Substance related disorders Flashcards
1
Q
What is substance use, abuse, phsyical dependence?
A
- sporadic consumption of alcohol/drugs w/ no adverse consequences
- abuse: frequency of alcohol/drug use may vary, there are adverse consequences experienced by the user
- physical dependence: state of adpatation that is manifested by a drug class-specific withdrawal syndrome
2
Q
What is psychological dependence, addiction?
A
- psychological dependence: a subjective need for a specific psychoactive substance, either for its positive effect or to avoid negative effects of its abstinence
- addiction: primary, chronic, neurobiologic disease, with genetic, psychosocial, and enviro factors influencing its development and manifestations:
characterized by behaviors that include impaired control over drug use, compulsive use, cont use despite harm and craving, and continuing use despite adverse consequences in the abusers life
3
Q
Epidemiology of substance abuse?
A
- 10% of general pop has problems due to substance abuse
- genetic differences
- age differences: prevalence is reduced as age increases
4
Q
Special populations affected by substance abuse?
A
- adolescents
- anyone with psych comorbidity
- those who smoke or abuse alcohol
- elderly - alcohol
- health care workers: rx drugs
- pregnant women may fear admitting to drug abuse
5
Q
How do you recognize the drug abuser?
A
you won’t know unless you ask:
- quantity
- amt of money spent daily/weekly/monthly
- frequency of use and time of last use
- route of admin
- if hx of use is disclosed ask about prior detox or addiction tx and abstinence periods
6
Q
Physical changes due to substance abuse?
A
- drug use is leading cause of impotence in US
- wt loss and sleep disturbance
- evidence of localized or systemic infections
- on abdominal exam may palpate enlarged or shrunken liver
- respiratory or nasal problems (cocaine, smoking - tobacco, marijuana)
- need marks: tracks
- STIs in pts who are trading sex for drugs
7
Q
CAGE questionnaire? Best in what pop?
A
- commonly used in medical setting and has been validated as a sensitive and specific tool for detectin problem drinking (esp in men)
- 2 or more positive answers indicate a likely dx of alcohol dependence
- Have you ever felt the need to Cut down on your drinking?
- have you ever felt Annoyed by criticism of your drinking?
- have you ever had Guilty feelings about your drinking?
- do you ever take a morning Eye-opener (steady your nerves or get rid of hangover)
8
Q
Why does an individual take a substance to start with?
A
- have to get to the bottom of this with your pts
- is it solely for the high?
- what about over time when there is no longer euphoria? Is it maintain an equilibrium?
- is it to counter something else going on? - does the person have anxiety, depression, are they escaping something?
- *you must always seek to determine what fxn a substance is serving for a pt
9
Q
What is considered risky or hazardous drinking? What is unhealthy alcohol use?
A
- in men younger than 65 - it is more than 14 drinks a week and in women that are younger than 65 - more than 7 drinks a week
- unhealthy alcohol use: uses that can result in health consequences
10
Q
Alcohol abuse definition?
A
assoc with one or more of the following, occurring in a 12 month period:
- failure to fulfill work, school or social obligations
- recurrent substance use in physically hazardous situations
- recurrent legal probs related to substance use
- cont use despite alcohol related social or intrapersonal problems
11
Q
What is alcohol dependence (alcoholism)?
A
a maladaptive patterns of use assoc w/ 3 or more of the following, occurrence at any time in the same 12 month period:
- tolerance
- withdrawal
- substance taken in larger quantity than intended
- persistent desire to cut down or control use
- time is spent obtaining, using or recovering from the substance
- social, occupational or recreational tasks are sacrificed
- use continues despite physical and psychosocial problems
12
Q
epidemiology of alcohol?
A
- over 50% of people 12 and older reported drinking regularly
- over 23% reported binge drinking in last 30 days, 6.9% reported heavy drinking
- 40% of all traffic fatalities are alcohol related
- alcohol related health problems 3rd leading cause of preventable death in the US
- leads all other substances in substance related deaths!!
