Substance Use Flashcards
Benzodiazepine treatment of alcohol withdrawal
all patients receive thiamine 100mg IM, then 100mg PO for 3 days
Benzodiazepine (3 regimen options) for CIWA 10+
1) Fixed Dose Regimen usually QID usually Chlordiazepoxide (Librium) or Diazepam (Valium)
most effective, for severe
regimen tend to give more benzodiazepine for longer period than needed
indicated for:
history of severe withdrawal such as seizure or delirium tremens
pregnant
has acute medical or surgical illness
hold diazepam if drowsy or over sedated
2) Front Loading Regimen
frequent high dose of benzodiazepine given early in course of withdrawal for only a short period of time with close observation ex. emerg
Diazepam 20mg q1-2 hours PRN for CIWA score >10 until CIWA <8 observe for 2-4 hours after last dose
3) Symptom Triggered Regimen individualize benzodiazepine dosage and frequency based on symptom severity (CIWA score)
most conservative treatment regimen tend to give less
not effective for preventing seizure or delirium tremens, because it would be too late to give benzodiazepine if patient present with seizure or delirium tremens
Caution with benzo in alcohol withdrawal patients
Cannot drive
Treatment of seizure and delirium tremens
generalized seizure usually resolve spontaneously
severe or repeated seizure treated with IV Diazepam 5-10mg
uncomplicated alcohol withdrawal seizure do not require long term use of antiepileptic
delirium tremens requires constant observation and treated with IV diazepam
Benzodiazepine intoxication management
ABCs
if severe overdose, activated charcoal to absorb
use of Flumazenil (competitive benzodiazepine receptor antagonist with weak agonist property) as antidote to benzodiazepine is controversial, because it could produce rapid benzodiazepine withdrawal and increase risk of seizure
Flumazenil does not treat alcohol intoxication
if agitated, Haloperidol and Lorazepam if needed
What is an adverse effect that can occur after benzodiazepine use that doesn’t occur with alcohol
Rebound insomnia, anxiety
DSM criteria for benzo withdrawal
A) cessation or reduction in alcohol / benzodiazepine that was originally heavy and prolonged use
B) patient exhibits >2 symptoms shortly after cessation or reduction in alcohol / benzodiazepine
autonomic hyperactivity (sweating, tachycardia)
increased hand tremor
insomnia
nausea and / or vomiting
transient visual, tactile or auditory hallucination or illusion
psychomotor agitation
anxiety
generalized tonic-clonic seizures
C) symptoms and signs cause significant distress and impairment in psychosocial function
D) symptoms and signs not attributable to another medical condition, psychiatric disorder or intoxication / withdrawal of another substance
DSM criteria benzo intoxication
A) patient recently used alcohol / benzodiazepine
B) patient has clinically significant problematic behavioural or psychological changes that develop during or shortly after alcohol / benzodiazepine ingestion
C) patient exhibits >1 of the following symptoms and signs during or shortly after alcohol / benzodiazepine use slurred speech incoordination unsteady gait nystagmus (involuntary eye movement) impairment in attention or memory stupor or coma
D) symptoms and signs not attributable to another medical condition, psychiatric disorder or intoxication of another substance
Benzos and their half lives
short acting (<6 hours half life): triazolam, midazolam
intermediate acting (6-24 hours half life): oxazepam, lorazepam, temazepam, nitrazepam, alprazolam, clonazepam
long acting (>24 hours half life): diazepam, chlordiazepoxide, clorazepate, flurazepam
Benzo withdrawal management
Treated with a slow taper
taper with long acting benzodiazepine such as diazepam or clonazepam
if using alprazolam, then need to taper with alprazolam
taper according to symptoms
taper with regular dispensing to avoid patient taking all of benzodiazepine at one time
dispense daily, twice weekly or weekly depending on dose and patient reliability
if low dose (<50mg/day of diazepam equivalent), then outpatient tapering
if moderate dose (50-100mg/day of diazepam equivalent), then inpatient tapering
outpatient can be considered if the patient satisfies all of the following
not physically depend on other substances
is medically and mentally stable
unlikely to use benzodiazepine from other sources
if high dose (>100mg/day of diazepam equivalent), then inpatient tapering
outpatient tapering has 2 possible regimens
1) proportional dose taper
taper by 10% of dose until dose is at 20% of original dose,
then taper 5% every 2-4 weeks
2) dose taper by amount
taper by ~5mg per week
if dose >50mg diazepam equivalent, then taper 5mg every 3-4 days
once below 20mg diazepam equivalent, then slow pace of taper
inpatient taper is faster than outpatient due to provided support and control of dosing
start taper at 1/2 to 1/3 of the original dose administered TID or QID
if significant withdrawal on this dose, increase next day’s total dose
taper by 5-15mg per day or no more than 10% of daily dose while slowing taper as dose decreases
during tapering, there could be recurrent of original disorder for which benzodiazepine was prescribed (anxiety, insomnia), rebound symptoms and withdrawal symptoms
Opioid intoxication DSM criteria
A) patient has recently used an opioid
B) patient exhibits problematic behavioural or psychological changes that developed during or shortly after opioid use patients
usually experience euphoria at first followed by apathy, dysphoria, psychomotor agitation or retardation and impaired judgment
C) pupillary constriction (or rarely pupillary dilation due to anoxia from severe overdose) and 1+ of following symptoms and signs
drowsiness or coma
slurred speech
impairment in attention or memory
D) symptoms and signs not attributable to another medical condition, psychiatric disorder or intoxication of another substance
What differentiates opioid from alcohol/benzo intoxication?
