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Pharm III > Lecture 8 (psych)- Exam 4 > Flashcards

Lecture 8 (psych)- Exam 4 Flashcards

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1
Q

*

A
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2
Q

Generalized Anxiety Disorder
* What is it? How long is the period?
* Patient exhibits what?
* Worry associated with what?

*

A
  • Persistent, excessive anxiety occurs most days in a 6-month period
  • Patients exhibit worry or apprehension that is difficult to control
  • Worry associated with ≥ 3 of the following:
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3
Q

What is the monitoring tool for anxiety? What are the levels?

levels LY

A

GAD 7

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4
Q

What is the first line treatment for GAD?

A
  • Cognitive behavioral therapy OR
  • Pharmacotherapy
  • Cognitive behavioral therapy plus pharmacotherapy (more severe cases)
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5
Q

GAD treatment
* Treatment part of what?
* _ preference
* What are other treatment add ons

A
  • Treatment modality part of shared decision making with patient
  • Patient preference
  • Exercise, meditation, socialization, etc.
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6
Q

GAD - pharmacotherapy
* What is the first line meds? Start how?
* What should you follow?

A
  • SSRIs and SNRIs
  • Start at lowest end of dose range – some suggest starting at 50% below usual starting dose for depression
  • Following same dosing / titration guidelines as when treating depression
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7
Q

GAD - pharmacotherapy
* What are adjunctive treatment? (2)

A
  • Hydroxyzine pamoate (anti-histamine)
  • Benzodiazepines (not first line for maintance-short term)
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8
Q

GAD - pharmacotherapy
* What are the alternative treatments?(3)

A
  • Buspirone
  • Pregabalin
  • Mirtazapine
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9
Q

Hydroxyzine pamoate
* What type of drug?
* What is the MOA?

A

Antihistamine

MOA:
* Competes with histamine for H1-receptor binding sites
* Antagonist of 5HT2A, DAD2 and alpha1 receptors

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10
Q

Hydroxyzine pamoate
* What are the SE? (3)

A
  • Drowsiness (before bedtime)
  • Orthostatic hypotension
  • Dizziness
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11
Q

Buspirone
* What is the MOA?
* How long should you wait before determining effectiveness?

A
  • 5HT1A agonist at postsynaptic membrane; exact mechanism unknown
  • Give minimum of 4 to 6 weeks at maximumly tolerated dose before determining effectiveness

  • Initial dose 10mg/day; titrate dose every 1 to 2 weeks to maximum of 60mg/day
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12
Q

Buspirone
* When is it used?

A

Used as second-line treatment
* Patients who do not tolerate first-line therapies
* Adjunct for patients not responding to maximum doses of first-line therapy

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13
Q

What are the SE of buspirone (4)

A
  • Dizziness
  • Nausea
  • Drowsiness
  • Headache
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14
Q

What is GABA?

A

Gamma-aminobutyric acid
* MC inhibitory neurotransmitter in the human brain

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15
Q

Benzodiazepines
* Gaba agonist cause what? (4)

A
  • Sleep
  • Anxiety relief
  • Muscle relaxation
  • Memory impairment
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16
Q

Benzodiazepines (BDZ)
* What is the MOA?

A
  • Bind to GABAA receptors at a site separate from GABA receptor sites and stimulates the release of GABA
  • GABA activation increases the frequency of GABA receptor opening allowing the influx of more Cl- ions
  • Cl- ion influx causes the cell to be more negatively charged (hyperpolarized)
  • Less likely to fire an action potential or respond to stimuli

Benzo increase freq vs barb open cl channels longer

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17
Q

Benzodiazepines (BDZ)
* Inhibit the effects of what?

A

BZD inhibit the effects of neurons that are responsible for anxiety and arousal

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18
Q

Benzodiazepines (BDZ)
* What are the disorder that CNS depressants are used for? (6)

A
  • Anxiety
  • Panic disorder
  • Seizures
  • Insomnia
  • Anesthesia
  • Treatment alcohol withdrawal
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19
Q

What are the short (4), intermediate (3) and long acting (3) BDZ?