13
Q
Medical morbidity of alcohol?
A
assoc with greater risk of:
- HTN, cardiomyopathy
- hepatitis, cirrhosis (1/2 cases in US secondaray to ETOH), pancreatitis
- TB, pneumonia
- psych probs: anxiety, depression, and eating disorders
- cancers of the stomach, mouth, larynx, breast, and esophagus
14
Q
Screening tools for alcohol use? Who should be screened?
A
- single item screening
- alcohol use disorders identification test (audit)
- CAGE questions (not as reliable for caucasian women)
- screen all adult pts: intervention most likely to succeed in pts who are in risky drinking or hazardous drinking categories
- a large # of pts need to be screened to achieve benefit
- screening essential pts with + family hx, who smoke, have frequent ER visits, or who are on meds that interact with ETOH
15
Q
CRAFFT screening for adolescents and college students?
A
- Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?
- do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
- do you ever use alcohol or drugs while you are Alone?
- Do you ever use alcohol or drugs while you are Alone?
- do you ever Forget things you did while drinking or doing drugs?
- Do your family or Friends ever tell you that you should cut down on your drinking or drug use?
- have you ever gotten into Trouble while you were using alcohol or drugs
- 2 or more positive answers indicate problem use, abuse or dependence
- performs better then CAGE for this age group
16
Q
What is considered moderate drinking?
A
- men: 2 drinks or less a day
- women: 1 drink or less a day
17
Q
What is considered heavy drinking?
A
- men: drink more than 14 drinks per week, or 4 drinks per occasion
- women: drink more than 7 drinks a week or 3 drinks per occasion
18
Q
What is considered binge drinking?
A
- men: 5 or more drinks in a row
- women: 4 or more drinks in a row
19
Q
Drink equivalents?
A
1 mixed drink with 1.5 fl oz of 80 proof liquor = 5 oz of wine = 12 oz of beer or wine cooler
20
Q
Etiology of alcohol related disorders?
A
- multifaceted including psychosocial, genetic and or behavioral factors
- genetics:
3-4x higher for severe alcohol problems in first degree relatives with alcohol problems - rate of alcohol problems increases with the number of alcoholic relatives and severity of illness
21
Q
Absorption of alcohol?
A
- 10% consumed alcohol is absorbed in the stomach, remainder from the small intestines
- when concentration of alcohol in stomach becomes too high - mucus secretion and pyloric valve closure results in slowed absorption
- pylorospasm results in vomit - rookie drinkers
22
Q
metabolism of alcohol?
A
- 90% metabolized in liver through oxidation
- metabolized by 2 enzymes:
ADH catalyzes conversion of alcohol into acetaldehyde, which is toxic - ALDH catalyzes conversion of acetaldehyde into acetate
23
Q
Effects of alcohol on the brain? Diff levels and effects?
A
- CNS depression (like benzodiazepines)
- relatively mild levels: thought, judgement, and restraint are loosened
- increasing levels: voluntary muscle dysfxn and entire motor area of the brain depressed
- yet increasing levels: confusion, stupor, coma, and finally primitive centers that control breathing and HR are affected and can result in death either secondary to direct respiratory depression or aspiration of vomitus
24
Q
Effects of alcohol on the liver?
A
- metabolism of alcohol leads to chemical attack on liver (it is unknown if damage is caused by acetaldehyde or other metabolites)
- even after all alcohol intake has stopped and all alcohol has been metabolized, the processes that damage liver cells may continue for weeks to months
- clinical and chemical effects often become worse before disease resolves
25
Q
3 patterns of hepatocellular injury by alcohol?
A
- fatty liver
- alcoholic hepatitis
- cirrhosis (rate is 10-15% of all alcoholics)
26
Q
What is wenicke-korsakoff syndrome?
