Substance Use Disorder Therapeutics Flashcards
Substance Use Disorder DSM 5
Clinically significant impairment or distress manifested by at least two of the following in a 12 month period:
Substance taken in large amounts over longer period of time than intended, persistent desire or unsuccessful effort to cut down, great deal of time spent obtaining substance, strong cravings, continued use despite worsening problems, giving up other activities for drug and use continued despite knowing their is a problem
Best option(s) for Nicotine use disorder
Pharmacotherapy shows highest levels of success
Verenicline or combination of NRT patch with faster acting form give optimal results
Consider NRT for smoking reduction
First line Nicotine UD drugs
NRT (patch, gum, lozenge, spray, inhaler)
Bupropion (zyban), Verenicline
Second line Nicotine UD drugs
Nortriptyline, Clonidine
more ADEs
NRT common ADEs
All formulations: blurred vision, dizziness, headache, nervousness, pounding in ears
Patch: abnormal/vivid dreams, skin irritation
Nasal spray: irritation, burning, runny nose, watery eyes
Inhaler: airway irritation
Gum/lozenge: mouth sores, sore throat
Serious AEs: Tachycardia (monitor HR, BP), arrhythmia, anaphylaxis
NRT counseling points
Park gum
Do not chew or swallow lozenge
Remove patch before MRI
Patch is disposable (fold ends together and discard in garbage, do not cut)
Why is it bad to cut the nicotine patch? Additional useful information about the patch?
Causes rapid evaporation of nicotine
Remove patch before bedtime if patient experiences night time issues
Patch may be worn 16-24 hours (if left on longer, will cause skin irritation)
Verenicline as Nicotine UD drug
Partial agonist at a4b2 nicotinic receptors
Monitor patient for true abstinence and renal function
Common AEs: NV, flatulence, constipation, dream disorder, headache and insomnia
Rare and Serious AEs: angina, MI, CVA, visual disturbances, hostility, mood changes, suicidal ideation, seizures
Drug-Drug Interactions: bupropion, ethanol
Counseling: take after eating and with full glass of water, limit alcohol
Black Box Warning for Verenicline
CAUTION USE IN PSYCH PATIENTS (may worsen psychiatric symptoms)
Bupropion as Nicotine UD drug
Inhibits neuronal uptake of DA and NE
Monitor abstinence from tobacco, renal function, BP and psychiatric/neuro reactions
Common AEs: tachyarrhythmia, constipation
Serious AEs: cardiac dysrhythmia, seizure, depression, mania, psychotic disorder, suicidal thoughts
Drug-Drug Interactions: MAOIs, metoclopramide, methylene blue, linezolid
Counseling: avoid bedtime dosing due to insomnia, BID doses take 8 hours apart, skip missed dose
Contraindications for Bupropion
abrupt discontinuation of alcohol, benzos, barbs, antiepileptic drugs, MAOI use within 14 days, prior/current diagnosis of bulimia or anorexia, seizure disorder
Nortriptyline for Nicotine UD
TCA (inhibits serotonin and NE reuptake, also blocks H1 and a1)
Metabolized by 2D6
Monitor abstinence from tobacco, ECG (if cardiac diagnosis or hyperthyroidism), behavior changes, suicidal ideation
Common AEs: Constipation
Serious AEs: CV stuff, bone marrow suppression, hepatic failure, suicidal ideation
Drug-drug Interactions: QT prolonging agents, MAOIs, methylene blue, linezolid, metoclopramide
Contraindications with Nortriptyline
Use within 14 days of MAOI, use with linezolid or IV methylene blue, during acute recovery of MI
Clonidine in Nicotine UD
Centrally acting alpha 2 agonist
Dose usually 0.1 mg PO BID (if BP under 90/60, skip next dose; lower initial dose in renal impairment)
Monitor BP, HR
Common AEs: contact dermatitis, erythema, xerostomia, HA, dizziness, sedation
Drug-drug interactions with other antihypertensive drugs
Counseling: do not abruptly discontinue (rebound HTN), may cause somnolence
Nicotine patch dosing guidelines
if less than 10 cigs/day (21 mg patch x6 weeks, 14 x2 weeks, 7 x2 weeks)
If 10 or more/day (14mg patch x6 weeks, 7mg x2 weeks)
Nicotine gum or lozenge guidelines
if more than 10 (4mg gum/lozenge 1 piece q1-2h for 1-6 weeks, then 1 piece q2-4h for 7-9 , then 1 piece q4-8h for weeks 10-12)
If less than 10 use 2 mg lozenge
Bupropion dosing regimen
Begin 1 week before quit date (start 150mg/day for 3 days, then increase to 150 bid at interval of 8 hours - max dose is 300/day)
Verenicline dosing regiment
Begin 1 week before quit date (0.5mg for 1-3 days, then 0.5 BID for days 4-7, then 1 mg BID for 12 weeks)
Nortriptyline dosing regimen
Begin 1 week before quit date (75-100mg daily for 6-14 weeks)
Acute/mild alcohol withdrawal
Usually occurs within first several hours of cessation
Symptoms: anxiety, irritability, GI distress, increased BP and HR
Generally supportive care, close monitoring, thiamine is sufficient
Severe withdrawal
Can occur up to several days after cessation
Symptoms: decreased attention, disorientation, hallucinations, tremor, tonic-clonic seizures, respiratory alkalosis, fever, alcohol withdrawal, delirium/delirium tremens
Benzos are primary treatment (Lorazepam, chlordiazepoxide, diazepam, oxazepam)
Thiamine should be given (to prevent Wernicke-Korsakoff syndrome)
Adjunct therapy: CBZ for withdrawal seizures, Beta blockers (tremor, HR, BP, sweating), Clonidine (tremor, HR, BP), Antipsychotics (low dose haldol)
Considerations for benzo in alcohol withdrawal
Lorazepam and oxazepam are preferred for patients with severe hepatic disease, elderly, or those with delirium, dementia or another cognitive disorder
These agents are shorter acting than others
Wernicke-Korsakoff Syndrome
Triad of confusion, ataxia and nystagmus
Technically 2 distinct syndromes: Wernicke encephalopathy (acute confusion), Korsakoff Dementia
Alcohol UD maintenance therapy
Consider naltrexone injection if significant concern in adherence (acamprosate maybe?)
Weigh risks and benefits of disulfiram (best administered with witness)
Non-pharm with pharm always better