constricted pupil and response to Naloxone challenge in opioid intoxication
Opioid intoxication management
stabilize patient (assess ABC, maintain airway, ventilatory & cardiac life support if necessary)
Naloxone (opioid antagonist) 0.4-0.8mg IM is the antidote to opioid intoxication, which will reverse neurologic, cardiovascular and reparatory depression by opioid
opioid dose with more potent opioid (fentanyl) or longer acting opioid (methadone) require Naloxone at higher doses and over longer period of time
Opioid withdrawal DSM criteria
A) patient has either of the following: cessation or reduction in opioid use that was originally heavy and prolonged (> several weeks) administration of opioid antagonist after period of opioid use
opioid antagonist include Naloxone or Naltrexone
partial opioid agonist such as Buprenorphine can also cause withdrawal
B) patient has >3 of the following symptoms within minutes to several days after criteria A dysphoria nausea or vomiting muscle aches lacrimation (runny eyes) or rhinorrhea (runny nose) pupillary dilation piloerection (goose bumps) or sweating diarrhea yawning fever insomnia
C) symptoms and signs cause significant distress and impairment in psychosocial function
D) symptoms and signs not attributable to another medical condition, psychiatric disorder or intoxication / withdrawal of another substance
Life threatening intoxications and withdrawals
Stimulant and alcohol and benzo intoxication
Alcohol and benzo withdrawal
Management of opioid withdrawal
1) Quit cold turkey (abstinence) with use of non-opioid medication support
patient given medication to treat opioid withdrawal symptomatically
Clonidine 0.05-0.1mg up to 0.1mg PO QID for hypertension
antidiarrheals (Loperamide) for GI upset
anti-nauseants (Dimenhydrinate) for nausea
analgesics (NSAID) for muscle aches and pains
night sedation (Trazodone or Benzodiazepine) for anxiety and insomnia, which should only be given for 5-7 days
indicated if preference, younger, oral opioid use, socially and medically stable, short duration of use
2) Taper using long acting opioid Oxycontin or Codeine by decreasing total dose by 10% per week
3) Substitution with Methadone or Suboxone
(Buprenorphene / Naloxone) Methadone or Suboxone are long acting opioid used for detoxification or maintenance
Methadone is a long acting opiate that relieve drug craving and withdrawal symptoms for 1 day without sedation nor euphoria diminish reinforcing effect of illicit opioid
Suboxone contains Buprenorphine and Naloxone Buprenorphine is a partial opioid agonist with high affinity for opioid receptor, thereby displacing other opioid agonist
therefore, buprenorphine does not elicit euphoria due to partial opioid and displaces effects of other opioid Naloxone is an opioid antagonist added, which is only active when not taken sublingually
opioid antagonist cause withdrawal to deter patients from injecting suboxone
before starting Suboxone, patient need to stop for ~1 day and be in moderate withdrawal (COWS score >13)
Suboxone is a tablet taken sublingually under supervision at pharmacy every 2-3 days
Suboxone has lower risk of overdosing in high amount or with alcohol / benzodiazepine
Suboxone may be easier to taper off than methadone
Suboxone indicated when Methadone is contraindicated or not accessible
patients qualifies for substitution only if they fulfill all of the criteria
meet DSM criteria for substance use (usually physical and psychological dependence on high daily doses of potent opioids for >1 year)
documented opioid use based on a positive urine drug screen for opioid and history
lower likelihood of benefit from non-opioid substitution programs such as abstinence or taper e.g. patient wants to continue using