A

Short: ATOM
Intermed: TLC
Long: FDC

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20
Q

BDZ
* Benzodiazepines with shorter elimination half-lives are more likely to produce what?
* Benzodiazepines with longer elimination half-lives usually produce more what?

A
  • Benzodiazepines with shorter elimination half-lives are more likely to produce acute withdrawal on abrupt cessation after prolonged use
  • Benzodiazepines with longer elimination half-lives usually produce more delayed and somewhat attenuated withdrawal symptoms
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21
Q

What are the BZD safe for liver dysfunction? Why?

A

Oxazepam, temazepam and lorazepam (LOT)-> because metabolism is conjugation

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22
Q

BDZ
* What are the SE? (6)

A
  • Sedation
  • Dizziness
  • Impaired coordination
  • Decreased reaction time
  • Decreased problem solving
  • Amnesia
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23
Q

BDZ
* What is going on with the beer’s list?

A

not recommended for older adults; increased risk of side effects and falls
* Use smallest dose of short-acting agents without active metabolites

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24
Q

BDZ
* What is the issue with combined substances?(3) What are the substances?(3)

A

ETOH, opioids, CNS depressants
* Combined use increases risk of respiratory depression, coma, and death

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BDZ * Not recommended for what? * What is the major SE? (3) * **What is the antidote?**
Not recommended for long-term use * Risk of tolerance, dependence, withdrawal signs and symptoms, abuse – taper slowly Zzzzs (sleepy), hypnotic, sedative **Overdose – flumazenil = antidote**
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BDZ * Most are Metabolized by what? * Not recommended for patients with what? * What are the three agents?
Most benzodiazepines metabolized by CYP450 enzymes to active metabolites Not recommended for use in patients with liver dysfunction Three agents that can be used: * Lorazepam * Oxazepam * Temazepam
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BDZ - Taper * When do you need to taper?
If daily treatment for > 4 weeks * Taper by 25% per week; slower at end of taper * Consider changing equivalent dose of long-acting BDZ (diazepam, clonazepam)
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BDZ - Taper * What are the signs of withdrawal? what should you do?
* Agitation, insomnia, irritability, GI symptoms * Stop taper; hold dose for 1 to 2 weeks and resume taper * Avoid increasing dose if possible
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Panic Attack * Feature of what? * What is Panic attack?
* Feature of many anxiety disorders but not a disorder in and of itself * Panic attack: period of extreme anxiety that peaks w/in 10 minutes and declines in 30-60 minutes
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Panic Attack * Associated with what?
Associated with ≥ 4 of the following:
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Panic disorder * What is the criteria for dx?
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Panic Attacks and Panic Disorder * What is the nonpharm therapy?
CBT (most effective); biofeedback relaxation, desensitization
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Panic Attacks and Panic Disorder * What is the short term and maintenance treatment?
Short-term treatment * Benzodiazepines for acute management short-term management or rescue therapy( ex GAD with triggers/attacks) * Avoid in patients with a history of substance abuse Maintenance treatment * SSRIs * SNRI-venlafaxine Continue medication for 8-12 months; risk or relapse 25 to 50%
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Phobias * What are the types?
Specific and social Five Types: * Animal * Natural environment * Blood injection injury * Situational (social, agoraphobia) * Other
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Phobias * What is it? * Patient has insight of what?
* Irrational fear/ anxiety when presented with an object or situation resulting in fear and/or avoidance of trigger * Patient has insight that fear is irrational
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Phobias - Treatment: Social phobias and agoraphobia * What are the 3 options? (general)
* No treatment * CBT with exposure and desensitization preferred * Pharmacotherapy
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Phobias - Treatment: Social phobias and agoraphobia * What are the examples of pharm therapy?(3)
* Beta-blockers (propranolol and atenolol)-> Performance anxiety * SSRIs – limited benefit * Benzodiazepines – short-term (flight anxiety)
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Acute Stress Disorder * Sx occur when? * Most prevalent when?
* Symptoms occur w/in one month of traumatic event and last from 2 days to 4 weeks * Most prevalent in younger ages
