Exam 3 Flashcards
Naloxone (Narcan)- class, indication, when to rx, half life
Potent opioid
antagonist
* Treatment of choice for
opiate overdose
* Routinely prescribe for
all patients with opioid
use disorder
* Very short half life
Length of effects 30-90 min
Methadone (Dolophine)- class, administration, federal restrictions, monitoring for adverse effects
Long-acting full opioid
receptor AGONIST at mu
receptor
* 1x/daily
* Restricted federally licensed
substance abuse treatment
programs
* Monitor for QTC prolongation
(cardiac abnormalities)
Buprenorphine (Buprenex, Sublocade)
Buprenorphine/Naloxone(Suboxone)- class, effect, indication, med forms
- Partial Opioid receptor agonist/ opioid
antagonist - Decreases cravings; *** Opioid Use disorder w/ comorbid pain= Suboxone can be used in managing pain
- Can precipitate withdrawal if used too soon after full opioid agonist – it will displace any residual opioids from the mu receptors.
- Sublingual preparation that is safer= Suboxone: Waiver needed to prescribe in outpatient settings
- Suboxone= available Buccal film, sublingual film, sublingual tab
- Buprenorphine= Available sublingual tab; subdermal implant, SQ injection
naltrexone-
class, administration including forms, what patients is this good for? Adverse effect/monitoring
Competitive opioid antagonist
* Precipitate withdrawal if used
within 7 days of heroin use
* Available orally or monthly depot
injection.
Pill works approx. 24 hours; Injection may last up to 30 days.
* **Treatment of choice for highly
motivated patients.
* Risk for LFT elevation
- Available PO (Revia)
- Available IM (Vivitrol)
***NO LIQUID
What could inappropriate use of opioids indicate?
may be an indication that the patient’s pain is uncontrolled
Opioid intoxication sx and management
Drowsiness
N/V
↓GI motility (Constipation; abdominal cramps)
Sedation
Slurred speech
Miosis(constricted pupils)
Seizures
Respiratory depression
Arthralgia/myalgia
Mgt:
Airway support
In overdose, give Naloxone (opioid antagonist)
Ventilator if required
Patients art risk of overdose should be prescribed a naloxone (Narcan) kit to keep at home for emergencies.
Opioid withdrawal- sx, management, buprenorphine or methadone for withdrawal?
Flu-like symptoms (body aches, anorexia, rhinorrhea, fever)
Diarrhea
Anxiety
Insomnia
Mgt: Buprenorphine/naloxone; Clonidine, dicyclomine (Bentyl)
Moderate symptoms= Symptomatic treatment with;
Clonidine for autonomic s/s
NSAIDs for pain, Baclofen for muscular spasms
Benzos for anxiety & agitation
Loperamide for diarrhea
Dicyclomine for abdominal cramps
Promethazine for nausea
Antinausea medications
Hypnotics for insomnia (e.g. trazodone, low dose quetiapine, diphenhydramine)
NOTE: In clinical experience, when administered for detoxification and not maintenance, buprenorphine is more effective at suppressing and controlling withdrawal symptoms as the taper nears completion compared with methadon
cocaine intoxication- sx & tx
Euphoria
Heightened self esteem
Decrease BP
Tachycardia or bradycardia
Nausea
Dilated pupils
Psychomotor agitation or depression
Chills and sweating
Dangerous/Deadly: Seizures, cardiac arrythmias, paranoia, hallucinations
**NOTE: Cocaine has vasoconstrictive effects= can cause MI, stroke
Txt: Lorazepam
cocaine withdrawal- disulfiram (Antabuse) use, meds for sx, contraindicated med
disulfiram/Antabuse use in Cocaine use disorder = increase synaptic dopamine in the brain reward circuit and act as an agonist treatment in the setting of cocaine use disorder
NOTE: Medications for cocaine-induced chest pain and myocardial infarction = Nitroglycerin, Aspirin
**No Metoprolol
(Beta blockers are contraindicated in patients with cocaine induced chest pain – further lowers coronary blood flow thereby worsening ischemia)
ETOH intoxication
- Impaired fine motor control
- Impaired judgement and coordination
- Ataxic gait and poor balance
- Lethargy, difficulty sitting upright, difficulty with
memory, - Nausea/Vomiting
- Coma = Levels 300mg/dL and over
- Respiratory depression and death possible
(***Know ETOH Intoxication vs. Withdrawal)
ETOH withdrawal (mild/mod/severe)
(***Know ETOH Intoxication vs. Withdrawal)
Mild: Insomnia, Irritability, Hand tremor
Moderate: Autonomic hyperactivity (diaphoresis, tachy, HTN), Fever
Severe: Seizures (12-48 hours post consumption); Hallucinations; Delirium Tremens (48-96 hours after last drink)
* Anxiety
* Anorexia
* Nausea/Vomiting
* Psychomotor agitation
NOTE: Use the Clinical Institute Withdrawal Assessment(CIWA) to monitor withdrawal
CIWA protocol (what does it assess? number scale mild/mod/severe?)
