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NUNP 543 > Substance use (including AUD, Smoking & Opioid) > Flashcards

Substance use (including AUD, Smoking & Opioid) Flashcards

1
Q

Substance use disorders

Substance abuse (C&G definition)

A

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more specific symptoms, occurring with a 12-month period.

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2
Q

Substance use disorders

Substance intoxication

A

A reversible substance-specific syndrome caused by ingestion

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3
Q

Substance use disorders

Substance dependence (C&G)

A

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) specific symptoms, occurring at any time in the 12-month period.

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4
Q

Substance use disorders

Substance withdrawal

A

A substance-specific syndrome caused by the cessation of (or reduction in) substance use that has been heavy and prolonged.

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5
Q

Substance use disorders

impaired control

A

Use of a substance in larger amounts or for longer time than originally intended.

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6
Q

Substance use disorders

Social impairment

A

Recurrent substance use leading to a failure to meet personal and social obligations.

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7
Q

Substance use disorders

risky use

A

Recurrent substance use leading to a failure to meet personal and social obligations

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8
Q

Substance use disorders

pharmacological criteria

A

Requirement for a markedly increased dose to achieve desired effect or markedly reduced effect at standard dose

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9
Q

Substance use disorders

Age (highest prevalence for substance use in general)

A

Youth age 15-24 years – highest report of illicit substance use and 5x more likely to report harm due to drug use.

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10
Q

Substance use disorders

Subjective Hx

A
  • Onset, duration, and course of presenting complaints
  • Question about relatives with hx of etoh, tobacco, or drug use problems.
  • Assess when started, amount of use, type etc…with least invasive questions first.
  • Start with past to present use (first to last use)
  • -past treatment interventions (pharm managment/OAT, A&D counselling, residential treatment programs, etc), past withdrawal management, past complications (seizures, OD), length of sobriety
  • OD hx,
  • Follow CAGE (cutdown, annoyed, guilty, eye-opener): 2/4 is highly predictive of addiction
  • Note usual weight and recent loss in what time frame.
  • Review suicidal ideation and/or past hx.
  • length of sobriety
  • drug costs/day, source of money
  • concurrent resp depressants (ETOH, benzo)

Trauma-informed social history:

  • housing
  • employment history
  • legal history, current legal issues
  • financial concerns
  • social/emotional supports
  • family history
  • safety: interpersonal violence, children
  • hx of trauma: ask about past trauma using ACE tool
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11
Q

Substance use disorders

Objective assessment

A

BP, RR, HR, WT
INSPECT:
-Gen appearance, dress, grooming, breath odour, wanted appearance, attitude, sad affect, impaired psychomotor ability, or tremors

  • Conduct a dermal examination for spider angiomas, bruises, track marks, colour, pallor, rash, jaundice, petechiae, gynecomastia in men (hallucinogens)
  • Examine the eyes for sclera colour and features, pupil size and reactivity
  • Inspect the nasal mucosa or erythema, oedema, spider telangiectasia, and discharge; look for septal lesions or perforation, deviation, and polyps.
  • Inspect the mouth/pharynx: oral lesions, poor dental hygiene, erythema, teeth for uneven surfaces and decay, and gum erosion.

PALPATE:

  • Neck and thyroid
  • Axilla and groin for lymphadenopathy
  • Abdomen; note hepatomegaly/tenderness

PERCUSS:
- Chest, note pulmonary consolidation
Abdomen for hepatosplenomegal

AUSCULTATE:
- Heart for murmur, new S4 gallop, single S2, and arrhythmias.
Lungs for rales, effusion, and consolidation.

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12
Q

Substance use disorders

Smoking cessation pharm management (in adjunct or instead of NRT)

A

Buproprion – 7 to 12 week treatment. Pt can smoke for first 2 weeks. Risk seizures.

**Varenicline – client chooses stop date and medication is started 1-2 weeks before. Warn patient of adverse effects: vivid dreams, aggression, anxiety. Preferred.