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Acute Stress Disorder * What is the txt? What is not helpful?
* Trauma-focused CBT-> Reduces symptoms and progression to PTSD * Anxiolytics (benzodiazepines) – short term * **Antidepressants generally not helpful**
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Posttraumatic Stress Disorder (PTSD) * What is the criteria for it?
The trauma is persistently re-experienced (>1 month) has ≥ 1 of the following: * Intense memories * **Disturbing dreams * Repeatedly reliving the event** * Physiologic distress when exposed to reminders of the trauma * Avoidance of stimuli that remind patient of the event
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Posttraumatic Stress Disorder * What is the first line txt?
* Trauma-focused psychotherapy * Exposure * Exposure + CBT * Eye Movement Desensitization and Reprocessing (EMDR)
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Posttraumatic Stress Disorder * When do you use pharmacotherapy? What are the medications?
Alternative based on patient preference / access to psychotherapy * SSRIs first-line pharmacotherapy * Paroxetine and sertraline most studied
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PTSD * No difference in what?
No difference in outcomes if psychotherapy combined with pharmacotherapy
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Posttraumatic Stress Disorder * What is the first line for sleep disturbance/nightmares?
Sleep disturbance / nightmares * First-line: prazosin (+therapy) * Take 30 to 60 minutes before bedtime * Reduction of nightmares / sleep disturbances in 50% of patients | Pra(y)zosin before bed
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What is the MOA of prazosin?
* blocking central alpha-1 receptors in the brain, which might lead to better, deeper sleep
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Obsessive compulsive disorder * What are obsessions and compulsions?
* Obsessions: recurrent intrusive thoughts that lead to anxiety * Compulsions: actions to decrease anxiety from the obsessions
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OCD Treatment: * What is first line? (general)
Systematic desensitization and pharm
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OCD Treatment: Behavioral * What is the systematic desensitization?
* Exposure ritual/response prevention (ERP) has been demonstrated to be the most effective treatment for OCD. * Cognitive behavior therapy * Thought stopping
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OCD Treatment: Behavioral * What is the pharm?
Selective Serotonin Reuptake Inhibitors (SSRIs) – first-line (high-dose usually required) **Clomipramine (TCA) may be an adjunct to an SSRI in some patients**(first line) * 40 to 60% of patients will respond to pharmacotherapy * Response = decrease in symptoms by 20 to 40%
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What is the description of AN? What is the treatment? | *
Description: * Patients have distorted body image and intense fear of becoming fat or weight gain * Low BMI * Females / homosexual males Treatment: Nutritional rehabilitation * Psychotherapy * Limited role for pharmacotherapy * Olanzapine used for weight restoration
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Eating disorders * What is the bulimia nervosa decription? * What is the treatment? | *
Description: * Binge eating followed by purging, use of laxatives/diuretics, or excessive exercise to avoid gaining weight * Normal to high BMI Treatment: Nutritional rehabilitation * Psychotherapy + pharmacotherapy best Pharmacotherapy * First line – fluoxetine (Prozac) * Goal: 60 mg/day (high dose) * Second-line – sertraline, escitalopram | Blumia pts get the flu
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What is binge eating disorder? What is the treatment? | *
Description: * Binge eating episodes ≥ 2days/wk for 6 months * Patients generally obese Treatment: * Psychotherapy * Pharmacotherapy: Lisdexamfetamine (Vyvanse) and other stimulants
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PMS management * What is the management for mild PMS?
Does not cause personal, professional, or social dysfunction * Stress reduction strategies * Exercise * Meditation ## Footnote Mild: does not affect daily life
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PMS management * What is the management of moderate/severe PMS or PMDD?
Patients who desire contraception * Estrogen/progesterone contraception Patients not interested in hormonal contraception: SSRIs * Continuous * Luteal phase * Symptom onset
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Postpartum Depression * Consider if ? * Sxs start when?
* Consider if symptoms persist longer than 2 weeks * Symptoms start in the first 4 weeks post delivery
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Postpartum Depression * What is the criteria?