Areas assessed – Nausea & vomiting, tremor, paroxysmal sweats, anxiety,
agitation, tactile disturbances, auditory disturbances, visual disturbances,
headaches, orientation
CIWA scoring and what it means.
* < 10= mild;
* 10-15= moderate
* 15+= severe
First line txs ETOH use disorder (class, effect, forms, special consideration for OUD)
naltrexone (Revia; IM-Vivitrol)
- Opioid receptor antagonist
- Can be used for both ETOH and Opioid Use disorders
- Reduces desire/cravings
- First line treatment
- PO or monthly injection (Vivitrol), Implant
- Will precipitate withdrawal in patients with physical opioid dependence
*metabolized by the liver
Acamprosate (Campral)
- Likely modulates glutamate transmission
- First line treatment in maintaining abstinence after detox
- Used for relapse prevention (post detoxification)
- Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
- Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
- Contraindicated in severe renal disease.
- Decreases craving
First line treatment in maintaining abstinence from ETOH after detox (MOA, use, metabolism, contraindication, effect)
Acamprosate (Campral)
Likely modulates glutamate transmission
* First line treatment in maintaining abstinence after detox
* Used for relapse prevention (post detoxification)
* Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
* Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
* Contraindicated in severe renal disease.
* Decreases craving
Disulfiram(Antabuse)- effect, concurrent ETOH use, what to avoid, contraindications, patient population
2nd line tx ETOH use disorder
Blocks enzyme(Aldehyde dehydrogenase) in the liver
*Causes aversion reaction to ETOH(flushing, headaches, n/v, palpitation, SOB, vertigo, hypotension)
** Do not administer until the person has been alcohol free at least 12 hours
* Educate patients to refrain from using
anything that contains alcohol (vinegar,
aftershave, perfumes, mouthwash, cough medicine) while taking and up to 2 weeks after discontinuation.
* Contraindicated in severe cardiac disease, pregnancy, psychosis
* For highly motivated patients
bupropion/Wellbutrin in ETOH use disorder
Bupropion increases the risk for withdrawal seizures in ETOH patients
Tx for ETOH withdrawal
Benzos(Lorazepam,
Diazepam, Chlordiazepoxide-
Librium)= To keep patient calm and lightly sedated
MOA: Enhance the effects of GABA
Tegretol, Valproic or Gabapentin= use in mild withdrawal
Thiamine, folic acid and
multivitamin= for nutritional deficiencies
Thiamine (to prevent or
treat Wernicke’s encephalopathy= B1 deficiency) and Folate
Fluid and electrolyte balance
leading causes of death in patients with serious mental illness
The leading causes of death in patients with serious mental illness are heart disease, cancer, and cerebrovascular or respiratory disease, which can all be linked to smoking
tobacco use disorder tx options (3)
VARENICLINE(CHANTIX)
* Mimics action of Nicotine
* ***The most effective tobacco cessation
* Reduces rewarding aspects
* Prevents withdrawal symptoms
BUPROPION
(ZYBAN)
* Inhibits reuptake of dopamine and norepinephrine
* Helps reduce craving and withdrawal symptoms
NICOTINE
REPLACEMENT
THERAPY(NRT)
* Available as transdermal patch, gum, lozenge, nasal spray and inhaler
* Nicotine patch- watch for vivid dreams or sleep disruptions
WELL KNOWN METHODS TO PROVIDE BRIEF STOP
SMOKING ADVICE
5A’s:
1. Ask for the smoking status
2. Brief advice to quit
3. Assess the motivation to quit
4. Assist by providing evidence-based
treatment
5. Arrange Follow-up
ABC method/Ask and Act:
1. Ask
2. Brief advice
3. Cessation support
** Every smoker would receive an offer for treatment regardless of their motivation to treat status**
Substances r/t sexual dysfunction
Overall, substances such as alcohol, Cocaine and opioid use disorder can lead to sexual dysfunction.
