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Neuro Quiz 9 > Treatment of Substance Abuse > Flashcards

Treatment of Substance Abuse Flashcards

1
Q

DSM5 Criteria for Substance Use Disorder

A

A. A pattern of substance use leading to significant impairment or distress. Must meet at least two of the following criteria within a 12-month period:

  1. The substance is often taken in larger amounts or over a longer period of time than was intended
  2. There is a persistent desire or unsuccessful efforts to cut down or control substance use
  3. A great deal of time is spent in activities necessary to obtain, use, or recover from the substance
  4. Craving to use the substance
  5. Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home
  6. Continued substance use despite having social or interpersonal problems because of the substance use
  7. Usual and important activities are given up or reduced because of the substance use
  8. Recurrent substance use in situations in which it is physically hazardous
  9. Substance use is continued despite having recurrent physical and psychological problems caused by the substance use
  10. Development of tolerance to the substance
  11. Withdrawal symptoms occur when the substance is not used for several hours to days
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2
Q

Define Early remission

A

Patient has been sober and not met any criteria for substance use disorder for at least 3 months but for less than 12 months (with the exception that “craving to use the substance” may be met)

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3
Q

Define Sustained Remission

A

Patient has been sober and not met any criteria for substance use disorder for 12 months or longer (with the exception that “craving to use the substance” may be met)

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4
Q

Screening for alcohol use disorder?

A

CAGE questionnaire
C Do you feel you need to CUT DOWN on your drinking?
A Do you become ANNOYED when someone comments about your drinking?
G Do you feel GUILTY about your drinking?
E Do you need an EYE-opener to take the edge off?

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5
Q

Cage Scoring

A
  1. A score of 2 or more (meaning the patient answered “yes” to at least 2 questions) is positive for “at risk drinking”
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6
Q

Alcohol Withdrawal

A

a) Withdrawal symptoms begin within a few hours from the last drink, peak at 24-36 hours, can last 5-7 days
b) Stages of withdrawal

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7
Q

Stage 1 of Alcohol Withdrawal

A

moderate autonomic symptoms – shaking, anxiety, sweating, tachycardia, hypertension, hyperthermia, N/V, insomnia, hyperreflexia, craves alcohol. Starts 6-8 hours after blood alcohol begins to decrease, can last 5 days

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8
Q

Stage 2 of Alcohol Withdrawal

A

increased autonomic symptoms, transient hallucinations (auditory, visual, tactile). Starts 24 hours after the last drink, can last 1-3 days

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9
Q

Stage 3 of Alcohol Withdrawal

A

seizure activity. This stage can occur 6-48 hours after the last drink.

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10
Q

Stage 4 of Alcohol Withdrawal

A

Delirium Tremens (DTs) which present as severe agitation, increased autonomic activity, mydriasis, high fever, shock, possible arrhythmias. The onset is 3-5 days after the last drink. Average mortality of 5-15%.

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11
Q

Clinical Institute for Withdrawal Assessment

A

CIWA
Assess alcohol withdrawal symtpoms
9 items are ranked 0 (absent) – 7 (severe), 1 item is ranked 0 - 4. The highest possible score = 67
i. A score of less than 8 is associated with mild withdrawal symptoms
ii. A score of 8 – 15 is associated with moderate withdrawal symptoms
iii. A score of > 15 is associated with severe withdrawal symptoms

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12
Q

Alcohol Treatment Plan

A
  1. Supportive therapy
  2. BZDs
  3. Gabapentin
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13
Q

Alcohol Supportive Therapy

A

Monitor vitals, respiratory depression, and vomiting
Replace fluids
Thiamine 50-100 mg for at least 1-4 weeks

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14
Q

Why Thiamine supplementation?

A

Critical for the prevention and treatment of Wernicke’s encephalopathy
Cofactor in normal glucose metabolism and should be administered before IV fluids containing glucose are given
• If left untreated, Wernicke’s may progress to permanent cognitive impairment (Korsakoff’s psychosis)

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15
Q

BZDs Symptom Triggered Dosing

A

A patient’s symptoms are monitored by using the CIWA and doses of benzodiazepines are administered based on the CIWA score:
 CIWA greather than 15, a moderate – high dose of a BZD is given
 CIWA = 8-15, a lower dose of a BZD is given
 CIWA less than 8, no BZD doses given

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16
Q

BZD’s should not be given:

