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
Acomprosate
Stabilizes glutamatergic function (for effective than naltrexone in those with goal of abstinence)
Excreted by kidneys (caution in renal impairment)
Monitor for abstinence, renal function, depression and suicidality
Common AEs: Diarrhea
Counsel: takes 5-8 days for effect, continue taking if “slip”, notify doctor if suicidal thoughts or depression, do not crush, do not take missed dose if close to time of next dose
Naltrexone for Alcohol UD Maintenance therapy
Pure opioid antagonist preventing rewarding effects of alcohol (abstain 3-7 days before initiation)
Monitor signs and symptoms of alcohol withdrawal, depression and suicidal thoughts, LFTs
Caution on hepatotoxicity (usually when given more than 100mg a day)
Drug-drug interactions: opioids
Disulfiram for alcohol UD maintenance therapy
Irreversibly binds to ALDH (can occur if taken within 2 weeks of alcohol)
Reaction can last up to 2 weeks (HA, N/V, flushing, warmth, hypotension, tachycardia, anxiety, dyspnea)
96% protein bound
Common AEs: metallic/garlic aftertaste, dermatitis
Rare/serious: hepatotoxicity, peripheral neuropathy, renal failure, cardiac disease
Drug-drug interactions: alcohol, metronidazole, warfarin (and other highly protein bound drugs)
Counsel on reaction, caution on drinking, let counselor know if you slip, watch for side effects
Disulfiram contraindications
Use of metronidazole, recent alcohol ingestion, psychoses, severe myocardial disease or coronary occlusion
Which alcohol maintenance drug can be used in liver disease?
Acamprosate
Other options for alcohol UD maintenance therapy
SSRIs, baclofen (helpful in advanced alcohol liver disease), ondansetron (effective in younger patients alone or in combo with naltrexone), Gabapentin, Topiramate
Describe mild-moderate opioid overdose
Symptoms: pupil contraction, slurred speech
If short-acting opioid, observe and release after a few hours
If longer acting, observe for 24-48 hours
Describe Severe opioid overdose
respiratory depression, may be fatal, requires treatment
Symptoms: limp body, loss of consciousness, vomiting, choking sounds, respiratory depression, cyanosis
Naloxone reverses respiratory and CNS depression (o.4mg to 2mg, repeat 2-3min prn, if no response after 10mg, question narcotic ingestion)
Naloxone
Mu opioid antagonist
30-80 minute t1/2
Monitor RR, BP, HR
Common AEs: Increased or decreased BP, increased HR, sweating, N/V
Rare/Serious: Cardiac arrest, coma, encephalopathy, seizure, pulmonary edema
Opioid UD medication withdrawal strategies
- abrupt d/c with clonidine to suppress symptoms
- Clonidine-naltrexone (closely observe for first 8 hours)
- Methadone substitution (gradually taper by 5mg/day)
- Buprenorphine substitution
Clonidine in opioid UD
Centrally acting a2 agonist (decreases NVD, cramps, sweating; does not help muscle aches, insomnia, distress and drug cravings)
Monitor BP, HR
Common ADs: hypotension, xerostomia, dizziness
Serious: AV block
Notable drug-drug interactions: other antihypertensives
Do not abruptly discontinue (rebound hypertension), may cause somnolence
Opioid UD maintenance therapy guidelines
Agonist considered first line (methadone, buprenorphine/naloxone)
Use buprenorphine in monotherapy if pregnant
Start low, go slow
Methadone in Opioid UD maintenance therapy
Full mu agonist
Metabolized by CYP3A4; 8-59 hours half life
Monitor ECG/QT, follow-up at 30 days and then annually
Common AEs: constipation, NV, sweating, sedation, dizziness, sexual difficulty, hypotension
Notable drug-drug interactions: QT prolonging drugs, CYP3A4 inhibitors/inducers, other CYP interacting drugs, serotonergic drugs
Counsel: advise against self-medicating with CNS depressants, serious overdose and death can occur
Methadone contraindications
Acute bronchial asthma, paralytic ileus, significant respiratory disease
Buprenorphine
Partial mu agonist, kappa antagonist
Poor oral, good sublingual bioavailability (CYP3A4 metabolism)
Monitor LFTs
Use in combo with naloxone (decreased risk of diversion from injection or snorting) or alone
Common AEs: constipation, NV, headache, sweating, hypotension, insomnia, sedation, drug withdrawal
Serious: hepatitis, hepatic failure, respiratory depression, MI
Drug-drug interactions: naltrexone, selected opioids, 3A4 inducers/inhibitors, drugs that cause CNS or respiratory depression
Counsel: strongly advise against self-medicating with CNS depressants, serious overdose or death can occur
