Substance Use Disorder Flashcards
Goals of TX :
1. Treat __ and __ where possible
2. reduce ___
3. Reduce ___ disorders (secondary illnesses)
4. Prevent ____
5. Improve ____
6. Minimize ____
7. Prevent or reduce ___ and ___ of ___
- Intoxication, withdrawal
- innapropriate use
- substance induced
- death from the substance
- QOL
- Ae’s of tx
- severity, frequency , relapse
Opioid Physio Effects : Intoxication
1. D, S, I, C, I, E or A
TOXICITY:
2. S, B, H , E , C, F
WITHDRAWAL
3. D, N or V, M, L or R, P, P, or S, D, Y, F, I , A, R , A
- Drowsiness, slurred speech , impairment in attention or memory , constricted pupils (miosis), itching, euphoria, agitation
- Shallow, slow respirations,
Bradycardia , hypothermia, excessive drowsiness, coma, FATAL OVERDOSE - Dysphoric mood, N/V, Muscle aches, lacrimation , rhinorrhea, pupillary dilation, piloerection , sweating, diarrhea, yawning, fever , insomnia, autonomic hyperactivity , restlessness, anxiety
TX ALGORITHM :
1. If they’re intoxicated/experiencing toxicity … whats first line?
2. If they’re experiencing withdrawal/use disorder, whats first line? and whats supportive therapy ?
- Naloxone
- Buprenorphine +/- naloxone, Methadone, Naltrexone –> CLonidine Or lofexidine
Naloxone :
1. MOA?
2. Onset ?
3. Dose? IM/Nasal spray
4. Administration?
- What formulations are available of naloxone? (4)
- WHich version is FDA approved for OTC?
Kim , know how to give narcan
- Opioid receptor antag
- < 5 mins
- IM 0.4-2mg
Nasal spray : 2-8 mg (depends on product) - Can repeat eevry 2-3 mins PRN (IM has longest duration)
-Continue dosing until patient is breathing or max dose is reached - IM injections (vials), IM injections (Zimhi) which are prefilled syringes, Intranasal spray , Intrananasal spray (atomizer)
- Narcan 4mg
Symptomatic Management of Opioid Withdrawal:
1. Insomnia
2. HA, muscle aches, pain :
3. Abdom cramps
4. Diarrhea
5. N/V
6. Noradrenergic Hyperactivity
- trazodone prn
- tylenol and or ibuprofen
- dicyclomine
- loperamide PRN
- Zofran PRN
- CLonidine , Lofexidine
Clonidine :
1. MOA?
2. Off label for management of ?
3. Onset ? duration ?
4. Monitor for?
5. Precautions ? (2)
Lofexidine :
1. MOA?
2. FDA approved indications?
3. Onset?
4. Duration ?
5. warnings/precautions? Discontinue agent over? (4)
- alpha 2 agonist
- autonomic hyperactivity secondary to opioid withdrawal
- 0.5-1hr, until withdrawal sx’s resolve
- withdrawal sx’s and BP/HR, QTc interval
- CNS depression, avoid abrupt discontinuation after 6-10 days of use
- alpha 2 agonist
- opioid withdrawal sx’s in adults
- 3-5 hrs
- 5-7 days after last opioid use (up to 14days)
- Hypotension, syncope, dizzy , sedation
-QT prolongation
-CNS depression
-Discontinue agent over 2-4 days
Medications for Opioid Use Disorder (MOUD) :
1. Buprenorphine +/- Naloxone
-MOA?
2. Formulations?
3. Onset ?
4. Metab?
5. Can precipitate ___, dosing is typically started when ?
- Partial mu opioid R agonist.
-COmbined w/naloxone to decr misuse if crushed/injected - PO/SL (w. and w/o naloxone)
-SQ (weekly-Brixadi and monthly-Brixadi+Sublocade) - 20-40 mins (po), 24 hrs SQ
- Hepatic, CYP3a4 and UGT
- opioid withdrawal
-after withdrawal starts
Buprenorphine AE”s:
1. Warnings and Precautions for :
-C, Use in pre existing ___, H, H, H, Q, REMS REQUIREMENTS !
- Adverse effects:
-With SL formulation ?
-Oral ___
-C, N
-___ depression
-____ syndrome
-S
- CNS depression
-Hepatic dysfunction
-Hepatic events (hepatitis)
-Hypersensitivity events
-Hypotension
-QTc prolongation - Dental ae’s such as dental carries, tooth decay
-Hypoesthesia
-Constipation , nausea
-Respiratory
-Withdrawal
-Sweating
MOUD : Methadone
1. MOA?
2. Peak onset ?
3. Dosed how often for OUD?
4. Metab through ?
5. CI’s ? (4)
6. Warnings/Precautions BOXED warnings ?
7. AE’s (5)
- Full mu opioid receptor agonist
- 2-4 hrs
- daily
- Hepatic via CYP enzymes (So be weary of patients who have hepatic impairment)
- Respiratory depression , bronchial asthma, GI obstruction, hypersensitivity
- Abuse, misuse
-Respiratory depression
* QT prolongation (avoid in QTc
> 500msec)
* Neonatal opioid withdrawal
syndrome
* CYP interactions 3A4, 2B6, 2C19, 2C9, or
2D6
* Risk with concomitant CNS depressants
* Medication errors with oral solution (1mg/ml, 2mg/ml)
* Serotonin Syndrome
* Severe hypotension - Sweating , orthostasis, constipation , cns depression, pruritis, rash, urticaria
Naltrexone :
1. MOA
2. Indication ?
3. Biphasic release pattern so onset is?
4. Duration
5. Contraindications:
H, P, F, C, P, Patient must be off all opioids for ?
