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Pharmacology > Substance Use Disorder > Flashcards

Substance Use Disorder Flashcards

1
Q

Opiates Withdrawal

A
  • 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
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2
Q

Opiates Withdrawal timing

A
  • 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
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3
Q

Methadone

A
  • 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)
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4
Q

Methadone Withdrawal

A
  • 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
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5
Q

Heroin

A
  • 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
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6
Q

Heroin background

A

“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
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7
Q

Fentanyl

A
  • 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
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8
Q

Dextromethorphan

A
  • 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
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9
Q

Dextromethorphan MOA/Background

A
  • 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
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10
Q

Loperamide

A

-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

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11
Q

General Approach to tx of opiate use

A
  • Buprenorphine, methadone, clonidine, lefexidine, naloxone
  • Fluid replacement
  • Other supportive care measures
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12
Q

Opioid Tx: Methadone (OTP)

A
  • 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
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13
Q

Opioid Tx: Naltrexone

A

-Mu-opioid antagonist
Oral tablet & Extended-release injectable
-FDA approved following opioid detox and help prevent relapse

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14
Q

Opiate Tx: Buprenorphine

A
  • 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”
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15
Q

Opiate Tx: Naloxone

A

-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)

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16
Q

Benzodiazepines/Sedative-Hypnotics

A
  • 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
17
Q

Withdrawal of Benzos/sedatives/hypnotics

A

-Nervousness, sweating, trembling, HTN, Tachycardia, weakness, tremors, seizures

18
Q

Tx of acute intoxication of benzos

A

Flumazenil 0.2 mg IV/min, repeat up to 3 mg max (0.3 mg, then 0.5 & repeat)

19
Q

Benzo withdrawal strategies

A
  • 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)
20
Q

Cocaine

A

-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

21
Q

Amphetamine, Methamphetimes

A
  • “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)
22
Q

Ecstasy, Meth analogs

A
  • 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
23
Q

Tx of cocaine and other stimulants

A
  • 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
24
Q

Alcohol BAC%

A
  • 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
25
Q

Alcohol Withdrawal

A
  • 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
26
Q

Alcohol dependence

A
  • 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
27
Q

y-Hydroxybutyrate

A
  • 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

Pharmacology (24 decks)

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