week 9 Substance use DOs/Addictive DOs Flashcards
what is the primary nuerotransmitter involved in addiction?
dopamine
what key areas are involved in addiction?
dopamine mesocorticolimbic system,
ventral tegmental area (VTA), nucleus accumbens amygdala
olfactory tubercle.
whats the tx for Mild to moderate alcohol intoxication?
no formal tx
whats the tx for severe alcohol intoxication (blood alcohol levels > 300 mg/dl, death >
400 mg/dl) ?
Hint: maintain prevention hourly
Maintain cardiopulmonary functions.
Prevention of aspiration.
Hourly Serial blood alcohol levels.
whats used to prevent Warnicke’s encephalopathy in alcohol intoxication?
Thiamine 100 mg IM/IV daily X3 preceding administration of glucose containing solutions
what can be given (if necessary) for agitatioin in alcohol intoxication?
Haloperidol
what drug class must be avoided during acute intoxication (alcohol)?
benzodiazepines
what medical problems need to also be managed in stimulant intoxication?
hyperthermia, HTN, cardiac arrhythmias, stroke, and seizures.
what drugs are used to manage psychological problems in stimulant intoxications?
Benzodiazepines Antipsychotics
what are serious s/s of opioid intoxication?
cardiac/respiratory depression
what is given to reverse opioid intoxication?
naloxone
What are Goals of treatment for withdrawal from ethanol, cocaine, amphetamines, and opioids ?
Evaluation of withdrawal symptoms.
Is pharmacologic intervention is necessary?
Management of medical consequences.
Referral for substance abuse program.
what are the 4 different alcohol withdrawal syndromes?
- Uncomplicated.
- With seizures.
- With delirium (delirium tremens).
- With hallucinations (Alcohol hallucinosis).
how are symptoms of UNCOMPLICATED ALCOHOL WITHDRAWAL rated?
Hint: see water
using a validated scale e.g., Clinical Institute Withdrawal Assessment Scale for Alcohol- Revised (CIWA-Ar). Ratings are: 8-10 outpatient Tx > 15 inpatient Tx > 20 pharm Tx (always)
what are evidence based treatment of choice for uncomplicated alcohol wd?:
Benzodiazepines are evidence based treatment of choice: Lorazepam Oxazepam Diazepam Chlordiazepoxide
what is tx for ALCOHOL WITHDRAWAL SEIZURES?
Requires medical treatment Benzodiazepines: Diazepam IV Lorazepam IV/IM Electrolyte imbalances Thiamine IV/IM
whats the tx for ALCOHOL WITHDRAWAL DELIRIUM, DELIRIUM TREMENS (DT)?
Acute care management Parenteral benzodiazepines: Diazepam IV Lorazepam IV/IM Antipsychotics? Thiamine IV/IM
whats the tx for ALCOHOLIC HALLUCINOSIS (Usually auditory)?
Antipsychotics agents
is there pharm tx for stimulant (cocaine, amphetamine)w/d?
No data to support medication use
what does opiod w/d tx consist of?
Usually not life threatening
Manage and stabilize medical conditions
Clinical withdrawal scale (COWS)
Symptomatic treatment to minimize withdrawal
symptoms
Treatment
µ - opioid agonist (methadone) Only at federally approved methadone clinics.
µ - partial agonist (buprenorphine)
Buprenorphine + naloxone (Suboxone); SL filmtabs, SL tabs
2 mg/0.5 mg or 8 mg/2 mg
Buprenorphine (generic); SL tabs
what are s/s and tx for stimulant w/d (cocaine, amphetamines)?
Profound depression with suicidal thoughts
Usually outpatient care
No data to support medication use
what are some components for nicotine w/d tx?
NICOTINE WITHDRAWAL
Standard of care to provide smokers with advice and assistance to quit, or referral to specialized services.
Several neurotransmitters are affected
CAGE, 4 C’s, and the Fagerstrom test for nicotine dependence
All nicotine replacement therapies are regulated
by FDA.
what are the components of the CAGE QUESTIONNAIRE FOR NICOTINE DEPENDENCE?
- Have you ever felt a need to CUT down or control your smoking, but had difficulty doing so?
- Do you ever get ANNOYED or angry with people who criticize your smoking or tell you that you ought to quit smoking?