Same diagnostic criteria as Major Depressive Disorder (DSM-5) * Five or more symptoms present during 2-week period with at least one symptoms being * Depressed mood * Loss of interest or pleasure Remember: SIG E CAPS
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Postpartum Depression * What is the treatment?
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Schizophrenia and other Psychotic Disorders * What is brief psychotic disorder? Schizophreniform? Schizophrenia? Schizoaffective disorder? | *
Brief psychotic disorder * Duration at least 1 day but less than 1 month Schizophreniform disorder * 1-6 months duration Schizophrenia * 6 months duration Schizoaffective disorder * Schizophrenia and major depression/Bipolar
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Diagnosis of Schizophrenia * What is the criteria
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Diagnosis of Schizophrenia * How long is the duration? What if 1-6 months?
Duration of illness for at least 6 months (including prodromal or residual periods in which above criteria may not be met) * If between 1-6 month – it is schizophreniform d/o
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Diagnosis of Schizophrenia * Sx not due to what?
Symptoms not due to medical, neurological, or substance-induced disorder (dementia, UTI, Drug use, Delirium).
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Bottom-line schizophrenia * What is needed for acute psychosis?(3)
* Hospitalization – psychiatric * Psychiatric consultation * Psychosocial therapy
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Bottom line schizophrenia * What can happen acutely if not cooperative/agitated? * What agents are preferred?
Antipsychotic medication * Initial dose may require IM administration if patient not cooperative / agitated * Second generation preferred – exact agent depends on patient-specific factors and provider preference
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Bottom-line schizophrenia * How do you start medications? (dose) * What are the two more favorable drugs? * What is resevere for 3rd/4th line? Why?
Start low and titrate dose every two to 4 weeks to lowest effective dose * Aripiprazole and risperidone have favorable side effect profiles * Clozapine very effective but reserved for third-line or fourth-line therapy due to risk of agranulocytosis / seizure risks
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Bottom-line schizophrenia * When do you have initial response? * What are the inital adverse effects?(3)
* Initial response: within first two weeks; four to six weeks to full effect * Initial adverse effects: sedation, orthostatic hypotension, restlessness
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Bottom-line schizophrenia * What are the maintenace treatment goals?
* Minimize symptoms and functional impairment * Minimize antipsychotic side effects * Avoid relapses * Full integration into society * Multidisciplinary care * Patient education to promote treatment adherence
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Bottom-line schizophrenia * What do you do if patient has full response to pharmacotherapy? * What do you do if patient has partial response to pharmacotherapy?
Full response to pharmacotherapy * Continue same medication Partial response to pharmacotherapy * Check for compliance – long acting, IM dosage forms available to help with compliance * Switch to alternative to non-clozapine second-generation antipsychotic-> Clozapine reserved for 3rd or 4th line treatment
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Bottom-line schizophrenia * What do you need to do depending on underlying psychosis? * What happens life long in many cases? * Monitor what?
* Discontinuation – depends on underlying psychosis * True schizophrenia life-long in many cases * Monitor closely for adverse effects
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## Footnote *
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## Footnote *
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What is teh DSM-5 Dx criteria of ADHD?
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ADHD rating scales * What are the different sclaes? * Who and how do they fill them out? * Establish what?
Conners’ Rating Scale / Vanderbilt scales * Parent version and teacher version * Complete separately * Establish diagnosis including inattentive, hyperactive or both
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ADHD rating scales * What do some other scale also evaluate? * Complete what is ideal?
* Some scales also evaluate for ODD, conduct disorder * Complete neurodevelopment workup ideal if available (2 day process)
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ADHD * What is the cause? * What are the NT levels?
Cause: environmental and genetic (not completely understood) Patients with ADHD are thought to have decrease levels of NE and DA * DA= reward, risk, impulsiveness * NE= attention and arousal
