Treatment of SUD Flashcards
3 Treatment Goals
- Treatment of acute overdose.
- Detoxification - controlled withdrawal.
- Maintenance of abstinent state; prevent relapse.
Opiates
- Acute Overdose
Overdose –> respiratory depression.
(+) opiate antagonist - naloxone (IV, nasal spray).
Available to IV drug users and their families.
Opiates
- Four Approaches of Detoxification
- “Cold Turkey”
- Methadone Detox
- Clonidine Treatment
- Antagonist-Accelerated Withdrawal
Opiates
Detox - Cold Turkey
Can be accelerated by administration of naloxone. Symptom relief with diazepam (sedative) and anti-diarrheal agents. (Gooseflesh withdrawal symptom.)
Opiates
Detox - Methadone
Administer oral methadone (cross dependence) to relieve symptoms; reduce dose on pre-determined regimen. Symptoms mild but intense craving is still present.
Opiates
Detox - Clonidine Treatment
Administer clonidine (centrally acting adrenergic alpha2-R agonist) to reduce symtoms of withdrawal from low - moderate opioid use. Inhibits firing of locus ceruleus neurons. Recall - The alpha2-R is present on pre-synaptic neurons and inhibits NE release. No longer used.
Opiates
Detox - Antagonist-Accelerated Withdrawal
- Administer naltrexone (opiate antagonist) for a rapid but severe withdrawal. (Used by some wealthy opiate addicts to reduce tolerance and begin using again.)
- Can also administer an anesthetic (midazolam) to induce a sedated state.
- Can also administer a partial opiate agonist (buprenorphine) to assist in detox.
Opiates
- Two Methods of Maintenance
Relapse is common during following days and months; relapse after one year drug free is < 20%.
- Methadone Maintenance - opioid agonist
- Antagonist or Partial Agonist Therapy
Opiates
Methadone Maintenance
Over a year+, legally supplied daily dose of oral methadone (opioid agonist) induces a high level of tolerance to other opiates. If you go out and shoot heroin, no high will result. Gives you time to break drug-seeking and using habits. Methadone is used bc its long 1/2-life gives stable levels of the drug.
Opiates
Antagonist or Partial Agonist Therapy
- After complete detox, give long-term oral naltrexone (antagonist, longer 1/2-life than naloxone) to block the effects of any self-administered opiate drug. Retention of patients is low because they will stop taking naltrexone during cravings to get high.
- Buprenorphine (partial agonist, mixed agonist-antagonist effects) block self-administered opiate effects but also produces a mild “high” that is different than a true heroin high.
Describe the logic behind combination buprenorphine/naloxone tablets.
Available via prescription for maintenance treatment of heroin and prescription opioid addiction. BUT people were starting to seek the medication for IV abuse.
- Sublingual - buprenorphine (partial agonist) is absorbed but naloxone (antagonist) is not; buprenorphine produces mild euphoria but also blocks the mu-R from any additional heroin.
- IV - naloxone (antagonist) is fully available and blocks all mu-R; prevents both the co-administered buprenorphine or heroin from having any euphoric effect.
Note - no studies of naloxone during pregnancy. Use buprenorphine alone.
Stimulants - Cocaine and Amphetamines
Review Mechanism and Toxicity
Cocaine - inhibits DAT, NET, SERT
Amphetamines - releases DA, NE, 5HT
Acute Toxicity
- Sympathetic Stimulation - cardiac arrythmias, HTN
- Central Stimulation - agitation, anxiety, decreased appetite
Chronic Toxicity
- Withdrawal Symptoms - depression, anhedonia, weight gain
Stimulants - Cocaine & Amphetamines
Acute Overdose and Withdrawal
NO specific treatments. Treat symptoms as needed.
Diazepam - controls agitation and seizures.
Beta-blockers - prevents arrhythmias.
Hydralazine - decreases BP.
Stimulants - Cocaine & Amphetamines
Maintenance
Nothing available to prevent cravings, which many report never go away. Investigating behavioral modification treatment.
Nicotine
Alternative sources - chewing gum, inhalers, patches.
Varenicline (Chantix) - partial agonist; reduces central stimulation by nicotine and reduces DA release.
Hallucinogens
Acute Overdose and Withdrawal
- Protect patient and others from psychotic behavior; “talk down” or quite reassurance is often best treatment but may not work with PCP.
- Symptomatic
- Diazepam - prevents convulsions.
- Haloperidol - treats psychotic episodes; avoid anticholinergic phenothiazines due to risk of anticholinergic-induced psychotic symptoms.
- Hydalazine - treat HTN.
Ethanol
- Acute Overdose
- Gastric lavage - prevents further absorption.
- Maintain cardiopulmonary function, temperature, acid-base balance.
- Give fluids to reverse dehydration.
- Give antacid to reduce gastric acid secretion (ranitidine, omeprazole, etc).
Treatment of Methanol and Ethylene Glycol Poisoning
- methanol –> formaldehyde
- ethylene glycol (antifreeze) –> glycoaldehyde, glycolic acid, oxalic acid
- give ethanol or fomepizole – compete for alcohol dehydrogenase, reduce formation of toxic metabolites
Alcoholism
- Withdrawal
- Fluids, electrolytes, thiamine, other vitamins.
- Seizures? Diazepam
- Hallucinations? Haloperidol
- Acid Secretion? Omeprazole, Ranitidine
Alcoholism
- Maintenance
- Social, psychotherapy (AA, etc.)
- Phamacologic Treatments
- Disulfiram (Antabuse) - aversion therapy, inhibits aldehyde dehydrogenase –> acetaldehyde builds up and causes unpleasant symptoms.
- Naltrexone - opiate antagonist, reduces reinforcing effects of ethanol; shown to decrease cravings and relapses.
- Acamprosate - unknown mechanism (inc GABA, dec Glu); reduces cravings and relapses.