What med is good for insomnia in substance use disorders?
Gabapentin has been considered as a treatment for insomnia in patients with substance use disorders - also helps with anxiety ( No sedative effects, not metabolized by the liver, does not lower seizure threshold, no blood monitoring)
For geriatric pt, if TCA needed, which is safest?
If TCA is indicated = consider Nortriptyline(fewer anticholinergic side effects)
Tx for elderly with MDD and decreased appetite
Consider mirtazapine (Remeron) = MDD w/ symptoms of insomnia and decreased appetite
Med that can be used as adjunct w/ antidepressants in elderly if severe depression and/or psychomotor retardation
Methylphenidate= can be used in low doses as an adjunct to antidepressants
for patients with severe depression and/ or psychomotor retardation.
Delirium in elderly (what it is, acute/chronic?, subtypes, causes)
- Medical Emergency
- Reversible
- 40% mortality
- Commonly experienced by patients in the ICU and post-op
A person with delirium may experience changes in their awareness of where they are. They may seem “out of it,” lethargic or uninterested in their surroundings. They may be confused, anxious, or see or hear things that are not there. Thinking and remembering are impaired, and anxiety, euphoria or fear may occur
- Develops over hours to days = Acute
- Subtypes: Hyperactive (agitated, restless, hyperalert); Hypoactive(lethargic, slowed,
apathetic); Mixed(cycles between hyperactive and hypoactive - Causes: DELIRIUM(Drugs, Electrolyte imbalance, Low oxygen sat, Infection, Reduced sensory input, Intracranial(strokes), Urinary retention, Myocardial)
Types of Dementia
- Group of disorders characterized by gradual development of cognitive deficits
- Irreversible
Types:
1. *Alzheimer’s disease (AD)= most common
2. *Vascular disease = 2nd most common
3. *Lewy body disease (LBD)
4. *Frontotemporal degeneration (FTD)
5. HIV infection
6. Huntington disease (HD)
Etiology of SUD (neurotransmitter/pathway, etc)
- Positive rewards of reinforcement= mediated by DA pathways
- Reinforcement occurs in the Ventral tegmental area (VTA) and the Nucleus accumbens (Reward center)
- DA release within the reward center is enhanced = by the release of natural morphine-like neurotransmitters(Neuropeptides- enkaphalins, beta endorphins)
- Repeated drug use= DA system becomes increasingly sensitized
Acamprosate (Campral)- MAO, indication, contraindication, effect
Likely modulates glutamate transmission
* First line treatment in maintaining ETOH abstinence after detox
* Used for relapse prevention (post detoxification)
* Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
**** Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
* Contraindicated in severe renal disease.
***** Decreases craving
When to consider Acamprosate?
after ETOH detox to prevent relapse ?
Topiramate(Topamax)- indication, MAO, effect, SEs
2nd line for ETOH use disorder
anticonvulsant
- Potentiates GABA and inhibits Glutamate
- Reduces cravings
- For SE remember DOPE-a-max (impaired cognition, nausea, weight loss, metabolic acidosis.
withdrawal tx for ETOH use disorder (mild vs mod/severe)
- Benzos(Lorazepam, Diazepam, Chlordiazepoxide-Librium)= To keep patient calm and lightly sedated
MOA: Enhance the effects of GABA - Tegretol, Valproic or Gabapentin= use in mild withdrawal
- Thiamine, folic acid and multivitamin= for nutritional deficiencies
- Parenteral Thiamine (to prevent or treat Wernicke’s encephalopathy= B1 deficiency) and Folate
- Fluid and electrolyte balance
Banana Bag ingredients/What are we trying to prevent?