A
- occurs in persons who have been drinking heavily for many years - rare to see in persons younger than 35, caused by thiamine deficiency due to poor nutrition/malabsorption
27
Q
What is wernicke’s encephalopathy?
A
- acute sxs which are completely reversible when tx w/ high dose thiamine: characterized by gait ataxia, vestibular dysfxn, confusion and ocular abnormalities
(remember to give thiamine b/f glucose to prevent encephalopathy)
28
Q
What is korsakoff’s syndrome?
A
- chronic condition where only 20% of pts recover - can be tx with po thiamine
- characterized by impaired recent memory and anterograde amnesia
- this isn’t as well tx with thiamine as wernickes
29
Q
How is drinking good for the heart?
A
- several studies have shown that drinking in moderation may have health benefits particularly in regard to CAD and the risk of MI
- meta-analysis of 34 studies found that 1-2 drinks a day in women and 2-4 drinks in men, are inversely related with total mortality while GREATER intake INCreased mortality
- pts will bring this up all the time, pts ofte fail to consider their comorbidities
30
Q
Goals for tx alcohol dependence?
A
short term:
- ID and initiate tx for pts at risk for withdrawal (determine stage)
- promote attendance at AA or other support groups
- early intervention
long term goals:
- extended management over time
- determining efficacy of tx
31
Q
Mild sxs of alcohol withdrawal?
A
- insomnia
- tremulousness
- mild anxiety
- GI upset/anorexia
- HA
- diaphoresis
- palpitations
- mild sxs begin w/in 6 hrs of cessation of drinking
- they resolve w/in 24-48 hrs
32
Q
WHen do withdrawal seizzures occur? Tx?
A
- occur w/in 48 hrs after last drink
- tonic-clonic
- occur in 3% of chronic alcoholics
- tx with benzodiazepines - not anticonvulsants
33
Q
What is alcoholic hallucinosis, when does this develop?
A
- within 12-24 hrs of last drink
- resolves with 24-48 hrs
- not delirium tremens
- usually visual: but can be auditory or tactile
34
Q
What agents shouldn’t be used for tx of alcohol dependence?
A
- ethanol
- antipsychotics
- anticonvulsants
- central actiing alpha-2-agonists
- B-blockers
- baclofen (muscle relaxant)
35
Q
What is delirium tremens, how common? When does it begin, last? RFs? Why is it so impt to dx this?
A
- 5% of pts who withdraw from alcohol will develop this
- sxs and signs:
hallucinations
disorientation
tachycardia
HTN
low grade fever
agitation
diaphoresis - begins 48-96 hrs after last drink, can last 1-5 days
- RFs:
hx of sustained drinking
hx of previous DTs
over 30
presence of concurrent illness - mortality rate of 5%
36
Q
DDx of alcohol withdrawal?
A
- dx of exclusion
- differential:
infection
trauma/head
metabolic derangements
drug overdose
hepatic failure
GI bleed
37
Q
General tx measures for alcohol dependence?
A
- place pt in quiet, protective enviro, may need mechanical restraint, most pts tend to be dehydrated with hypokalemia - replace with IV fluids and KCl
- thimaine - 100 mg IV or IM b/f glucose
38
Q
Tx for minimal sxs of alcohol withdrawal syndrome?
A
- no disorientation or hallucinations
- thiamin and supportive care
39
Q
Tx for mild sxs of alcohol withdrawal syndrome?
A
- thiamin and supportive care
- meds to reduce sxs and monitoring
40
Q
Tx for moderate and severe alcohol withdrawal syndrome?
A
- thiamin and supportive care
- hourly monitoring, especially respiratory rate
- meds: benzos
41
Q
What benzos are used in tx of alcohol withdrawal syndrome?
A
- diazepam (valium), chlordiazepoxide (librium), lorazepam
- can give orally or IV
- scheduled vs sx targeted
sx targeted - preferred - pt will be more alert
42
Q
Other meds used in alcohol withdrawal syndrome?