- Have you ever felt GUILTY about your smoking or about something you did while smoking?
- Do you ever smoke within half an hour of waking up (EYE-opener)?
- —Two “yes” responses constitute a positive screening test.
how to ASSESS NICOTINE ADDICTION USING THE “FOUR CS” TEST?
Qs on: compulsion control consequences cutting down (and w/d sx)
what are therapies for smoking cessation?
nicotine patch nicotine gum nicotine lozenge nicotine nasal spray nicotine vapor inhaler bupropion clonidine varenicline TCADs (nortriptyline, doxepin)
what are NON-PHARMACOLOGIC TREATMENTS FOR TOBACCO CESSATION?
Behavioral treatment increases abstinence rates (5 A’s) Ask if they smoke Advise to quit Assess motivation for change Assist if willing to change Arrange for follow-up
How to assist if a patient wants to quit smoking with Bupropion?
Start bupropion-sr 1-2 weeks before quit date
Help the patient set a quit date
Remove all tobacco products the night before the quit date
Follow-up with the patient on the quit date or the next day for support
Provide NRT: patch, nasal spray, mouth inhaler, gum, or lozenge
Identify and educate a support person
Educate about the high risk for relapse and how to cope with it: “don’t quit quitting”
what are some goals of treating SUBSTANCE DEPENDENCE/goals in recovery from addiction?
develop a sober social network
develop coping skills
(e.g., 12 -step)
relapse prevention skills/strategies (toolbox of coping skills)
addressing/processing hx of conflicts, abuse etc in life
searching for spiritual meaning in life
what are NON-PHARMACOLOGIC THERAPY for addiction recovery?
Psychotherapy should be core therapeutic strategy MET (motivational enhancement therapy) CBT TSF (12-step facilitation) Contingency management Group Therapy
what is the PHARMACOLOGIC THERAPY-MAINTENANCE THERAPY for alcohol dependence?
Disulfiram
Natrexone
Acamprosate
what are the aspects of DISULFIRAM in alcohol dependence Tx?
Classic ethanol-disulfiram reaction
Negative reinforcement, drinking is avoided to prevent unpleasant effects.
Dose: 250 mg orally/daily (range 125- 500 mg daily)
only after the blood alcohol level is zero.
Adverse effects:
Rash, drowsiness, metallic or garlic-like taste, and HA
Optic neuritis, peripheral neuropathy, hepatotoxicity
Monitoring:
Baseline LFT’s and periodic assessment (q1-6 months)
Drug interactions:
Warfarin (increased INR)
Phenytoin, Theophylline (increased blood levels)
Benzodiazepines (except lorazepam, temazepam and oxazapam) (increased blood levels)
what are the aspects of NALTREXONE in alcohol dependence Tx?
Competitive opioid antagonist especially at µ- opioid receptors, that decreases alcohol intake
Decreases relapse to heavy drinking, but not for total continuous abstinence.
Contraindicated in patients with severe liver and renal impairment
Dose:
Oral,50 mg/day (range (25-100 mg)
IM, 380 mg once monthly
Dosage forms:
Tabs, 50 mg (Depade, ReVia)
IM Suspension, 380 mg (Vivitrol)
Adverse effects:
Nausea, headache, fatigue, and nervousness
Monitoring:
Baseline LFT’s and periodic assessment (q1-6 months)
Drug interactions:
Opioids (decreased effects)
Acamprosate (increased bioavailability, minor clinical significance)
what are the aspects of ACAMPROSATE in alcohol dependence Tx?
NMDA receptor antagonist Increases continuous abstinence rates in alcohol dependent patients for periods of 3-12 months. Dose: Oral, 666 mg tid CrCl 30-50 ml/min: 333 mg tid CrCl < 30 ml/min: avoid use Dosage forms: Tabs, 333 mg (Campral) Adverse effects: Nausea, vomiting, and diarrhea Possibly increased rates of suicidal thinking Monitoring: Baseline renal function for CrCl Drug interactions: naltrexone (increased bioavailability of acamprosate, minor clinical significance)
what are the Tx strategies for STIMULANT DEPENDENCE
?