thiamine, multivitamin, folic acid, magnesium sulfate in a saline solution
to prevent or treat Wernicke’s encephalopathy= B1 deficiency
Cocaine withdrawal sx
Post intoxication depression “Crash”
- Fatigue
- Malaise
- Hypersomnolence
- Depression
- Anhedonia
- Hunger
- Constricted pupils
- Vivid dreams
Tx options for cocaine use disorder
NO FDA approved med
Off-label= Naltrexone, modafinil, Topamax
Supportive care (control HTN, arrhythmias)
Mild-moderate agitation= Benzodiazepines
Severe agitation or psychosis – antipsychotics
amphetamines (intoxication/withdrawal/tx)
- Classic amphetamines vs. Substituted (designer , club drugs, MDMA – ecstasy, MDEA- eve)
- Often used in dance clubs and raves
- Have both stimulant and hallucinogenic properties
- Intoxication is similar to cocaine
- Can cause ongoing psychosis
- Withdrawal can cause prolonged depression
Txt: Rehydrate, correct electrolyte and treat hyperthermia
Phencyclidine (PCP) intoxication/tx
Rage
Erythema
Dilated pupils
Delusions
Amnesia
Nystagmus
Excitation
Skin dryness
Txt: Supportive care (rehydration, electrolyte balance etc.)
Benzos for agitation, anxiety, muscle spasms
Haldol for severe agitation and psychosis
Phencyclidine (PCP) withdrawal
No withdrawal
Recurrence of intoxication due to release of the drug from body lipid stores.
Sedative hypnotic intoxication
Benzos, barbiturates, Zolpidem, zaleplon, GHB(date rape drug), etc
Intoxication:
Drowsiness
Confusion
Hypotension
Slurred speech
Incoordination
Ataxia
Mood lability
Impaired judgment
Respiratory depression or death in OD
Biggest risk of sedative hypnotic withdrawal
Abrupt abstinence after chronic use can be life-threatening/seizures
Sedative hypnotic intox. tx
Intoxication Treatment:
Maintain airway, breathing and circulation
Supportive care (improve respiratory status, control hypotension)
Activated charcoal and gastric lavage to prevent further GI absorption= in Overdoses
***Benzos= Flumazenil in OD (Benzo antagonist)
Sedative hypnotic withdrawal tx
Withdrawal Treatment:
Benzodiazepines (stabilize patient and taper gradually)
Carbamazepine or valproic acid (taper not as beneficial)
Marijuana (cannabis, pot, weed, grass) benefits and intoxication
Contains THC(tetrahydrocannabinol) which produces the “high”
Benefits:
N/V; increasing appetite in AIDS patients, chronic pain from cancer and lowering intraocular pressure in glaucoma
Intoxication:
Euphoria, anxiety, impaired motor coordination, mild tachycardia, Conjunctival injection “red eyes”, dry mouth, Munchies= increased appetite
Cannabis induced Psychotic d/o= paranoia, hallucinations and delusions
Marijuana (cannabis, pot, weed, grass) withdrawal/tx
Withdrawal:
Irritability, anxiety, restlessness, aggression, strange dreams, depression, headaches, insomnia, low appetite
Supportive care
Based on symptoms
Nicotine effect and withdrawal
Effects:
Restlessness
Insomnia
Anxiety
Increased GI motility
Withdrawal:
Intense craving
Dysphoria
Anxiety
Poor concentration
Increased appetite
Weight gain
Irritability
Restlessness
Insomnia
Opioids effect on body
Opioid medications/drugs stimulate mu, kappa and delta opiate receptors
Effects on the dopaminergic system which mediates their addictive and rewarding properties
Opioid agonist therapy effect on mortality
Opioid Agonists (Buprenorphine/Methadone)
Decreased mortality d/t overdose
Opioid antagonists and considerations with substance use
Opioid Antagonists (Naltrexone)
Precipitates withdrawal in patients actively using opioids
Need to successfully complete opioid withdrawal prior to treatment (at least 7 days w/o opioids)
buprenorphine vs methadone
Buprenorphine
Preferred as initial treatment
Lower risk of death in overdose – lower potential of causing respiratory depression.
Providers can prescribe this in outpatient settings – no waiver required.
Fewer drug-drug interactions.