A
- for refractory DTs - add phenobarbitol and propofol (monitor respirations)
- antipsychotics lower seizure threshold - DONT USE
- seizures: if status epilepticus use phenobarbitol
- DONT use carbemazepine
43
Q
Outpt therapy of alcoholism - acomprosate (campral)? SEs, CI?
A
- synthetic derivative of homotaurine - analog of GABA
- MOA not clearly understood (take it b/f drinking - take a drink - get super sick)
- used for relapse prevention with counseling
- SE: diarrhea, low pulse, high or low BP, HAs, impotence
- CI: kidney disease
44
Q
Outpt therapy of disulfiram (antabuse)? SEs, drug interactions?
A
- inhibits the activity of acetaldehyde dehydrenase (ALDH) which results in 5-10 fold increase in acetaldehyde levels after alcohol ingestion
- leads to flushing, dyspnea, N&V, HA, blurred vision, vertigo, and anxiety
- SE: hepatotoxic, can cause depression, psychosis - need to monitor psych sxs
- increases drug levels of phenytoin, isoniazide and anticoagulants
- pt has to be motivated to follow through with this - if liver already harmed - don’t use
- works better than acomprosate
45
Q
Stimulants epidemiology?
A
- methamphetamine:
2nd to cannabis most widely abused drug in the world, 5% of US pop have used it - cocaine: highest prevalence unemployed men in their 20s w/ only a high school educationin urban areas, use is highly assoc with use of other legal and illegal substances
46
Q
Pharm of metahmphetamine?
A
- displaces epi, NE, dopamine, and serotonin into synaptic cleft
- also activates NT reuptake systems
- this results in surge of adrenergic stimulation
- sxs and signs produced: high energy, increased HR, pupil dilation, Increased BP, agitated, psychosis)
- readily absorbed via oral, pulm, nasal, IM, IV, rectal, and vaginal routes, body stuffing has been reported
47
Q
General appearance of a pt with meth intoxication? VS?
A
general appearance:
- malnourished, agitated, disheveled
- severe intoxication can exhibit abrupt changes in behavior and become very violent
- “meth mouth”, other stigmata of trauma, diaphoresis
- VS: tachy, HTN, hyperthermic
- other: N/V, seizures, delirium, psychosis
- may have sympathomimetic toxidrome: adrenergic excess
48
Q
DDx of meth intoxication?
A
Other toxicologic conditions:
- cocaine and PCP
- theophylline and ASA overdose
- MAOI, serotonin syndrome, antcholinergic poisoning
nontoxicologic:
heat stroke
thyrotoxicosis
pheochromocytoma
49
Q
Meth intoxication tx?
A
- sedation for agitation
- protect airway
- control BP and temp
50
Q
Biggest risk is what in meth intoxication? Tx?
A
- cardiovascular collapse
- tx:
vasoactive amines
correct metabolic acidosis
fluid resuscitation
51
Q
MOA of cocaine?
Pharmokinetics?
A
- blocks presynaptic reuptake pumps for dopamine, NE and serotonin
- also blocks voltage gated membrane Na channes
pharmacokinetics: cocaine base - can be smoked
- cocaine salt is readily injected or snorted
- when used with alcohol forms cocethylene - longer acting
52
Q
Cocaine intoxication - intended effects, adverse effects, and physiological effects?
A
- intended effects: increased energy, alertness, sociability, elation or euphoria, decreased fatigue, need for sleep and appetite, “total body orgasm”
- adverse effects:
anxiety, irritability, panic attacks, paranoia, gradiosity, impairment in judgement, psychotic sxs - physiological effects: tachycardia, pupil dilation, diaphoresis, nausea
53
Q
Effects of cocaine acute intoxication on CV, CNS, lungs?
