Substance Use Disorder Flashcards
Bio markers of alcohol abuse -
CDT
GGT
To use with other data eg clinical interview, but labs could be motivators to patients
GGT- increases after weeks of consumption - high sensitivity, elevated in those dx’d with alcohol dependence, but false posibitives because may be elevated from obstructive liver dz or taking anticonvulsants
CDT- protein increases after weeks of drinking due to impairment of glucosulation of transferrin, may be earlier indicator
Brain pathway of substances of amuse
Mesolimbic reward pathway
Originates in ventral tegumental area (VTA) and projects to the nucleus accumbens (NA)
Other bio markers of alcohol use
Ast
Alt
Mcv
Def of alcohol abuse
Maladaptive pattern of use associated with recurrent substance related adverse consequences
- after dependence is ruled out
Alcohol dependence
Characterized by cognitive, behavioral, physiological symptoms indicating patient continue to use despite problems
- chronic relapsing d/o
Order of glucose, thiamine
Give thiamine (B1) FIRSt before glucose B1 - b4 glucose :)
Goals for alcohol withdrawal tx
1) complete detox and reduce sx
2) keep pts safe and comfortable
Pharmacotherapy of alcohol withdrawal
Benzodiazepines are first choice for managing and minimizing alcohol withdrawal sx
Cross tolerance between EtOH and BZD
BZD critical UBS preventing progression to more severe stages of alcohol withdrawal including delirium and seizure activity
Naloxone
For acute opioid intoxication
0.4-2mg IM or IV every 2-3 min til breathing or total dose of 10mg given
Registration for opioid agonist use
FDA approved - bup and naloxone for withdrawal and long term relapse prevention
Programs must be registered with
CSAT Center for substance abuse treatment
SAMHSA - substance abuse and mental health services administration
Standards for pt admission criteria
Methadone - only opioid tx programs
Buprenorphine - qualified physicians with X DEA number can treat up to 30 pts first year after certified and up to 100 pts thereafter first year after notifying CSAT
Methadone
Single dose 20-30 mg
Titrate dose by 10-20 mg daily to suppress major withdrawal sx
Usual doses 40-60mg for withdrawal
Maintenance dosing - 80-120 mg/day
No reliable relationship between serum concn and outcomes
Variable pk, half life 24-36 hrs
QT prolongation so be careful about meds that affect electrolyte concn
- if QT > 500msec consider dc or reduce dose
3a4 inhibitors increase effects
So be
Buprenorphine
Ceiling effect becaus of partial agonist
So if incomplete effect - may have to switch to full agonist (methadone)
Injection not use for opioid tx
With naloxone - for outpt
Usually without naloxone only for Inpt opioid wigrdrawl
Combined with naloxone to prevent abuse potential if crushed or injected
Death with injected benzo has results
Duration 24 hrs plus because of strong affinity for receptor
Also decreass effect of other opioid for this
Clonidine
Alpha agonist
Treats sx of withdrawal not withdrawal craving
Tx NV diarrhea cramps sweating
Other adjunctive drugs for opioid withdrawal
Loperamide for diarrhea Compazine for NV Trazodone for insomnia Hydroxyzine for anxiety Ibuprofen for cramps
Fagerstrom test for nicotine dependence
How soon after awake du you have first cigarette? 0-3 pts, within 5 min =3 pts
Do you find it difficult to avoid smoking where forbidden (1 pt)
Which cigarette would be most difficult to give up? Morn=1 pt all others zero
How many cigs per day? 0-3 - 31 or more is 3 pts
Do you smoke more in first hours of day? 0 no, yes 1
If you are so ill you spend day in bed, do you still smoke? 1=yes
Scoring:
0-2 very low
3-4 low
5 moderate
6-7 high
8-10 very high
5 A’s of nicotine dependence tx
Ask Advise Assess Assist Arrange
Pharm tx of nicotine dependence
All first line: bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch,
Second line options: clonidine an nortriptyline
Moa of varenicline
Partial neuronal alpha 4 beta 2 nicotinic receptor agonist
May prevent nicotine related dopamine release in Mesolimbic pathway
Varenicline dose
Days 1-3 0.5mg once daily
Days 4-7 0.5 mg twice daily
Quit smoking on day 8
ADRs are GI dose related nausea, CNS headache insomnia abnormal dreams
Must be renally adjusted crcl <30 ml/min to half dose (0.5mg qday)
CV risks - angina and nonfatal MI
Pregancy and NRT
Nicotine replacement is D
Varenicline is C
Naltrexone
FDA approved for tx of alcohol dependence
Oral and ER IN injecting susp monthly
Combine study showed benefit
25mg test PO dose
50mg PO qday or 380mg q4w
Don’t begin tx till pt opioid free for 7-10 days
Completely absorbed
ADR include GI nv decr appetitecns ha anxiety depression
Hepatotoxic at doses >100-300mg/day
Mu antagonism blocks pleasure effects, in part for to decrease DA release to nucleus accumbens
Acamprosate
Mixed results Review by Garbytt et al positive Combine study - didnt do well 666m tid NMDA blocker and GABA activator, possible restore GABA glut balance Renal dose crcl 30-50 adjust to half tid Crcl < 30 contraindicated ADR GI psych- CNS insomnia depression
Downside of symptom based dosing EtOH withdrawal
More monitoring and personnel req
Disulfiram (Antabuse)
Load with 500mg qday for 1-2 weeks , or start right with 250mg qday Ses Disulfiram rx's- sweating nv anxiety dizziness - till 14 days post dosing Lft Vision changes Neuropathic a Psych sx eg psychosis Contraindicated w metronidazole