A

Until patients blood alcohol level is less than 0.08%

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17
Q

BZDs Fixed Dosing

A

Schedule dose of BZDs are prescribed and tapered over 3-7 days
Not preferred bc they tend to get more than neccesary

18
Q

Seizures or DT + BZDs

A

Receive at least 24 hours of scheduled BZD dosing

19
Q

Longer acting BZDs

A

Diazepam and chlordiazepoxide

20
Q

Gabapentin in Alcohol Withdrawal

A

Outpatient management

Mild withdrawal only and less sedating

21
Q

Treatment of Relapse Alcohol

A 
Psychosocial therapy ( drugs wont be beneficial without this)
Naltrexone, acamprosate or disulfram
22
Q

Naltrexone dose, AE, DI, counseling, use

A

50 mg QD or IM once monthly
Hepatotoxicity and injection site reactions
WILL CAUSE OPIOID WITHDRAWAL
First line agent

23
Q

Naltrexone Benefits and Limitations

A

B: Once monthly
L: Hepatotoxicity and opioid meds

24
Q

Acamprosate dose, AE, DI, use

A

TID
N/D, depression and anxiety
NO DRUG INTERACTIONS!!!
First line therapy

25
Q

Acamprosate Benefits and Limitations

A

B: Well tolerated, no DI
L: Renal impairment changes (less than 30, don’t use)

26
Q

Disulfram dose, AE, DI, counseling, use

A

500 mg daily for 1-2 weeks then decrease to 250 mg daily
Metallic taste, smell disturbances, hepatotoxicity
Inhibits 3A4 and metronidazole
MUST avoid all alcohol
Rarely used due to adverse effects and limited efficacy

27
Q

Disulfram Monitoring

A

Liver enzymes and disulfram reaction (alcohol

28
Q

Opioid Withdrawals

A

Start 8 hours after last opioid use, peak is usually at 36-72 hours, and may last up to 5-8 days

29
Q

Opioid Withdrawal Treatment Options

A

Methadone and Buprenorphine

30
Q

Methadone

A

Full mu agonist
Only used by registered opiate treatment programs
Start at 20-30 and titrate up (no ceiling effect)
One symptom suppression is achieved, reduce by 5-10 mg/day over 7-21 days
Prolong QTc

31
Q

Buprenorphine

A

Partial mu agonists
16 mg max
Better safety profile
Can be treated outpatient

32
Q

Buprenorphine Dosing

A

Must be in mild-moderate withdrawal before giving first dose or else it will cause withdrawal
Titrate up to 16mg, starting at 4 and taper over 7-10 days

33
Q

Opioid Replase Prevention

A

Psychosocial therapy
Methadone
Buprenorphine + Naloxone (suboxone)

34
Q

Methadone for Relapse Prevention

A

More effective for higher tolerance
Dispensed from a registered TPC (methadone clinic) daily
May be given permission to take home multiple doses of methadone

35
Q

Methadone Maintenance therapy

A

History of opioid dependency for greater than 1 year
Do not have to meet the greater than 1 year criteria if they are pregnant, relapsed form jail or prison and treated for opioid dependence in past

36
Q

Buprenorphine + Naloxone (Suboxone)

A

12-24 mg daily

Naloxone when crushed becomes active and blocks effects of buprenorphine

37
Q

Methadone Benefits and Limitations

A

B: Cheaper, no ceiling effect
L: More adverse effects (QTc), daily methadone clinic

38
Q

Buprenorphine Benefits and Limitations

A

B: Less adverse effects, less risk of miss use
L: More expensive, has a ceiling effect

39
Q

Nicotine Relapse Prevention

A

Bupropion Sustained Release (Zyban) or Varenicline (Chantix)

40
Q

Bupropion Sustained Release

A

Zyban
Start medication 1-2 weeks before quit date
150 mg daily x 3 then increase to BID on day 4
3-6 months

41
Q

Varenicline

A 
Chantix
Start meds 1 week before quit date
Day 1-3: 0.5 mg every AM
Day4-7: 0.5 mg BID
Day 8: 1 mg BID
3 montsh
42
Q

Varencline AE

A 
Nausea
Insomnia
Vivid dreams or nightmares
Black box warning: increase risk of depression, agitation, suicidal ideation
Decrease a person's tolerance to alcohol
Increase risk of seizures

Neuro Quiz 9 (4 decks)

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