A
- CV: arterial vasoconstriction and enhanced thrombus formation, causes tachycardia, and HTN
- CNS: agitation, seizures, HA, coma, intracranial hemorrhage
- lungs: when smoked can cause angioedema and pharyngeal burns
passive cocaine exposures: those in close proximity to users of inhalational cocaine can present with toxicity
54
Q
Initial labs of stimulant intoxication management?
Specific management?
A
- fingerstick glucose
- acetaminophen and salicylate levels
- EKG
- pregnancy test in women of childbearing age
- others as indicated
- management:
towards pt’s condition
toward sx problems
55
Q
Components of cannibis?
A
- psychoactive component: delta-9-tetrahydrocannabinol (THC)
- THC: has increased from 1-5% in 60s to 10-15% currently
- plant is processed into 3 drug products:
dry leaves and flowers (herbal cannabis)
pressed, dry resin or secretion (hashish)
oil (hash oil)
56
Q
Epidemiology of cannabis?
A
- most commonly used illegal substance worldwide
- more commonly used in US
- men 2x as much as women
- blacks use it greater than whites and hispanics
- lifetime cannabis use is greater in those who are separated or divorced compared to those married
- use assoc with other substance use - alcohol and other ilict drugs
- cannabis used at early age is assoc with use of other substances at later age
- use occurs more frequently in those with mental illness
57
Q
Pharmacology of cannabis?
A
- THC reaches brain, crosses BBB and bidns to endogenous cannabinoid receptors (CB1)
- THC activates CB1 receptors in mesolimbic dopamine system, which is hypothesized to modulate the positive reinforcing and rewarding effects of most drugs of abuse
- abstinence of drug cuases withdrawal sxs
- repeated chronic use leads to down regulation of the receptor - tolerance which leads to having to have increased amt to have same effect
58
Q
Comorbid mental illnesses assoc with cannabis use?
A
- occur frequently in pts with cannabis disorders
- mood disorders: 61% of those with cannabis dependence, 36% of those with cannabis abuse
- anxiety disorders: 46% in those with cannabis dependence, and 25% in those with cannabis abuse
59
Q
Genetics of cannabis use?
A
- there is substantial degree of heritability of cannabis dependence (60% genetic)
60
Q
Psychosocial aspect of cannabis use?
A
- used to relieve tension and cope with stress
- many young adults believe it is relatively harmless
- actually it can lead to school dropout, using other illict drugs, interpersonal problems, crime and unemployment
61
Q
Cannabis effects - mood, perception, thought content?
A
- usually causes euphoria, decreases anxiety, and tension
- time perception is distorted, time is perceived faster
- increased self consciousness and transient grandiosity can occur as well as paranoia and even psychosis
62
Q
Cannabis effects - cognition, and psychomotor fxn?
A
- decreases rxn time and impairs attention, concentration, short term memory, and risk assessmnet
- impairs motor coordination, and ability to do complex tasks - lasts 12-24 hrs past initial euphoria
63
Q
Physiologic signs of cannabis use?
A
- tachycardia
- increased BP
- increased RR
- conjunctival injection
- dry mouth
- increased appetite
64
Q
Marijuana withdrawal sxs?
A
- craving for marijuana
- irritability
- restlessness
- depression
- anxiety
- decreased quantity and quality of sleep
- vivid or strange dreams
- decreased food intake, with assoc wt loss
- increased aggression
- physical tension
- sweating
- runny nose
- stomach pain
- nausea
65
Q
Tx for marijuana addiction?
A
- difficult
- buspirone (buspar) has shown to be helpful for tx withdrawal sxs
- inpt tx advised
- changing setting where the pt is habitually using marijuana
- at times oral THC in reducing doses
- tx underlying comorbid psychiatric disease appropriately and carefully
66
Q
What are hallucinogens?