Methadone
For individuals with high tolerance
Appropriate for patients with higher level o f physical dependance or prior misuse/diversion of buprenorphine
Requires daily visits to a licensed opioid treatment program (OTP)
What med for OUD w/ comorbid pain
Suboxone can be used in managing pain
What can happen if buprenorphine started too soon after last opioid use
If buprenorphine is used too soon after a patient’s last opioid use, Buprenorphine will displace any residual opioids from the μ receptors and can precipitate withdrawal symptoms
Hallucinogen intoxication sx/tx
Illusions
Hallucinations
Body image distortions
Labile affect
Dilated pupils
Tachycardia
HTN
Hyperthermia
Tremors
Incoordination
Sweating
Palpitations
Txt: May use Benzos and antipsychotic medications for agitation
Hallucinogen withdrawal
Does not cause physical dependence or withdrawal
Inhalant (what are they?) & intoxication sx/tx
Inhalants generally act as CNS depressants
Most common in preadolescents or adolescents
E.g. solvents, glue, paint thinners, fuels, isobutyl nitrates (“huffing” “laughing gas” “rush”)
Intoxication
Perceptual disturbances
Paranoia
Lethargy
Dizziness
Nausea/vomiting
Headache
Nystagmus
Tremor
Muscle weakness
Ataxia
Slurred speech
Euphoria
Clouding of consciousness
Stupor or coma
Txt: Airway monitoring; Chelation depending on solvent
Inhalant withdrawal & tx
Does not usually occur
Irritability
Sleep disturbance
Anxiety
Depression
Nausea/vomiting
Craving
No specific tx (I guess tx sx/emergencies?)
Inhalant and other Psychoactive Substance Use disorders
Loss of ability to control the use of inhalants
Compulsivity to use inhalants
Negative emotional state when not sniffing/breathing inhalants
Common among teenagers
E.g., volatile solvents, aerosols, gases, nitrites
Methods: Sniffing, spraying into nostrils or mouth, bagging, huffing- breathing in from rag soaked with the chemical; inhalation from balloons
Clinical presentation inhalant/psychoactive use disorder
Ataxia
Smell of chemicals on body or clothing
Sores and scabs around nose and mouth (Glue Sniffer’s rash)
Slurred speech
Drowsiness
Headaches
Emergency effects inhalant/psychoactive use disorder
Agitation
Fever
Seizures
Hallucinations
Confusion
Loss of consciousness
Coma
Fatal accidental injury
treatment/management inhalant/psychoactive use disorder
Treat presenting symptoms
Benzodiazepines for managing withdrawal and emergency symptoms (e.g., Valium, Lorazepam.
Caffeine use disorder/ intoxication & tx
Caffeine is Most used psychoactive substance in the United States
Coffee, tea or energy drinks
Intoxication
Anxiety
Insomnia
Muscle twitching
Rambling speech
Flushed face
GI disturbance
Restlessness
Excitement
Tachycardia
More than 1g= tinnitus, severe agitation, cardiac arrhythmias
More than 10g = Death can occur secondary to seizures and respiratory failure
Txt: Supportive and symptomatic
Caffeine withdrawal
Occurs if cessation is abrupt
Headache
Fatigue
Irritability
Nausea
Vomiting
Drowsiness
Muscle pain
Depression
Geriatric considerations w/ SUD
When assessing and treating older adults, clinicians not only need to take the above factors into account but also need to consider the potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants.
The Alcohol Use Disorders Identification Test (AUDIT) and the CAGE often a`re used to screen for at-risk substance use or misuse among older adults
Alcohol problems are common among older adults.
The use of pharmaceutical drugs is prevalent in older adulthood, and the risk of misusing prescription and over-the-counter medications, which include substances such as sedatives/hypnotics, narcotic and nonnarcotic analgesics, diet aids, and decongestants, also increases with age.
Incidentally, benzodiazepines also tend to be one of the most inappropriately prescribed psychotherapeutic medications among older adults
Screening tool for alcohol use disorder in geriatric population
The Alcohol Use Disorders Identification Test (AUDIT) and the CAGE often are used to screen for at-risk substance use or misuse among older adults
Tx considerations in geriatric population
Clinicians should be cautious when prescribing or recommending a treatment, take both risks and benefits into account when determining a treatment plan, and clearly communicate guidelines for appropriate use to patients.
Clinicians also should carefully consider discontinuing medications that do not prove effective
Illicit drug use among older adults is rare.
Thus, rates of illicit substance use and abuse among older adults will likely continue to rise in the next several decades because of the aging of the baby boom cohort.
When assessing and treating older adults, clinicians not only need to take the above factors into account but also need to consider the **potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants.**
Alcohol, Cocaine and opioid use disorder can lead to sexual dysfunction T/F
true
Withdrawal seizures are commonly associated with which substances?
Bzo’s, etoh
If a TCA is indicated in geriatric patient, what TCA & why?
consider Nortriptyline(fewer anticholinergic side effects)
Med for geriatric pt with MDD + sx insomnia and/or decreased appetite
mirtazapine/Remeron
