substance use disorders Flashcards
define illicit drug use
anything that is illegal (marijuana, cocaine, heroin) AND misuse of prescription drugs
define misuse
use in any way not directed by a doctor
define binge drinking
5 or more drinks for males
4 or more drinks for females
(12 oz beer, 5 oz wine, 1.5 oz liquor)
define heavy alcohol use
binge drinking on 5 or more days in the past 30 days
4 categories that define when substance use becomes a disorder
impaired control
social impairment
risky use
physical dependence
define addiction
a chronic, relapsing brain disease characterized by compulsive drug seeking & use, despite harmful consequences
considered a brain disease because drugs change the brain
true or false: opioid withdrawal is life threatening
false
general timeline of opioid withdrawal, depending on which opioids were used
short acting opioids: 6-12 hours after last dose
long acting opioids: 30 hours after the last dose
generally peaks at 72 hours
what are some symptoms of opioid withdrawal
n/v, stomach cramps, diarrhea, goosebumps, depression, drug cravings
can also include sweating/chills, shake/tremor, muscle ache, agitation/anxiety, more.
what is special about fentanyl
it is highly lipophilic, leading to its concentration in fat tissue and additional considerations during withdrawal management
what are some “comfort medications” used for opioid withdrawal
Pain: APAP, NSAIDs, diclofenac
anxiety: hydroxyzine
diarrhea: loperamide
insomnia: trazodone, melatonin
what do the ASAM national practice guidelines for OUD say about opioid withdrawal management
- methadone or buprenorphine recommended> abrupt cessation of opioids
- detoxification on its own, without treatment, is NOT a treatment method for OUD and is not recommended.
describe the role of alpha 2 agonists in opioid withdrawal
clonidine and lofexidine may be used for symptomatic relief during withdrawal management; they work by reducing sympathetic outflow from CNS, decreasing peripheral resistance/vascular resistance, heart rate, BP
what are the side effects seen from alpha 2 agonists
orthostatic hypotension, sedation, dizziness, somnolence, fatigue
describe which of the following are full or partial agonists, or antagonists:
methadone, buprenorphine, naltrexone, naloxone
methadone= FULL agonist
buprenorphine= PARTIAL agonist
naltrexone and naloxone= antagonists
what is the role of methadone in opioid withdrawal treatment
only given in specially licensed methadone clinics, unless
1. inpatient & admitted for something OTHER than opioid withdrawal
2. outpatient for 72 hours max to cover patient until they go to the clinic
what are the pearls to definitely know about methadone
- causes QT prolongation
- has drug interactions
- preferred agent in pregnancy (DOES NOT PRECIPITATE WITHDRAWAL!)
what is the difference in methadone dosing between withdrawal treatment, and maintenance treatment
withdrawal: 20-30 mg (NTE 40)
maintenance: higher; initial 20-30 but titrated 5-10 mgs every few days to 80-120 mg daily
methadone side effects
QT PROLONGATION
hypotension, dizziness, drowsiness, constipation, nausea/vomiting, respiratory depression
what is the most important thing to know about buprenorphine in opioid withdrawal treatment
given the HIGH BINDING AFFINITY, this drug will displace ANY opioids in the patient’s system causing PRECIPITATED WITHDRAWAL
MUST WAIT UNTIL PATIENT IS IN WITHDRAWAL TO GIVE! very unfortunate
which drugs are used for opioid withdrawal treatment, and which drugs are used for maintenance
withdrawal: methadone, buprenorphine
maintenance: methadone, buprenorphine, naltrexone
what is a disadvantage to consider when using methadone as a maintenance treatment?
patient has to present to the methadone clinic DAILY to ingest doses
which is the preferred drug in pregnancy and why
methadone– withdrawal leads to fetal harm and is not necessary to start methadone
what is a good maintenance dose for buprenorphine
16-24 mg/day, but 24 is better
lower doses associated with a greater risk of treatment discontinuation
counseling for buprenorphine
typical ADEs associated with opioids; requires proper administration technique (SL/buccal) and mouth should be rinsed after use to prevent long term dental decay.
true/false: buprenorphine prescribing requires an X waiver?
false; it previously did but now you just need a regular DEA number
talk about the pros/cons of buprenorphine formulations?
1: monoproduct: contains only BUP, may increase risk of diversion/misuse
2: combination: contains BUP and naloxone to act as a deterrent for misuse
3: injectables Sublocade and Brixadi: contain only BUP; increased adherence and decreased diversion
what is the role of naltrexone in maintenance OUD treatment?
the long acting injectable Vivitrol is used (no PO form for OUD)
A must higher risk for opioid relapse & overdose, making it only for super stable patients.
how does the combo of buprenorphine/naloxone deter misuse?
naloxone is minimally absorbed PO; meaning in the combo product it is not pharmacologically active. It’s purpose in the combination is to discourage injection use because it would then become active and cause withdrawal
compare/contrast Sublocade and Brixadi
Sublocade: lower tolerability, forms a palpable depot/lump, higher plasma concentrations above what is achieved by SL BUP, not allowed in pregnancy
Brixadi: higher injection tolerability, no lump, lower plasma concentrations/similar levels to SL BUP, weekly formulation is allowed in pregnancy
what is the duration of therapy in OUD
generally as long as the patient sees benefit or until they desire to discontinue
what is the evidence behind higher doses of naloxone?