A
- substances whose primary effects include alteration of sensory perception, mood and though pattern
- Trip: effects experienced from acute intoxication - bad trip - acute intoxication with dysphoria, fear, agitation, or other unwanted effects predominate
- flashback: recurrence of sxs assoc with hallucinogen after the effects of the acute intoxication have worn off. May occur months or years after the last use of drug
67
Q
Pharmacology of hallucinogens? Effects?
A
- involves the interaction of numerous NTs: serotonin, dopamine, glutamate
- exact mecahnism unknown, but one property common to the drugs is their ability to bind 5-HT2A receptors (this serotonergic activity may cause serotonin syndrome)
- effects: phenomenon - synesthesia (blending of senses) - feel like your whole body is alive
68
Q
What is LSD?
A
- lysergic acid diethyl amide
available as capsule, pill or liquid, neuropsychiatric sxs, person remains oriented and aware their experience is drug induced
69
Q
What is dextromethorphan (DXM)?
A
- codeine analog
- OTC in cold and cough preparations
- recreational dose: 100-200 mg can produce hallucinations and coma
- anticholinergic delirium and acetaminophen toxicity have occurred
70
Q
What is mescaline?
A
- active ingredient in peyote cactus
- N/V often precede onset of psychedelic effects
71
Q
What is 4-bromo-2-5-dimethoxpheethylamine?
2CT-7 or blue mystic?
A
- 2CB or Bromo: gentler than LSD
- 2CT-7: little is known about it, deaths have been reported
72
Q
What is PCP? intoxication features?
A
- dissociative anesthetic similar to ketamine
- resurgence of use in certain cities
- commonly added to cigaretts, marijuana, or other herbs for smoking
- distinguishing features of intoxication:
bizarre violent behavior
nystagmus
catatonic stupor and coma can occur at higher doses
73
Q
main components of tx pts on hallucinogens?
A
- quiet, calm enviro
- supportive care
- careful, mild sedation if agitated with monitoring
74
Q
Use of inhalants?
A
- 13% of middle school and high school students report using inhalants in US
- since 2002 incidence increasing
- male=female
- inhalant abuse is common problem in adolescents - readily accessible, inexpensive an dlegal to buy and possess, perceived risk of use is loq
75
Q
What do inhalants contain? How do they effect the body?
A
- wide variety of chemical structures mainly hydrocarbons, nitrites or nitrous oxide
- highly volatile, lipid soluble and absorbed from pulmonary system
- they act as CNS depressants - inital euphoria is followed by lethargy
- nitrites cause intence vasodilation producing a sensation of heat and warmth, prolong penile erection
76
Q
Most commonly used inhalants? Techniques?
A
- US: glue, shoe polish, and toulene, then gas and lighter fluid, nitrous oxide (wippits), spray paints
techniques:
- spray directly on heated surface to vaporize (sniffing)
- saturate cloth and hold near nose or mouth (huffing)
- put substance in a bag that is placed over nose, mouth or head (bagging)
77
Q
Inhalant effects on CNS, GI, hematologic?
A
CNS: immediate - slurred speech, ataxia, disorientation, HA, hallucinations, violent behavior, seizures
long term: neurocognitive impairment, cerebellar dysfxn, and peripheral neuropathy
GI: N/V, anorexia, and wt loss, some solvents are hepatotoxic
hematologic: use of benzene can cause aplastic anemia and malignancy
- sudden sniffing death due to CV collapse
78
Q
Presentation of inhalant intoxication? Labs? Tx?
A
- extreme behavior probs
neuropsychiatric probs
altered mental status - labs: CBC, CMP, UA, ABGs (gas exchage), pulse ox, EKG, monitor
- may smeel sweet solvent odor of halogenated hydrocarbons
tx: supportive
79
Q
Smoking tobacco- results in?
A
- highly addictive
- etiology of:
lung cancer
COPD
CVD
second hand smoke: lung cancer in adults
URI, SIDS in infants and kis
80
Q
What is nicotine, how does it work?
