Substance Use Disorder Flashcards
DSM-5, TR substance use disorders
- the DSM-5 deletes the terms “ ___ “ and “ ___ “
- criteria are applied to 10 different drugs/drug classes
- abuse
- dependence
DSM-5, TR SUD
__ of the following, occuring in a 12 month period
2
risk of setbacks
- greatest during the ___ years of treatment
- more than likely in first ___ months of abstinence
- majority will be able to maintain complete or partial remission
- 15-20% pattern of chronic relapse
- 90% of those abstinent at ___ years
- > 90% of those abstinent at 10 years will be abstinent at 20 years
- first
- 12
- 10
treatment principles
- a person with SUD is ___ recovering, never recovered
- long term treatment is necessary to reduce risk of setback
- no one is perfect, setbacks are possible, have to work on ___
- patient must be engaged in treatment, significant work by both treatment providers and patient to maintain abstinence
- treatment providers must be non-judgemental
- treatment includes pharmacotherapy and psychotherapy
- individual or group treatment
- always
- self-esteem
Blood Alcohol Concentration
___ mg/dL ( ___ mg%)
- moderate impairment, legal definition of intoxication in most states
80, 0.08
stages of alcohol withdrawal
stage 1: 6-8 hours
- moderate autonomic hyperactivity
stage 2: 24 hours
- autonomic hyperactivity with ___ and ___ hallucinations
stage 3: 1-2 days
- 4% of those untreated develop grand mal seizures 7-48 hours after drop in BAC
stage 4: 3-5 days
- ___ (DTs) in 5% of patients (confusion, illusions, hallucinations, agitation, tachycardia, hyperthermia)
- auditory, visual
- delirium tremens
risk factors for delirium tremens
- prior history of DTs = higher risk of developing DT again (kindling)
- number of detoxifications
- consuming equivalent of 1 ___ of whiskey per day for 10-14 days prior to admission
- early symptoms of withdrawal
- ___ dysfunction
- pint
- hepatic
CIWA-AR
clinical institute withdrawal assessment
treating alcohol withdrawal
BZDs
no liver dysfunction: ___ / ___
- long t1/2 and decrease risk of breakthrough symptoms
- may also use ___ and ___ without liver dysfunction
liver dysfunction
- ___ and ___
diazepam, chlordiazepoxide
- lorazepam, oxazepam
- lorazepam, oxazepam
other treatment considerations
___ !!!
- always recommend if any suspicion of alcohol use
- dose: 100 mg daily, usually for duration of hospital stay, may be given after discharge, not considered long term-treatment
carbamazepine
- may be effective for mild/moderate symptoms
- unclear if prevents seizures of DT
valproic acid
- may reduce severity of alcohol withdrawal symtoms, including seizures
phenytoin
- not effective to treat withdrawal seizures, but will see patients taking months or years out from withdrawal seizures - d/c??
Thiamine
Wernicke’s encephalopathy
- result of ___ deficiency - co-factor in glucose metabolism
- wernicke can be precipitated by high ___ loads
- give before ___ containing fluids
korsakoff;s psychosis
- chronic
- treat with antipsychotics
- thiamine
- glucose
- dextrose
Disulfiram (Antabuse)
- ___ therapy
- unpleasant effects if alcohol is used (flushing, nausea, vomiting, tachycardia)
- potential for cardiovascular collapse, death
- must have highly ___ person
- monitor LFTs
- ___ mg daily usual maintenance dose
- disulfiram reaction for up to ___ days after d/c
- aversivemotivated
- 250 mg
- 14
so sensitive that hand sanitizer could set off topical reaction
Acamprosate (Capral)
- maintenance of ___
- ___ elimination, monitor function, avoid in severe impairment
- ___ warning, SE also include diarrhea, nausea, depression, anxiety
- ___ mg tabs - 2 tabs, TID
- is safe to take is person uses alcohol
- clinical effectiveness is limited by the number of tablets and doses per day
- abstinence
- renal
- suicidal
- 333
Naltrexone
- clinical trails show best response to naltrexone over acamprosate in combination with psychotherapy
- available in oral in IM doses
- decreases ___ drinking, helps to increase ___ between drinking days
- elevated ___ common, must monitor at baseline and routinely
- need to evaluate ___ management needs, patient should have wallet card or be able to tell emergency providers that they are taking this
- oral dose - 50 mg once daily
- IM dose = 380 mg IM every 4 weeks, brand only, so very expensive
- warning for injection site reactions
- binge, time
- LFTs
- pain
treating opioid withdrawal
symptoms/treatment
- muscle aches/tension = ___ or ___
- ___ = hydroxyzine/BZDs
- abdominal cramping/N/V = ___
- ___ = loperamide
- sweating, yawning, tearing, runny nose = ___ or ___
- acetaminophen or NSAIDs
- agitation, anxiety, insomnia
- ondansetron
- diarrhea
- clonidine, lofexidine
lofexidine is FDA approved for treating opioid withdrawal
treating opioid withdrawal
- short-term tapering doses of opioids or buprenorphine may be used in the ___ period
- buprenorphine should not be initiated until ___ - ___ hours after the last use of short-acting opioid (heroin or oxycodone) and ___ - ___ hours after the last use of methadone
- withdrawals
- 12-18, 24-48
use of a2 agonists for opioid withdrawal symptoms
- noradrenergic ___ causes many of the opioid withdrawal symptoms, leading to an increased risk of setback
- treating noradrenergic symptoms can serve as an entry to longer-term treatment with MOUD and psychosocial treatment
- craving is thought to be mediated by the mesolimbic reward pathway; physical withdrawal symptoms mediated by the locus coerulus
- ## hyperactivity
use of a2 agonists for opioid withdrawal symptoms
clonidine