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13
Q

Substance use disorders

Follow-up

A

weekly, then monthly

screen suicidality every visit

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14
Q

Substance use disorders

5 A’s of smoking cessation

A

Ask- Identify use

Advise- recommend reduction/cessation

Assess- readiness

Assist- non-pharm & pharm interventions

Arrange- Schedule follow-up

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15
Q

Substance use disorders

TWEAK

A 
Tolerance
Worry
Eye-opener
Amnesia
K(cut-down)
  • Use in pregnancy
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16
Q

Substance use disorders

5 A’s integrating substance use knowledge

A

Acquire knowledge

Anticipate harm that may be caused by your practices, reactions, judgements

Analyze the impact of policies

Avoid social judgements about SU

Approach all pt/s respectfully

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17
Q

Substance use disorders

CAGE

A

Cut down
Annoyed
Guilty
Eye-opener

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18
Q

Substance use disorders

SWIGECAPS

A 
• Sleep
	• Worthlessness
	• Interest
	• Guilt
	• Energy
	• Concentration
	• Appetite
	• Psychomotor changes
Suicidal/Safety
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19
Q

Substance use disorders

What is OUD?

A

Chronic relapsing problematic use of and addiction to opioids

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20
Q

Substance use disorders

Opioid use disorder Age and Sex

A

OD deaths
80% Age 29-49yrs
80% male

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21
Q

Substance use disorders

Risk factors for opioid OD

A
  • social isolation (3/5 OD deaths were using alone)
  • Indigenous (intergenerational trauma from colonization) over-represented in OD deaths
  • untreated psychiatric conditions
  • high ACE scores
22
Q

Substance use disorders

Opioid patho

A
  • dopamine reward pathway dysfunction
  • Increased dopamine release in nucleus accumbens (responsible for motivation and goal-directed behaviour)
  • dopamine is needed for memory to associate positive and negative emotions –> reinforces positive reward
  • drugs (amphetamines, cocaine, nicotine, opioids) cause 2-10x amt of dopamine compared to naturally rewarding stimuli)
23
Q

