Treatment of Substance Abuse Flashcards
DSM5 Criteria for Substance Use Disorder
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:
- The substance is often taken in larger amounts or over a longer period of time than was intended
- There is a persistent desire or unsuccessful efforts to cut down or control substance use
- A great deal of time is spent in activities necessary to obtain, use, or recover from the substance
- Craving to use the substance
- Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home
- Continued substance use despite having social or interpersonal problems because of the substance use
- Usual and important activities are given up or reduced because of the substance use
- Recurrent substance use in situations in which it is physically hazardous
- Substance use is continued despite having recurrent physical and psychological problems caused by the substance use
- Development of tolerance to the substance
- Withdrawal symptoms occur when the substance is not used for several hours to days
Define Early remission
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)
Define Sustained Remission
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)
Screening for alcohol use disorder?
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?
Cage Scoring
- A score of 2 or more (meaning the patient answered “yes” to at least 2 questions) is positive for “at risk drinking”
Alcohol Withdrawal
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
Stage 1 of Alcohol Withdrawal
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
Stage 2 of Alcohol Withdrawal
increased autonomic symptoms, transient hallucinations (auditory, visual, tactile). Starts 24 hours after the last drink, can last 1-3 days
Stage 3 of Alcohol Withdrawal
seizure activity. This stage can occur 6-48 hours after the last drink.
Stage 4 of Alcohol Withdrawal
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%.
Clinical Institute for Withdrawal Assessment
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
Alcohol Treatment Plan
- Supportive therapy
- BZDs
- Gabapentin
Alcohol Supportive Therapy
Monitor vitals, respiratory depression, and vomiting
Replace fluids
Thiamine 50-100 mg for at least 1-4 weeks
Why Thiamine supplementation?
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)
BZDs Symptom Triggered Dosing
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
BZD’s should not be given:
Until patients blood alcohol level is less than 0.08%
BZDs Fixed Dosing
Schedule dose of BZDs are prescribed and tapered over 3-7 days
Not preferred bc they tend to get more than neccesary
Seizures or DT + BZDs
Receive at least 24 hours of scheduled BZD dosing
Longer acting BZDs
Diazepam and chlordiazepoxide
Gabapentin in Alcohol Withdrawal
Outpatient management
Mild withdrawal only and less sedating
Treatment of Relapse Alcohol
Psychosocial therapy ( drugs wont be beneficial without this) Naltrexone, acamprosate or disulfram
Naltrexone dose, AE, DI, counseling, use
50 mg QD or IM once monthly
Hepatotoxicity and injection site reactions
WILL CAUSE OPIOID WITHDRAWAL
First line agent
Naltrexone Benefits and Limitations
B: Once monthly
L: Hepatotoxicity and opioid meds
Acamprosate dose, AE, DI, use
TID
N/D, depression and anxiety
NO DRUG INTERACTIONS!!!
First line therapy