No proven therapies for cocaine or amphetamine dependence
Disulfiram 250 mg/day has been used investigationally in treating cocaine dependence in combination with CBT.
what are the Tx strategies for opioid dependence?
Maintenance therapy may be appropriate for those patients who have failed one or more trials of abstinence. 2 strategies Opioid agonists Methadone- black box warning for QT prolongation and respiratory depression. buprenorphine Opioid antagonists Naloxone Naltrexone
what are the aspects of opioid agonists?
Methadone
Buprenorphine + naloxone (Suboxone)
Dose: 8-16 mg day (maximum 64 mg/day)
Dosage forms:
SL filmtabs, 2 mg/0.5 mg or 8 mg/2 mg (Suboxone)
SL tablets, 2 mg/0.5 mg or 8 mg/2 mg (Suboxone)
Buprenorphine (generic); SL tabs
Adverse effects:
Oral hypoesthesia, respiratory depression, headache, abdominal pain, constipation, vomiting, glossodynia, oral mucosa erythema, intoxication, disturbances in attention, palpitations, insomnia, withdrawal, hyperhidrosis, and blurred vision.
Monitoring:
Baseline LFT’s and periodic assessment (every 1-6 months)
Drug interactions:
CNS depressants (alcohol, opioids, benzodiazepines) CYP3A4 inducers: decreased buprenorphine levels CYP3A4 inhibitors: increased buprenorphine levels
Clonidine: increased blood pressure with naloxone component sodium oxybate; contraindicated due to additive CNS depression
what are the aspects of opioid antagonist(s)?
Naltrexone
Previously detailed on
earlier slide.
Long acting for health professionals or others that are motivated to maintain abstinence.
(Agbeli DB tip) what can aid in preventing of Wernicke Encephalopathy in alcohol withdrawal?
thiamine administration
(Agbeli DB tip) (in RED) what Tx is there for opioid use DO with comorbid pain?
(in RED) Suboxone can be used in managing pain
• (Agbeli DB tip) (in RED) Inappropriate use of opioids may be an indication that the patient’s pain is uncontrolled. True or False?
(in RED) True
• (Agbeli DB tip) (in RED) When to consider Acamprosate when managing alcohol use disorder in recovery?
(in RED) Safe for use in Hepatic dysfunction
MOA of Buprenorphine?
Buprenorphine is a partial agonist at the mu receptor, meaning that it only partially activates opiate receptors
• What is a concern if buprenorphine is initiated too soon after a patient’s last opioid use?
can induce withdrawal symptoms in patients dependent on opioids if it is administered quickly after the last dose of a pure agonist like fentanyl or oxycodone.
• Mechanism of action for naloxone (rapidly reverses an opioid OD)?
Naloxone is thought to act as a competitive antagonist at mc, κ, and σ opiate receptors in the CNS; it is thought that the drug has the highest affinity for the μ receptor.
can suboxone (Buprenorphine/Naloxone) be used for chronic pain?
yes
• Delivery methods for naltrexone ?
po, injection, implant, (NO LIQUID)
• Signs of opioid intoxication/withdrawal?
Acute Intoxication- Tx with naloxone. *Respiratory depression-low RR *Hypotension Bradycardia Hypothermic *Miosis (excess. pupil constriction) unconscious USE NALOXONE
Withdrawal *anxiety *Increased lacrimation *Muscle aches *Abdominal cramps and diarrhea USE BUPRENORPHINE/NALOXONE (suboxone) CLONIDINE BENTYL
what can be used for both ETOH and Opioid use DO?
naltrexone
MOA of disulfiram?
irreversibly inhibits aldehyde dehydrogenase (ALDH1A1) by competing with nicotinamide adenine dinucleotide (NAD)
Banana bag ingredients?
thiamine, multivitamin, folic acid
antabuse use in cocaine DO does what?
increase synaptic dopamine and acts as an agonist Tx
what are memory tools used as a brief intervention in smoking cessations?
Five A’s
Ask n Act
ABC
what re meds for cocaine-induced chest pain?
nitroglycerin
aspirin
NO metoprolol
what re the intoxication/withdrawal Sx for cocaine?
intoxication: auditory hallucinations agitation violent behavior muscle twitching tachycardia USE LORAZEPAM
withdrawal:
often no visible Sx
fatigue
irritability
