Substance Use Disorder Treatment

Question 1

Nicotine UD Drugs; First and Second line:

Answer 1

First Line

• Nicotine replacement therapy
  
  • Patch, gum, lozenge, spray, inhaler
• Bupropion (Zyban)
• Varenicline (Chantix)

Second Line

• Nortriptyline
• Clonidine

Question 2

Alcohol UD Drugs; Withdrawal

Answer 2

Withdrawal

• Benzodiazepines
  
  • Best: lorazepam, chlordiazepoxide, diazepam, or oxazepam.
• Vitamin replacement
  
  • Thiamin
• Adjunctive therapy
  
  • Carbamazepine, Beta blockers, clonidine
  • Antipsychotics

Question 3

Wernicke-Korsakoff Syndrome

Answer 3

Triad of confusion, ataxia, and nystagmus.

Question 4

Alcohol UD Drugs; Maintenance

Answer 4

Maintenance

• Naltrexone
• Acamprosate
• Disulfiram
• Others
  
  • SSRI’s
  • Baclofen
  • Ondansetron
  • Gabapentin
  • Topiramate

Question 5

Opioid UD Drugs

Answer 5

Intoxication

• Naloxone

Withdrawal

Medical withdrawal

• Clonidine
• Clonidine-naltrexone
  
  • If planning on naltrexone later
• Methadone substitution
• Buprenorphine

Maintenance

• Opioid agonist: First-line
• Methadone or buprenorphine/naloxone

Question 6

Why do we use benzodiazepines for alcohol withdrawal symptoms?

Answer 6

They reduce the severity of the symptoms in general, and they also reduce the frequency of seizures and delirium.

Question 7

Why do we provide thiamine to patients suffering from alcohol withdrawal?

Answer 7

To prevent Wernicke-Korsakoff syndrome.

Question 8

Why do we use carbamazepine for alcohol withdrawal?

Answer 8

For withdrawal related seizures.

Question 9

Why do we use beta-blockers for alcohol withdrawal?

Answer 9

Propranolol: For tremor, HR, BP, and diaphoresis (intense sweating).

Question 10

Why do we use clonidine for alcohol withdrawal?

Answer 10

For tremor, HR, and BP.

Question 11

Why do we use antipsychotic medications for alcohol withdrawal?

Answer 11

Low dose haloperidol: for delirium.

Question 12

Why do we use acamprosate for alcohol maintenance?

Answer 12

It appears to somehow help patients achieve abstinence, if that is their goal, by modulating their glutamine system. It’s most likely going to take a week to take effect, though.

Question 13

Why do we use naltrexone for ALCOHOL maintenance?

Answer 13

It can prevent the opioid-receptor-mediated effects of euphoria and reward that alcohol can induce.

Question 14

Why do we use disulfiram for alcohol maintenance?

Answer 14

Alcohol is converted to and aldehyde in the body, and would be further modified by ALDH normally. Inhibiting ALDH causes a build up of the aldehyde products in the body, which are responsible for the negative effects associated with alcohol.

Question 15

Why do we use the “other” drugs in alcohol maintenance?

Answer 15

SSRIs: mixed evidence.

Baclofen: for advanced alcoholic liver disease.

Ondansetron: anti-emetic effects; possible combo with naltrexone.

Gabapentin: helps with mood, sleep, and cravings.

Topiramate: reduces heavy drinking cravings

Question 16

Why do we use naloxone for Opioid UD Intoxication?

Answer 16

Naloxone will reverse their respiratory and CNS depression.

Question 17

Why do we use clonidine for Opioid UD Medical Withdrawal?

Answer 17

It helps with N/V/D, cramps, and sweating.

Question 18

Why do we use clonidine-naltrexone together for detoxification during Medical Withdrawal?

Answer 18

If the patient is going to be on naltrexone, we give them this clonidine-naltrexone combo so that the naltrexone will sweep their system, and the clonidine will be there to help if the process induces any major withdrawal symptoms; observe for 8-hrs after admin.

Question 19

Why do we use methadone for Opioid Ud Medical Withdrawal?

Answer 19

Methadone is a good opioid agonist substitution because it is a well regulated long-acting opioid that will be initiated with the plan of gradually lowering the dose until they are clean.

Question 20

Nicotine Patch Dosing

Answer 20

If > 10 cigarettes/day: start with 21mg daily for 6 weeks

• 14mg for 2 weeks
• 7mg for 2 weeks
• stop

If ten or less: start with 14mg daily for 6 weeks

• 7mg for 2 weeks
• stop

Question 21

Nicotine Gum or Lozange Dosing

Answer 21

Gum: >25 cigs/day, Lozange: < 30 min after waking:

• 4mg gum or lozange
  
  • Weeks 1-6: q1-2h
  • Weeks 7-9: q2-4h
  • Weeks 10-12: q4-8hr

Gum: <25 cigs/day, Lozange: >30 min after waking:

• 2mg gum or lozange; same schedule as above.

Question 22

Possible red flag for Nictoine Replacement Therapy (NRT)

Answer 22

Comprimised cardiovascular systems.

Question 23

Possible red flag for varenicline

Answer 23

Consider renal function.

**Black box: Caution use in psychiatric patients

• Problematic psychiatric side effects; vivid dreams, hallucinations, suicidality (rare), agitation, and hostility.

Question 24

Possible red flag for bupropion

Answer 24

Consider renal function.

CI: History of seizures, bulimia/anorexia, MAOIs, barbituates, benzodiazepines, or abrupt d/c of alcohol

Dosed bid, but 8-hrs apart. If they miss one, tell them they should just wait until the next morning.

Question 25

Possible red flag for Nortriptyline

Answer 25

Consider liver function

Metabollized by CYP-2D6

Question 26

Possible red flag for clonidine

Answer 26

Consider cardiovascular health

Don’t abruptly stop: rebound HTN

Caution driving

Question 27

Possible red flags for acamprosate

Answer 27

Consider renal impairment

Monitor for depression/sucidality

Diarrhea common at first

Question 28

Possible red flag for naltrexone

Answer 28

Hepatotoxicity at doses over 100mg/day

Consider nullifying effects on antidiarrheal and antitussive medications as well as opioids for pain