A
- addictive component in tobacco
- agonist at nicotinc subtype of acetylcholine receptors: reaches brain in 15 seconds, 1/2 life of 2 hrs
- activates the dopamine reward system
increases circulation of NE and epi - more addictive than opioids
81
Q
Nicotine use?
A
- mean onset: 16 yo
- few people start smoking after 20
- dependence develops quickly
- 20% of pop develops nicotine dependence at some pt in their life
82
Q
outcomes of nicotine use?
A
- death
- 400,000 premature deaths a year
- 30% of cancer deaths in US are caused by tobacco smoke
- suffocation
- chronic cough and SOB (COPD)
- mortality: atherosclerotic CVD, lung CA, and COPD
83
Q
Nicotine withdrawal sxs?
A
- loss of euphoric effects
- dysphoric or depressed mood
- insomnia
- irritability, frustration, anger, anxiety
- difficulty concentrating
- restlessness
- decreased HR
- increased heart rate
- increased appetite/wt gain
84
Q
Behavioral approaches that we can use to influence smoking cessation?
A
- ask
- urge to quit
- assess stage of change:
precontemplation
contemplation
determination
action
maintenance
85
Q
3 successful smoking cessation tx strategies?
A
- social support
- pharm therapy
- skills training or problem solving techniques
- clinician counseling: dose-response relationship b/t intensitivity of tobacco dependence counseling and its effectiveness in smoking cessation - give positive reinforcement to pt for quiting
86
Q
1st line smoking cessation drug? MOA, SE?
A
- Varenicline (chantex)
MOA: partial agonist of nicotinic acetylcholine receptors - reduces withdrawal sxs, blocks nicotine from tobacco thereby reducing the reward aspect of smoking - SE: nausea, insomnia, abnormal dreams, depression and suicidality (BBW)
- monitor for neuropsychiatric sxs
87
Q
Use of buproprion (zyban or welbutrin) in smoking cessation?
A
- MOA: enhances CNS noradrenergic and dopaminergic fxn
- SE: dry mouth, insomnia, HA, seizures, monitor for neuropsych sxs
- CI: seizure disorders and pregnancy
- careful with insurance coverage
- doesn’t work as well as chantix
88
Q
Use of nicotine polacrilex in smoking cessation?
A
- gum (nicorette) or lozenge
- gum use - need to pack it not just chew it to get effect
- withdrawal sxs not totally prevented
- some people become chronic gum chewers
- lozenge has higher rates of abstinence at one years
89
Q
Use of transdermal nicotine patches?
A
- several dosage formulations
- use/can do patch + other pharm
- reduces intensity of withdrawal sxs
- delivery of nicotine at night can cause sleep disturbance and vivid dreams
- increased am nicotine levels benefit some pts
90
Q
Opioids include?
A
- heroin: diacetlymorphine (dope, horse, smack, tar)
- opium
- Rx opiates: abuse of these increasing, used these more than cocaine, heroin, hallucinogens, ectasy and inhalants combined
91
Q
Prescription opioids?
A
- fentanyl - patch
- percocet (oxycodone/acetaminophen)
- vicodin (hydrocodone/acetaminophen)
92
Q
MOA of opioids?
A
- opioids activate specific transmembrane NT receptors (mu, kappa, delta) that couple G proteins
- G proteins are intermediates that initiate the intracellular communication process
- activation of CNS mu receptors results in euphoria, respiratory depression, analgesia and miosis
- stimulation of peripheral mu receptors causes cough suppression and constipation
93
Q
Classic signs of opioid toxicity?
A
- depressed, mental status
- decreased respiratory rate
- decreased tidal volume
- miotic pupils
- with meperidine and propoxyphene or presence of coingestants - such as sympathomimetics or anticholinergics - pupils may be normal or large
94
Q
VS changes and secondary survey findings in opioid toxicity?
A
- VS changes:
low HR
mild hypotension
hypothermia (can even occur at room temp) - secondary survey:
look for signs of trauma esp to the head, check for med patches that need to be removed, may need to do rectal/pelvic exams for hidden drugs
95
Q
DDx of opioid toxicity?