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ADHD * What are common coexisting conditions?(5) | *
**ODD, conduct disorder, anxiety, tic disorder, sleep disorders**
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ADHD * What is the treatment?
Behavioral psychotherapy – time management and organization skills * Parents – behavioral parent training * Teachers – behavioral classroom management * **First-line recommendation for most patients < 6 years** Medications * First-line: stimulants -> methylphenidate, dextroamphetamine, amphetamine salts Alternatives: non-stimulants -> atomoxetine, clonidine, guanfacine
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Stimulants: First-line therapy * Blocks what? * Improves what?
* Block the reuptake of DA and NE at the presynaptic neuron * Improves focus and impulsivity
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What are the SE of stimulants? | *
* Decreased appetite * Weight loss or lack of gain * Growth suppression * Stomach pain * Sleep disturbances * Headache * Irritability * Tachycardia / increased blood pressure
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Stimulants: First-line therapy * What are the events that can happen? What is recommended?
Cardiovascular events * EKG recommended for patients at risk * Some physicians will obtain annual EKG
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Stimulants: First-line therapy * Caustion with who? * CI in who?
* Caution: not recommended for patients with concomitant tic disorders – may exacerbate * CI: during or within 14 days of MAOIs (stimulants inhibit MAO – coadministration may cause hypertensive crisis)
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What are the frequent SE of stimulants reported by young adults?
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Stimulants * What class? * Not recommended for who?
* Class II controlled substances * Not recommended for patients with underlying addiction disorder
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Stimulants * Watch closely for what? MC in who? * MC reason is what?
Watch closely for diversion – self or friends * Diversion MC in college students (5 to 35%) * MC in Caucasians, fraternity and sorority members, students with low GPAs, students reporting ADHD symptoms * MC reasons for stimulant diversion included staying awake, studying, improved alertness, experimenting, and “getting high”
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What are the methylphenidate examples? | FYI
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Non-Stimulants: Atomoxetine * What line of therapy? * When do you give them? (4)
Second-line therapy * Parent/patient request to avoid stimulant * Cannot tolerate side effects of stimulant * Tic disorder * Stimulant non-responders (10 to 30%)
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Non-stimulant: atomoxetine * What is the MOA?
Selective NE reuptake inhibitor Increases concentrations of NE and DA in prefrontal cortex * Not a controlled substance * Slower onset of action * Not as effective
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Non-Stimulants: Atomoxetine * What are the SE? | *
* Somnolence * Dry mouth * Nausea/constipation/abdominal pain * Dizziness * Decreased appetite / weight loss * Insomnia * Irritability * Increase in heart rate and blood pressure * No impact on growth * **Hepatotoxicity**
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Non-Stimulants: Atomoxetine * What is the BBW? * What is CI? | *
* BBW: risk of suicidal ideation * CI: during or within 14 days of MAOI
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Non-stimulants: Alpha 2-agonist * What is the MOA * Resevered for who? | LY
* Exact mechanism unknown; thought to mimic NE effects at the alpha-2 adrenoreceptors in the prefrontal cortex * Reserved for patients who respond poorly to a trial for stimulants or selective NE reuptake inhibitors or who have unacceptable adverse effects
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Non-stimulants: Alpha 2-agonist * Works best to control what? * Can be used as what? * **What are the two examples?**
Works best to control hyperactivity and impulsivity Can be used as adjunct therapy to stimulants for ADHD with and without concomitant personality disorders (ODD, conduct disorder) * **Clonidine (Kapvay) * Guanfacine (Intuniv)** | kNOW NAMES
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Monitoring and Patient education * Follow what? * Evaluate what? (2) * Monitor what? * Ask about what?
* Follow weight and growth curves * Evaluate symptom improvements – objective measures ideal * Evaluate duration of effects * Monitor BP and HR * Ask about sleep and irritability
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Monitoring and Patient education * What do you need to educate on (3) | *
*** Eat before morning dose * Timing of dose and sleep * Drug holidays – weekends vs summer**
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Narcolepsy * Repeated what? * they also experience what?
