Substance Use Disorder Flashcards
Opiates Withdrawal
- Can be similar to a severe case of influenza
- Severe psychological distress, may increase risk of suicide
- Pupillary dilation
- Lacrimation
- Rhinorrhea
- Piloerection
- “gooseflesh”
- Yawning
- Sneezing
- Anorexia
- N/VD
Opiates Withdrawal timing
- Short acting: within 8-24 hours of last dose; may last 7-10 days
- Long-acting:within 36 hours, peak at 72 hours, may last 2 weeks or longer
- Post acute phase may last months, leading to craving, fear and irritability
- Will have reduced opioid tolerance in future
Methadone
- Short acting: 4-8hr
- Long half life: 15-60 hr. Full effects not seen on a dose for 3-5 days
- Multiple drug interactions: QTc prolongation; monitor ECG
- Respiratory effects can occur after and last longer than peak analgesic effects
- Euphoria, dysphoria, apathy, sedation, or attention impairment, slurred speech, miosis (for all opioids)
Methadone Withdrawal
- Few hours after d/c heroin to 3-5 days after d/c methadone
- If delirium occurs, may also have another drug at play
- Treatment of acute intoxication
- –Naloxone 0.4 mg IV q 3 minutes
Heroin
- Most common first time users: 18-25 year olds
- Increased availability, low cost, increased purity
- Often laced with fentanyl
- Metabolized to morphine
- Intranasal, IV, SQ, IM, smoking
- Oral not preferred, high first pass metabolism = slower onset of action
Heroin background
“chasing the dragon”
- Significant concerns for stroke, seizures, obstructive hydrocephalus, and leukoencephalopathy
- Lipophilic- crosses BBB quickly
- Onset: 5-10 minutes SQ; 3-5 minutes IN, IM, < 1 minute IV
- Half-life: 8 hours, decreases with continued use = earlier symptoms of withdrawal
- Sedation, decreased respiration, apnea, cardiac arrest, death
- Urine Drug Screen – often not reliable due to rapid metabolism
Fentanyl
- 50-100 times more potent than morphine
- Illicitly manufactured fentanyl (IMF): often mixed with heroin, cocaine & marketed as oral opioid and benzodiazepines
- Carfentanil: 10,000 times more potent than morphine
Dextromethorphan
- OTC medication – cough syrup
- “Robodosing” or “Robotripping”
- Depressant and mild hallucinogenic effect
- “Skittles” when taken as handfuls of cough and cold remedies
- High doses = hyperexcitability, lethargy, ataxia, slurred speech, diaphoresis, HTN, nystagmus, mydriasis
Dextromethorphan MOA/Background
- Even higher doses yield effect (dissociative anesthetic) similar to that of PCP (angel dust) or Ketamine (Special K) – usually seeking these effects when abusing the drug
- Treatment of OD: naloxone, although efficacy is questionable
Loperamide
-OTC medication to treat diarrhea
-Intestinal mu-opioid
-High doses can cross BBB
-Multiple drug interaction
Cardiac arrhythmias, respiratory depression, and CNS depression
-FDA & manufactures working to limit quantities
General Approach to tx of opiate use
- Buprenorphine, methadone, clonidine, lefexidine, naloxone
- Fluid replacement
- Other supportive care measures
Opioid Tx: Methadone (OTP)
- Mu-opioid agonist: suppresses withdrawal symptoms and controls cravings in maint. Therapy
- Initial dose 10-30 mg/day; reassess in 2-4 hours (>30 mg/day, watch for sedation)
- Age > 60 yo, limit initial to 10-20 mg/day
- Common dose 60-120 mg/day
- Drug interactions: QTc prolonging medications, CYP inducers, alcohol, benzodiazepines
Opioid Tx: Naltrexone
-Mu-opioid antagonist
Oral tablet & Extended-release injectable
-FDA approved following opioid detox and help prevent relapse
Opiate Tx: Buprenorphine
- Partial mu receptor agonist; lipophilic (long half-life)
- Provides some pain control; ceiling effect for respiratory depression (except with alcohol & benzos)
- Blunts full agonist activity of heroin or other opioids.
- Should be offered to OUD patients who are “appropriate candidates”
Opiate Tx: Naloxone
-Imperative!