___ - ___ mg/day (mild withdrawal)
up to ___ mg/day (severe withdrawal)
divided doses (0.1-0.2 mg/dose) given hourly
SE
- hypotension, less likely with ___
0.3-0.6
1.2
0.1-0.2
lofexidine
use of a2 agonists for opioid withdrawal symptoms
lofexidine (0.18 mg tabs)
dosing: ___ mg (3 tabs) QID x 5-7 days
- max dose: ___ mg/day (16 tabs)
- no single dose above __ mg (4 tabs)
- may continue for up to ___ days
- dosing adjustmnt in renal and hepatic impairment
- 0.54
- 2.88
- 0.72
- 14
ASAM - american society of addiction medicine
- pregnant women should be screened for OUD in prenatal care and offered ___ or ___ ; limited data for naltrexone
- incarcerated people of OUD shoud be screened and offered treatment; should NOT be required to switch meds if entering incarceration in meds
- combo treatment with opioids and ___ is not recommended due to increased risk of fatal overdose
- methadone, buprenorphine
- BZDs
maintenance treatment of opioid use disorders
- methadone and buprenorphine are the oral drugs used for ___ treatment
- ___ must be given in a licensed treatment program
- ___ is usually given in combination with naloxone in a sublingual tablet/film strip dosage form; poor bioavailability when swallowed, must be ___
- X-waiver removed
- maintenance
- methadone
- ## buprenorphine, sublingual
methadone treatment pearls
- ___ t 1/2 - once daily dosing is appropriate for use in methadone clinical or opioid treatment programs
- ___ slowly to dose that minimizes withdrawal symptoms, but does not provide euphoric effect
- witnessed dosing, patients must “earn” take-home bottles
- urine tox screen should be positive for methadone, generally negative for everything else
- CYP 2B6, ___ , 2C19, 2D6 substrate; use in caution in patients also taking moderate to strong inhibitors/inducers
- ___ prolongation is a serious concern - ECG monitoing is recommended
- long
- titrate
- 3A4
- QTc
buprenorphine clinical pearls
- given with ___ in same dosage form to decrease ___ - naloxone is not absorbed through the GI tract, so no effect if taken sublingually, but if injected, it will block effected of buprenorphine
- to avoid precipitating withdrawal, initiaite therapy when there are clear signs of withdrawal; adminiter in divided doses on day 1
- available in ___ films and tabs, must be dosed this way due to lack of gastric absorption
- ___ substrate - monitor closely when used with inducers.inhibitors
- monitor ___; use with serotonergic drugs may cause ___ syndrome
- risk of ___ depression in overdose is musch less than with opioids, including methadone, due to partial ___ effect
- naloxone, misuse
- sublingual
- 3A4
- LFTs, serotonin
- respiratory
- agonist
buprenorphine extended-release injections
- ER injection (Sublocade, Brixadi)
- moderate-severe OUD, patients initiated on sublingual buprenorphine and dose adjustment for at least __ days prior to first injection
- monitor for use with ___ drugs; risk for ___ syndrome
- 300 mg abdominal subQ injection every 4 weeks x 2 doses, then 100 mg every 4 weeks maintenance dose
- REMS
- ___ substrate - watch inducers/inhibitors
- 7
- serotonergic, serotonin
- 3A4
which to choose?
methadone
- clinical proof of efficacy
- FDA-approved for use in ___
- treatment program requires daily ___ unless patient graduates to “take-home” bottles
- must give urine samples and attend programming
- indiana ___ covers under medical billing
- stigma of program
- is there a program in the area?
- transportation?
- pregnancy
- attendance
- medicaid
which to choose?
buprenorphine
- effective treatment over ___ -term, longer-term clinical trials lacking
- office-based, can get __ -day Rx
- less stigma
- less ___ potential over methadone
- indiana ___ covers
- removal of X-waiver prescribing requirement may increase access
- short
- 30
- misuse
- medicaid
naltrexone long-acting injection (Vivitrol)
- given in same dose as that used for ___ use disorder
- is the “___ “ treatment, patients must be ready for this, discuss with patient about readiness to encourange
- risk for ___ if patient d/c treatment, must inform pt of this risk
- concern in OUD for patients trying to “overcome” opioid receptor blockade with ___ doses of opioids
- must inform pt about pain management issues - need to let providers know if injured or in need of acute pain management
- alcohol
- abstinence
- overdose
- higher
naloxone kits
- pharmacies allowed to dispense naloxone kits without prescription
- FDA approved OTC naloxone ( ___ , 4 mg)
Narcan
other substances - treatment
- no FDA approved drug therpies to treat addiction of cocaine, amphetamines, bath salts, K2, maijuana, etc
- psychosis that results from either K2/spice or bath salts intoxication is not generally responsive to treatment with ___
- K2/Spice or bath salt deaths caused by cardiovascular collapse, hypokalemia, and seizures
- use of ___ to treat hypertenition in cocaine intoxication is controversial
- ___ due to substance withdrawal is common - may last for months after d/c use of cocain - treat like clinical depression
- antipsychotics
- BB
- depression
therapies under investigation
- ____ has a growing body of clinical literature that supports use in SUD involving many different substances
- ondansetron, baclofen, topiramate, olanzapine, gabapentin, and sodium oxybate may be useful for ___ use disorder
- bupropion, topiramate, amphetamin-based stimulants (as replacement therapy) have been studied for ___ and ___ misuse
- ___ for heroin dependence
- N-acetyl cysteine
- alcohol
- amphetamine, cocaine
- scopolamine