In ___
- Warnings :
-__ thoughts/depression
-__ disorders
-___ impairment (Avoid in this state or __)
-___ impairment (use w/caution in mod to severe ) - AE’s :
Accidental ___ after naltrexone discontinuation
H
I
Naltrexone precipitated ___
S
GI upset (such as)
A, D, H, I , M
- Full opioid receptor antag
- prevention of relapse to opioid dependence following withdrawal
- 2hrs and 2-3 days
- 4 weeks
- Hypersensitivity , physiologic dependence on opioids, failure to pass naloxone challenge, , current use of opioid analgesics (including buprenorphine) , positive Urine tox for opioids,
7-10 days
-Acute opioid withdrawal - SUicidal
-Bleeding
-hepatic (failure)
-renal - opioid OD .
Hepatotoxic, inj site rxns , opioid withdrawal, syncope, (Abdom pain, decr appetite, diarrhea, N/V)
Anxiety, Dizzy, HA, Insomnia, Muscle aches
Special Populations :
1. Adolescents : What drug is approved?
What drug can be used w/parental approval?
Should incorporate ???
- Elderly : what 2 drugs can u use?
- Pregnancy/Lactation : What drugs can u use? (2)
NON pharm :
4. Psychosocial support such as?
5. Harm reduction supplies such as?
- Burprenorphine (18), used in those as young as 16
- Methadone
-Non pharm approaches - Buprenorphine and Methadone (monitor closely)
- Buprenorphine
-Easier admin and initiation. Lower risk of OD. Potentially milder neonatal abstinence syndrome (NAS)
Methadone : is standard of care. Admin IN CLINIC! Many CYP interactions. OD potential.
- Recovery support services, case management, specific social needs assistance. CBT.
- Narcan, fentanyl test strips , syringe exchange
Sedative Hypnotics :
1. Intoxication sx’s?
M, I, A, I, D, V, C, S, U, U, I ,S or C
- Withdrawal sx’s:
A. Behavioral and Psych ?
A,A,S,R,D,I,P,D,D,C,P,C
B. Pyshical sx’s?
T, S, N/V, S, Incr __, H, I or T, S, P, F
- Mood changes and lability
Impaired decision making
aggression
innaprop sexual behaviors
Drowsy
visual disturbances
confusion
Slurred speech
uncoord movements
unsteady gait
invol eye movement
stupor or coma - anxiety
* agitation
* sleep disturbances
* restlessness
* depression
* irritability
* psychosis
* delirium
* derealization
* confusion
* perceptual disturbances
* cognitive disturbances
B. tremors
* sweating
* Nausea/vomiting
* shortness of breath
* increased BP/HR
* headache
* involuntary muscle movements or twitching
* Seizures common, particularly in the setting of abrupt cessation
* psychomotor agitation
* “flu-like” symptoms
CANNABIS :
3. Acute effects?
4. Chronic ?
5. Withdrawal?
STIMULANTS :
1. Acute ?
2. Chronic?
3. WIthdrawal ?
- Well being feeling, relaxed, friendly, slowed cognition, panic, delirium and psychosis (highdose)
- Amotivation . Poor attention span, judgemnt, and communication . Distractibility, Loss of insight, Hyperemesis syndrome
- Anxiety, dysphoria, sleep changes, anorexia, HA, tremors, chills, irritability
- Euphoria, alertness, incr energy, Decr appetite, weight loss, Bruxism, tremor, anger, grandiosity
- Malnutrition, paranoia, dental carries, cardio effects /fatal OD
- Fatigue, vivid dreams, intense cravings, anxiety and agitation, anhedonia, hypersomnolence
Dissociatives (Ketamine): Effects
1. Acute
2. Chronic (2)
3. OD
Hallucinogens : Effects
1. ACute V.H.D.A.B.I, F, B
2. Chronic
- Euphoria, altered time perception, dissociation
-Hallucinations, delusions, paranoia
-Delirium, amnesia
-Autonomic hyperactivity
-Analgesia
Vertical nystagmus - Prolonged delirium/amnesia
-Isolation - Coma, extremely high temp, seizures, muscle breakdown
- Visual trails, heightened sensations , depersonalization, derealization, autonomic hyperactivity , bruxism, impaired judgement, feeling of losing one’s mind
bad trip (panic attack) - Flashbacks