A
- ethanol: no miosis or change in bowel sounds
- clonidine - bradycardia and hypotension more prominent
- sedative hypnotics - less respiratory depression
- CVA
- lyte abnormalities
- sepsis
96
Q
Tx of opioid toxicity?
A
- mainstay of tx: ABCs particulary airway management
- use of naloxone (opioid antagonist) to increase respirations to 12 or greater not to attain a normal level of consciousness
- several opioids possess uncommon toxicities requiring specific management
- opioids are implicated in more drug related deaths than any other ilicit agent
97
Q
Withdrawal sxs to opioids: 3-4 hrs from last dose?
A
- drug craving and anxiety
- fear of withdrawal
98
Q
Withdrawal sxs to opioids: 8-14 hrs last dose?
A
- anxiety, restlessness, insomnia, and yawning
- rhinorrhea, lacrimation, and diaphoresis
- stomach cramps and mydriasis
99
Q
Withdrawal sxs to opioids - 1-3 days from last dose?
A
- tremor, muscle spasm
- vomiting, diarrhea
- HTN and tachycardia
- fever, chills, and piloerection
100
Q
Sx managment for acute withdrawal?
A
- muscle relaxants
- NSAIDs
- antiemetics
- antidiarrheal agents
- sleeping agent with low abuse potential: melatonin, benadryl
101
Q
Long term opioid addiction tx?
A
- abstinence based tx programs
- naltrexone (opioid antagonist)
- opioid agonists:
methadone
buprenorphine
102
Q
use of naltrexone in opioid addiction tx?
A
- admin after pt completely detoxed
- oral or monthly depot prep
- antagonist prevents the pt from experiencing any euphoric effects with subsequent opioid use
- most effective in highly motivated pts:
closely supervised
can be mandated by legal or other authorities
103
Q
Use of methadone in opioid addiction tx?
A
- method of long term opioid tx
- admin of single daily dose in controlled setting with counseling and social services
- more than 180 days maintenace, and less than 180 days detoxification
- SEs:
constipation, drowsiness
reduced libido, excess sweating, peripheral edema, prolonged QT
104
Q
Use of buprenorphine in opioid addiction tx?
A
- partial opioid agonist
- sublingual preparation - subutex
- combined with naloxone (antagonist) - suboxone
- can be prescribed by clinicians in their office - need to go through their training program
- schedule III drug, methadone schedule II
105
Q
Use of clonidine in opioid withdrawal tx?
A
- alpha-2-adrenergic receptor agonist
- may decrease withdrawal sxs in pts using low doses of opioids
-SEs:
orthostatic hypotension
dry mouth
constipation - some pts combine clonidine and methadone to get euphoric effect - will abuse these meds
106
Q
What is used to tx anxiolytic disorders? Why is this a problem? What should you do when seeing these pts?
A
- often benzodiazepines are used to tx these and they can be highly addictive
- it is impt to take a good hx b/c people who have abused other substances are at higher risk to abuse benzodiazepines
- careful monitoring of drug abuse and using them short term at low doses is impt
107
Q
What are sxs of benzodiazepine withdrawal?
A
- increased body temp
- elevated BP
- increased pulse and RR
- aroused level of consciousness/delirium
- tremulousness
- increased DTRs/seizures
- disorientation
- psychotic behavior/hallucinations
108
Q
Tx of benzo withdrawal?
A
- mild to moderate:
most pts can be managed by a slow taper of the drug they were on over several months, objectively determining drug tolerance may be difficult - severe withdrawal: can be life threatening, use long acting benzos watching for respiratory depression
- severe/serious withdrawal: anticonvulsants can be used - carbamazepine or valproate
sx rebound may occur - insomnia and anxiety - ICU for severe withdrawal with abnormal vital signs
