Substance use (and misuse) Flashcards
Prescribing in substance misuse:
-There are non-pharma options to be considered.
-Avoid prescribing (esp at first consultation)
-Ask about all substance use (+ OTC/Illicit)
-Avoid putting meds on repeat.
-Identify opiod prescribing for new registration.
-Add alerts to prescribing systems
-If prescription is issued do:
1. Time limit with clear plan
2. Check polypharmacy and dose equivalents
3. communicate effectivly including intraprof
4. document clear indication and who is prescriving what
-Ensure all vaccines are up to date e.g. HIV, HB
Difficult conversations with patients
Dont be afraid to ASK and try finding the best approach.
-Assess goals: other than reducing pain what is the most important goal you hope to achieve (and revisit)
-Asses effects: how well has this medication worked to relieve your pain have you been bothered by any S/E
-Assess expectations: how long do you expet to continue using this medication.
What is an Audit c score?
It is the Alcohol use disorder identification test
A score from 0-12, 5+ indicates increasing or higher risk drinking. a 5+ score is considered a audit C positive
Below you can see the alcohol withdrawal symptoms.
If there is a cold turkey stop with alcohol serious withdrawal symptoms can occur.
What is Chlordiazepoxide and its uses?
-Chlordiazepoxide is a long acting benzodiazepine, anticonvulsant that is cross tolerant with alcohol.
-It can be started before alcohol withdrawal symptoms start.
-Usual dosing range is 20-40mg QDS, dosage is then reduced over 7-10 days.
-Given combined with Vitamin supplementation.
-This drug can also be prescribed PRN.
-Hepatic impairment may need dose reduction, or using a short acting benzo (e.g. lorazepam and oxazepam)
Which statement about Disulfiram (Antabuse™) is flase?
a) It is a prodrug that is activated in the liver
b) Is a glutamate antagonist
c) Prevents conversion of acetaldehyde to acetic acid and dopamine to noradrenaline
d) An adversive therapy used for alcohol withdrawal.
e) Combination with alcohol can be fatal.
Correct answer is B.
-The drug used for alcohol withdrawal that is a glutate antagonist is Acamprosate (Campral), it has a better safety profile and reduces reward pathways. but it has a marginal overall effectiveness.
What are the opioid antagonists used for Alcohol withdrawal maintenance?
Naltrexone:
-Licensed for alcohol misuse disorder.
-It is well tolerated and has a significant effect on drinking behaviour.
-Naltrexone block opioid receptors that modulate the release of DA in the reward pathway thus blocking the rewarding effects from heroin and alcohol.
Nalmefene:
-Another opioid antagonist.
-It effectively reduces heavy drinking days by reducing reward.(I think you don’t get that drunk)
-Can be used as a PRN drug in:
1. people who have failed to achieve abstinence or who require a reduction strategy (VS cold-turkey)
2. Those who cannot achieve abstinence but require some form of intervention with psychosocial support.
Which statement is correct regarding low risk drinking?
a) People are safest to not drink >18 units /week
b) It is best to consume the alcohol over 3 days or less
c)The risk is lower is the person has atleast two drink-free days a week.
Answer is C
The Physical, Psychological and other benefits of reducing alcohol intake:
For physical benefits the patient can expect to:
-Feel better in the mornings.
-Have more energy throughout the day.
-Have improved skin, being fitter and faster.
-Have better weight control and overall better functioning.
For other benefits:
-Lower risk of accident or injury.
-less chance of getting into fights.
-Developing better relationships and self-esteem
-Have more time and money.
-Can change people outlook on oneself.
Below you can find a list of Prescribable opioids:
Which of the following is NOT a problem area for opioid dependence:
a) Prisons - Some supervised consumptions is allowed
b)Medical use to dependence - e.g Elderly taking opioid for pain.
c)Peak ages are 30-35, This is higher is lower income areas.
d)Use in hospital for analgesic reasons.
Answer is D
The treatment process for opioid dependence is as follows:
Which of the following is NOT a drug used for Maintenance of opioid dependence? Answer can be more than one
a) Methadone
b) Naloxone
c) Buprenorphine
d) Nalmefene
e) Naltrexone
Answer is B and D.
-Naloxone is a full antagonist used as a emergency antidote from opioid OD. (Available as Narcan given Nassaly)
-Nalmefene is an opioid antagonist used as a maintenance drug in alcohol withdrawal, it acts on the reward pathways (to not get you drunk)
-Naltrexone is another opioid antagonist that is used as a OD formulation given for maintenance of alcohol withdrawal (Given for opioids as-well but is used as medicinal support to remain opioid free)
Methadone: Dosing, Adv and Dis.
–A full agonist that reduces peak levels from injecting.
–Longer half-life than diamorphine so suppresses withdrawal and craving.
–People can and do “use on top” (OD risk)
–Dosing:
-Usually given as a distinctive green liquid.
-DOSE titration:
20 - 30mg Day 1, then increase 5-10mg every few days up to a max of 30mg above starting dose in the first week. then increase once or twice weekly by 10-15mg.
Takes about 5 days for blood levels to reach a steady state
Doses might be split in in-patient units or prisons.
Needs daily dosing with administration.
-Maintenance optimal dose usually 40-120mg/day
-Methadone can increase QTc interval, esp over 100mg/day, so beware of patiens other meds, HD history, stimulant use, and any relevant Mdx.
– Prescriber should be contacted if dose is missed for 3 or more consecutive days (need a dose reduction)
Buprenorphine: Dosing, Adv and Dis.
–A partial agonist that reduces peak levels from injecting
–Has a longer half-life than methadone so suppresses withdrawal and craving.
–Not absorbed orally (sub-lingual, injection or rods)
–Cannot be used on top
–First dose given when there are objective symptoms of withdrawal to reduce the risk of precipitated withdrawal.
–dose dependent upon formulation/locality