-Competitive mu-opioid receptor antagonist
-Reversal of opioid overdose
IV, IM, SQ, IO, IN
IV: 60 seconds; IN 2-5 minutes
-Duration: depends on opioid that has been used
-Can be administered by nonmedical bystanders
-Okay to use if unknown opioid overdose & combo of products (low risk of s/e)
Benzodiazepines/Sedative-Hypnotics
- Intoxication: acute distress in OD or if combined with alcohol
- Withdrawal: acute distress – treat with taper to minimize seizure risk
- Intox Symptoms: memory impairment, drowsiness, visual and GI disturbances, confusion. -May appear intoxicated. Hypotension, nystagmus, urinary retention may also occur
Withdrawal of Benzos/sedatives/hypnotics
-Nervousness, sweating, trembling, HTN, Tachycardia, weakness, tremors, seizures
Tx of acute intoxication of benzos
Flumazenil 0.2 mg IV/min, repeat up to 3 mg max (0.3 mg, then 0.5 & repeat)
Benzo withdrawal strategies
- Taper over 4-8 weeks, sometimes longer
- Reduce daily dose 10-25% every 2 weeks (decrease risk for seizures)
- If multiple benzos used, might convert to one and then taper (diazepam)
- Can still see effects for several weeks after d/c drug (insomnia, anxiety, muscle spasms)
Cocaine
-CNS stimulant – block reuptake of catecholamine neurotransmitters such as NE and dopamine
-Excess dopamine leads to psychostimulant properties, psychotic behavior, high rate of addiction
-Rapidly absorbed
Inject, smoking, snorting
-Duration: 5-30 minutes, decreases with continued use
Amphetamine, Methamphetimes
- “speed” “meth” “crank” on the street
- “ice” “crystal” “glass” – HCL salt, looks like ice and inhaled by smoking
- Increase NE and dopamine activity by increasing release and inhibiting MAO
- Effects: diminish fatigue, increase alertness, suppress appetite.
- Higher doses = behavior changes, perception disturbances, psychosis
- Manufactured using ephedrine or pseudoephedrine reduction method (chemistry)
Ecstasy, Meth analogs
- Mildly hallucinogenic
- Effects last 4 – 6 hours
- Positive feelings, empathy, decreased inhibition with socialization
- Other effects: depression, irrationality, psychosis, physical symptoms
- Suppress need to eat, sleep, drink = 2-3 day parties
Tx of cocaine and other stimulants
- Lorazepam 2 – 4 mg IM q 30 minutes to 6 hours as needed for agitation
- Haloperidol 2 – 5 mg (or other antipsychotic agent) IV/IM q 30 min to 6 hours as needed for psychotic behavior
- Monitor cardiac function
Alcohol BAC%
- 0.07-0.09(15-21) Slight impairment of balance, speech, vision, reaction time. Memory, reason, caution impaired
- 0.10-0.125 (22-27) Sig impairment of motor coordination, loss of good judgment. Speech slurred; balance, vision, reaction, hearing impaired
- 0.13-0.15 (28-34) Gross motor impairment and lack of physical control. Blurred vision, loss of balance. Euphoria is reduced, dysphoria
- 0.3 (65) Loss of consciousness
- ≥0.4 (>87) Onset of coma, death due to resp depression
Alcohol Withdrawal
- Multiple Vitamin 1 daily until eating well
- Thiamine 50 – 100 mg daily x 5 days (min)
- Fluids
- Clonidine oral or transdermal for autonomic tone rebound and hyperactivity
- Labetalol for HTN urgencies
- Antipsychotics for agitation unresponsive to benzos, hallucinations, delusions
- Benzodiazepines for tremor, anxiety, diaphoresis, tachypnea, dysphoria, seizures
- —Diazepam 10-20 mg q1-2 hours
- —Chlodiazepoxide 100 mg q1-2 hour
Alcohol dependence
- Disulfiram – produces adverse reaction if pt drinks
- Naltrexone – thought to attenuate the reinforcing effects of alcohol
- Acamprosate – reduces alcohol craving; modulates NMDA receptor
- Anticonvulsants – reduces craving
- Antidepressants – reduces craving, treats concomitant depression & anxiety
y-Hydroxybutyrate
- Also known as GHB
- Characterized as a date rape drug (like flunitrazepam – Rohypnol®)
- Toxicity – coma, seizures, resp depression, vomiting. –Also known to cause amnesia, hypotonia, abnormal sleep, anesthesia.
- Doses > 50 mg/kg may ↓ cardiac output
- Can give naloxone and repeat 5x (2mg)
- Thiamine 100mg
- IV fluids
- Observe for brady, hotn, low o2 sats, arrhythmias
