SUD tx

Question 1

Dependence vs Addiction

Answer 1

Dependence: development specific sx of withdrawal after quick stop of med

Addiction: bad pattern of med use = significant impairment or distress
“without the med I’m gonna DIE”
- doing something despite the negative consequences

Question 2

Presentation

Answer 2

maybe intoxicated (go to detox if so)

• provide risk assessment tool according to needs
• base risk using tool & DSM-V criteria

Question 3

mild intoxication tx

Answer 3

supportive care

Question 4

ETOH sx

Answer 4

sx worsen to BAC (behaviors do not always reflect BAC: tolerance)

may be on other agents to incr. high

likely malnourished

Question 5

ETOH malnourishment tx

Answer 5

low thiamine (wernicke's syndrome)
- thiamine, B12, folate, Mg, MVI (banana bag)

make sure to follow-up with glucose if hypoglycemic
(< 70 mg/dL)

Question 6

ETOH + Behavior tx

Answer 6

incr. suicidal behavior

agitation (may cause seizure or respiratory depression!)

• haloperidol
• olanzapine
• benzo’s

ETOH has no reversal

hepatic encephalopathy

• anx
• depression
• tremor
• coma
• death

Question 7

ETOH withdrawal

Answer 7

CAN KILL YOU
- base on time since last drink

uncomplicated (clinical withdrawal assessment revised [CIWA-Ar])
8-10 = outpt tx
15+ = inpt tx
>20 = seizure + delirium tremens possible

Question 8

What do we use to treat uncomplicated withdrawal?

Answer 8

banana bag + benzo:

• lorazepam
• diazepam
• chlordiazepoxide

Question 9

Benzo dosing

1. sx based
2. loading based

Answer 9

1. lorazepam
   - CIWA-Ar q24h
   - give every time 8+
   (ok with decr. liver func.)
2. diazepam and chlordiazepoxide
   - can use lorazepam for breakthru prn
   - good for inpatient , monitoring
   - do you need quick onset or increased high?
   - -> quick onset = diazepam
   - -> increased high = chlordiazepoxide

Question 10

What makes a complicated withdrawal?

Answer 10

Seizure or delerium tremens (rapid onset of confusion)

Question 11

Complicated withdrawal: seizure tx

Answer 11

• maintain airway

IV diazepam q5min until resolved
- can give IM lorazepam until IV access is available

Question 12

Complicated withdrawal: delirium tremens tx

Answer 12

IV benzos

(may use haloperidol if SVR agitation or no response to benzo)

give thiamine

Question 13

Opioid intoxication sx

Answer 13

• miosis
• euphoria
• shallow breathing

*ensure viable airway & give naloxone

Question 14

opioid withdrawal

Answer 14

tx inpatient or through detox (med issues exacerbated)

• feels like flu + bad panic attack

monitor with COWS
> 5 = tx sx or give replacement tx (methadone or buprenorphine)

Question 15

opioid sx & their tx

Answer 15

1. insomnia (restlessness & anxiety)
   - benadryl
   - trazodone
   - hydroxyzine
2. headache
   - APAP, ibuprofen, NSAIDs
3. Noradrenergic
   - clonidine (keep SBP <90)
   - lofexidine
4. Cramps
   - bentyl
5. constipation
   - milk of mag
6. diarrhea
   - bismuth

Question 16

stimulant intoxication tx

Answer 16

1. manage physical/psych issues
   - physical: HTN, arrhythmia, stroke
   - psych: agitation, aggression, psychosis
2. give benzo, aspirin, nitroglycerin, nitroprusside

cocaine can be treated with LA benzo
–> antipsychotic if that fails (risperidal)

Question 17

stimulant withdrawal sx

tx

Answer 17

• depression & suicidal thoughts

tx outpt unless threat of harm
- provide psychosocial support

no med, high risk of relapse
–> get them to REHAB

(maybe: topamax, disulfiram, modafinil)

Question 18

NON-pharm tx (stimulant)

Answer 18

always combine with meds
COUNSELING

rehab is rarely covered on insurance, consider AA/NA

Question 19

What are the harm reduction efforts we are pushing towards?

Answer 19

• naloxone
• handouts on tx & recovery programs
• fentanyl testing strips
• syringe service programs
• needle exchange programs
• infectious disease screenings
• safe injection sites (currently violates controlled substance act)