Methadone or Buprenorphine doses MUST be kept to low
- Mother should report
URGENTLY any symptoms her baby gets:
1. Increased sleepiness (sedation)
2. Breathing difficulties
3. Limpness
What other treatments may be given to opioid dependence?
- Loperamide - for diarrhea
- Mebeverine - For controlling stomach cramps
- NSAIDs and paracetamol - for muscular pains and aches
- Metoclopramide or prochloperazine - N+V
- Topical rubefacients - muscular aches when withdrawal from methadone
- Short-acting Benzo or Z-drugs - for insomnia
- Lofexidine - For opioid withdrawal symptoms
- Naltrexone - to prevent relapse
- Naloxone - for overdose
What are the signs of opioid withdrawal?
- Muscle aches
- Restlessness
- Anxiety
- Lacrimaion (eye tearing up)
- Excessive sweating
- Inability to sleep
- Abdominal cramping DNV
If someone has strong alcohol dependence and abruptly stops it, what can happen?
- Seizures
- Delirium tremens
- Death
Therefore these people may need assistance in withdrawing alcohol acutely
Alcohol withdrawal symptoms: seizures of moderate AWS treatment
- Long-acting benzodiazepine
E.g. Chlordiazepoxide or diazepam - Carbamazepine
- Clomethiazole
Chlordiazepoxide or diazepam treatment regimes
- First line
- Fixed-dose reducing regimen (in primary care or inpatient) or
- Symptom triggered regimen (tailoring the drug regimen according to the severity of the withdrawal)
clomethiazole
- ONLY IN an INPATIENT setting
- should NOT be prescribed if the patient is liable to drink again
- if the patient has cirrhosis and drinks alcohol whilst on clomethiazole, risk of FATAl respiratory depression
What is delirium tremens?
- agitation, confusion, paranoia
- visual and auditory hallucinations
Delirium tremens: first line
- Oral lorazepam
- Parenteral lorazepam or haloperidol
How do you manage Alcohol dependence?
- Psychological
- e.g. СВТ - Pharmacological
- if the patient has not responded well to psychological
- OR has specifically requested pharmacological
Which pharmacological
treatments are used in alcohol dependence?
- Acamprostate calcium
- Oral Naltrexone
- Disulfiram
- Namefene
What should patients be counseled on whilst on Disulfiram?
THEY HAVE TO NOT DRINK
Also avoid exposure to small amounts of alcohol in:
1. Perfumes
2. Aerosol sprays
3. Low-alcohol or non-alcohol beer and whines
Why should they NOT drink whilst on disulfiram?
Risk of getting Disulfiram-like reactions:
1. Flushing
2. Throbbing headache
3. Nausea
4. Palpitations and tachycardia
5. Arrythmias
6. HYPOtension
7. Respiratory depression
8. Coma
Wernicke’s encephalopathy treatment
- Thiamine
- Pabrinex