no difference in survival
8 mg products had a significantly higher prevalence of opioid withdrawal signs & symptoms than the 4 mg products
naloxone side effects?
withdrawal
very safe & effective: very rarely anaphylactic reactions, pulmonary edema is related to the opioid used and not the narcan
what is the MOA of alcohol
GABA agonist: inhibitory
NMDA antagonist: additional inhibitory
net result being CNS depression
what is the kinetic order of alcohol
zero order elimination (NOT concentration dependent)
so it takes TIME to clear from the body
true or false: alcohol withdrawal is life threatening
true!
what are some risk factors for complicated alcohol withdrawal
heavy use
history of delirium tremens
comorbid conditions
seizure disorder
age 65+
long duration of use
VERY SERIOUS RISK FACTOR: patient is conscious/coherent at a BAC 0.30
what is delirium tremens?
hallucination, disorientation, tachycardia, fever, hypertension, diaphoresis, agitation
risk factors for delirium tremens
history of sustained drinking
history of previous DT
age >30
concurrent illness
significant alcohol withdrawal with an elevated alcohol level
LONGER period since last drink
patients who present with alcohol withdrawal more than ___ hours after their last drink are more likely to develop DT than those who present sooner.
48 hours
when is delirium tremens onset?
48-72 hours after last drink
first line drug of choice for alcohol withdrawal
benzodiazepines (because they are GABA agonists similar to alcohol)
dosing for benzodiazepines in alcohol withdrawal
can be “fixed dose taper” or “symptom triggered”
pros/cons of fixed dose taper vs symptom triggered for benzo dosing for alcohol withdrawal
symptom triggered: reduces amount of benzo use, reduces length of stay, maybe more appropriate if uncomplicated withdrawal
fixed dose: increased benzo requirement, increased length of stay, but maybe more appropriate if complicated withdrawal
which benzos are short acting
OLA
oxazepam
lorazepam
alprazolam
which benzos are long acting
CDC
clonazepam
diazepam
chlordiazepoxide
when to choose a short acting benzo for alcohol withdrawal
lower amount of alcohol use or lower amount of benzo use/low potency benzo
when to choose a long acting benzo for alcohol withdrawal
significant use of alcohol, presentation with high BAC, significant use of benzos or high potency benzos or longer acting benzos
which drug is reserved for severe withdrawal, failed benzo therapy, or history of complicated withdrawal
phenobarbital
what are some of the inferior options for treating alcohol withdrawal
gabapentin
dexmedetomidine
ketamine
carbamazepine
baclofen
what are (4) long term complications of alcohol use
wernicke encephalopathy
korsakoff syndrome
liver disease and cirrhosis
depression
define wernicke encephalopathy
acute, reversible neurologic complication of thiamine (vitamin B1) deficiency that is commonly associated with alcohol use disorder
what is the triad of symptoms of wernicke encephalopathy
Encephalopathy: altered mental state
oculomotor dysfunction: nystagmus, provoked by horizontal gaze to both sides
gait, ataxia: unsteady when walking
dosing of thiamine for alcohol withdrawal vs dosing for suspected wernicke encephalopathy
patients being treated for alcohol withdrawal: give thiamine 100 mg IM/IV x 3 days then 100 mg PO daily thereafter
suspect wernicke: thiamine 500 mg IM TID x 2 days, then 500 mg IM daily x 5 days, then 100 mg PO daily thereafter
do you wait for confirmation of wernicke encephalopathy diagnosis before giving thiamine
NO!! a delay in treatment risks permanent damage. if untreated it can lead to coma, death
what is korsakoff syndrome
an IRREVERSIBLE neuropsychiatric manifestation of wernicke encephalopathy which develops later if under treated or not treated. prognosis is poor and there is no effective treatment
what are some symptoms of korsakoff syndrome
confabulation, memory deficits, apathy, intact sensorium and long term memory
how is korsakoff syndrome prevented
parenteral thiamine
what are the 3 main drugs used for alcohol use disorder maintenance treatment
naltrexone
acamprosate
disulfiram
mechanism of naltrexone
mu opioid receptor antagonist
adverse effects of naltrexone
GI upset, headache, dizziness, insomnia, increased LFTs
improve compliance with vivitrol IM every 4 weeks
when is naltrexone contraindicated
liver impairment
mechanism of acamprosate
modulates glutamate transmission
when is acamprosate contraindicated
CrCL<30
mechanism of disulfiram
inhibits aldehyde dehydrogenase, causing buildup of acetaldehyde: a disulfiram reaction then ensues
reaction: sweating, headache, dyspnea, hypotension, flushing, palpitations, nausea, vomiting
what should you counsel patients about when dispensing disulfiram
hidden forms of alcohol (mouthwash, cooking ingredients, etc)
side effects of disulfiram
besides the intended side effects: severe and sometimes fatal hepatic failure
drugs for cocaine use disorder
non-psychostimulants: bupropion, topiramate
psychostimulants: modafanil, ER mixed amphetamine salts
drugs for amphetamine-type stimulant use disorder
non-psychostimulants: bupropion +/- naltrexone, topiramate, mirtazapine
psychostimulants: ER Methylphenidate