Substance use disorders

Tolerance

A

need for increased amount of drug to achieve effect

24
Q

Substance use disorders

Time for moderate to severe withdrawal from pharmaceutical grade opioids

A
  • Short acting opioids (heroin, morphine, IR oxycodone): 12-16 hours
  • Intermediate acting opioids (SROM, CR HM, SR oxycodone); 17-24 hours
  • Long acting opioids (methadone): 30-48 hours
25
Substance use disorders How have fentanyl analogues complicated Suboxone inductions?
precipitated withdrawal can occur 24+ hours after stopping
26
Substance use disorders What is a long term complication of opioid OD?
anoxic brain injury
27
Substance use disorders Two-Item Conjoint Screen (TICS)?
- have you ever drunk/used drugs more than you meant to? | - have you felt you wanted/needed to cut down your drinking/drug use?
28
Substance use disorders Screening for substance use, ask all patients:
"how many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?"
29
Substance use disorders Opioid withdrawal symptoms
``` HR Sweating GI upset (N/V/D/cramps) Tremor Restlessness Yawning Pupil dilation Anxiety/irritability Piloerrection Bone/joint aches Rhinorrhea/lacrimation Cravings ```
30
Substance use disorders Opioid OD Signs
- Respiratory depression (RR<10-12/min is best clinical predictor of opioid intoxication) - Gurgling/snoring - Minimally responsive --> unresponsive - Constricted pupils - Slow erratic HR - Cyanosis and cool/clammy skin
31
Substance use disorders atypical opioid toxicity
- chest wall rigidity - dyskinesia: involuntary muscle movement (ranging from twitching to chorea) - decorticate posturing - anisocoria (unequal pupils)
32
Substance use disorders DSM criteria for opioid use disorder
Two or more of the following (* if only two are tolerance/withdrawal, excludes those using Rx'd opioids for chronic pain) - often take > amts than intended - persistent desire or attempt to control use - ++ time spent securing substances - cravings - recurrent opioid use resulting in failure to fulfill social/professional/academic obligations - continued use despite social consequences - giving up social/work/rec pursuits - physically hazardous use - continued use despite physical/psych consequences - tolerance - withdrawal
33
Substance use disorders Labs when initiating OAT
Labs: CBC, Cr, LFT (esp ALT, GGT), HIV, Hep A/B/C, syphilis, chlamydia, gonorrhea • Preg test for women of childbearing age • Repeat LFTs 4 weeks after initiation esp if pre-existing liver disease Lab based urine drug screen: covers methadone, opiates, BZD, cocaine/cocaine metabolites, amphetamines *fentanyl and synthetic opioids (eg buprenorphine, oxycodone, HM) must be specifically requested when ordering UDS
34
Substance use disorders COWS/SOWS score to start Suboxone
COWS > 11 SOWS > 16 (moderate to severe withdrawal)
35
Substance use disorders Refer to addiction's specialist for OAT tx when:
* pregnant/breastfeeding * concurrent chronic pain, complex comorbidities * switching from another type of OAT * previous unsuccessful inductions * youth * complex polysubstance use * consideration for iOAT (injectable OAT: hydromorphone, diacetylmorphine)
36
Substance use disorders Opioid harm reduction resources
* Take home naloxone kit: free for all patients, caregivers, practitioners. For all patients at risk of OD. * Harm reduction supplies (sterile needles, pipes, etc) * Access to supervised consumption sites * Safer supply (prescription opioids): risk mitigation during dual public health emergency * Drug testing, toxic supply reporting * Education on safer use: where to inject, switch to intranasal/smoking, do not use alone * Link to Overdose Outreach Teams * Lifeguard app
37
Substance use disorders Contraindications and precautions for Suboxone
Contraindications: severe resp distress, delirium tremens, acute ETOH intoxication, severe liver failure Precautions: caution with other sedating meds (increase risk of resp depression with BZD, ETOH, other sedatives), CYP medications Monitoring:
38
Substance use disorders Suboxone MOA
buprenorphine partial opioid agonist w/ high binding affinity --> binds rapidly to opioid receptors (knocks off full opioid agonists eg heroin/fentanyl that may be present) naloxone helps to prevent diversion
39
Substance use disorders Suboxone adverse reactions
1) Headache 2) Nausea, vomiting, constipation, abdominal pain 3)  insomnia 4) hyperhidrosis
40
Substance use disorders Methadone adverse rxn
overdose/resp depression (no ceiling, full opioid agonist) prolonged QT!
41
Substance use disorders naloxone duration of action
20-90 min
42
Substance use disorders BCCSU/Canada Low Risk Drinking Guidelines: definition risky drinking
- Males 3+ drinks/day or 15+ drinks/week | - Females 2+ drinks/day or 10+ drinks/week
43
Substance use disorders C&G definition of binge drinking:
- males 5+ drinks on at least 1 day in last 30 days | - females 4+ drinks on at least 1 day in last 30 days
44
Substance use disorders AUD prevalence
- age: 15-49 ETOH is leading cause of death/disability - 18% of all Canadians age 15+ meet clinical criteria for AUD in their lifetime - 20% of Canadians 12+ drink in excess of recommended limits - Higher prevalence in sexual minority (LGBTQ)
45
Substance use disorders AUD patho (C&G?)
- Brain disorder caused by combination of genetics and environment - ?impaired metabolism, insensitivity to alcohol, alterations in brain wave
46
Substance use disorders Complications of AUD
``` anemia HTN cardiomyopathy hepatitis/AFLD/Cirrhosis Gout DM CA gastritis/varices/UGIB pancreatitis polyneuropathy dementias psychosis ```
47
Substance use disorders What is the PAWSS?
Prediction of alcohol withdrawal severity scale Score < 4 --> low risk, manage without pharm or with gabapentine as outpatient Score > 3 --> hospital admission, benzo for withdrawal management
48
Substance use disorders 2 first - line pharm management for AUD and their contraindications?
naltrexone --> contraindication in severe liver dysfunction or concurrent opioid use (best choice is patient wants to reduce drinking but isn't necessarily planning abstinence) acomprosate --> contraindicated in severe renal failure, breastfeeding A = abstinent (best choice if patient would like to stop altogether)
49
Substance use disorders What are two 2nd line pharm options for AUD and their contraindications?
topiramate --> contraindicated pregnancy, narrow angle glaucoma, nephrolithiasis gabapentine --> contraindicated in renal impairment, pregnancy, teens or > 65 yrs, concomitant CNS depressants, poor resp function, cognitive impairment
50
Substance use disorders Supplements for AUD
Thiamine (100 mg) folic acid (1 mg) B6 (2 mg)

NUNP 543 (22 decks)

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