* Repeated sleep attacks in which patients are unable to resist falling asleep suddenly * They also experience cataplexy and/or recurrent period of transition between sleep and wakefulness
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Narcolepsy * What are the sxs? * Irresistible attacks of what?timing?
* Symptoms include paralysis, hypnopompic and/or hypnagogic hallucinations * Irresistible attacks of sleep that occur daily over at least 3 months and not related to substance
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Narcolepsy * What is the first line therapy? What is the MOA? | *
**Modafinil** * Increases extracellular concentration of dopamine by inhibiting its reuptake * May inhibit NE reuptake * Increases daytime wakefulness
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Narcolepsy * What are the SE of modafinil?(3)
* Headache * Nervousness * Nausea
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Insomnia * What all three criteria need to be met? * What is key?
All three criteria much be met * Trouble falling or staying asleep * Adequate opportunity for sleep * Daytime dysfunction Good history key
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Insomnia treatment - nonpharmacologic * What can you for therapy?
CBT-Insomnia (CBT-I) * Efficacy = pharmacotherapy * Better long-term benefit * Delivered in four to seven sessions
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Insomnia treatment - nonpharmacologic * What is the sleep hygiene?
* Dark, quiet, cool room * Avoid sleep disturbing substances – caffeine, alcohol, nicotine * Avoid vigorous exercise before bed * Wind down routine * Program out conditioned arousal * Use bed for sleep and sex only – only go to bed when sleepy, leave bedroom if not sleepy
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Insomnia treatment - nonpharmacologic * What is the sleep restriction?
* 5-hour restriction with slow build * Can exacerbate underlying seizure disorder or precipitate psychiatric disorders
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Insomnia treatment - nonpharmacologic * Attention to what?
Attention to sleep-related worries * Address stressors * Tools to reduce nighttime worries
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Insomnia Pharmacologic treatments * What are the melatonin receptor agonist?
* Melatonin (OTC) * Ramelteon (Rx)
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Insomnia Pharmacologic treatments: melatonin receptor agonist * Hormone released by what? * What is not completely known? * No clear what? * Best for what?
* Hormone released by pineal gland during the dark period of the day * Mechanism of sleep induction not completely known * No clear dose-response relationship * Best for delayed sleep-onset insomnia (> 30 minutes to fall asleep)
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Insomnia Pharmacologic treatments: melatonin receptor agonist * What are the SE?(5)
* Headache * Sedation * Nausea * Slowed reaction time * No abuse potential
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Insomnia pharmacologic treatments * What is the selective H1 antagonists?(2) What is it good for?
Selective H1 antagonists * Doxepin * Tricyclic antidepressant with strong H1 antagonist activity * Therapeutic effects largest early morning hours; best for individuals who wake towards the end of the night/ early morning – sleep maintenance
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Insomnia pharmacologic treatments: Selective H1 antagonist * What are the SE? * Avoid use with what? * Ideal for who?
Adverse effects: * Daytime sedation * No abuse potential * Avoid use within two weeks of MAOI * Ideal for older patient with early morning awakening
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Insomnia pharmacologic treatments * What are the other H1 Antagonist not recommended? * Watch other for what?
Other H1 antagonists not recommended * Diphenhydramine (Benadryl) * Doxylamine (Unisom) Watch for anticholinergic adverse effects
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Insomnia pharmacologic treatments: nonbenzo BDZ receptor agonist * Selectively bind to what? * High concentrations in what? * Trigger what? * Increase what?
* Selectively bind to the alpha-1 subunit of the GABAA receptor * High concentrations in wake-promoting areas in the brain * Trigger chloride channel opening and cell hyperpolarization * Increase sedation
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Insomnia pharmacologic treatments: nonbenzo BDZ receptor agonist * Most for what? * What are the examples?
Most for both sleep onset and sleep maintenance insomnia * Eszopiclone (Lunesta) * Zaleplon (Sonata) – sleep onset * Zolpidem (Ambien) | Ezzz (make you sleepy)
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Insomnia pharmacologic treatments: nonbenzo BDZ receptor agonist * What are the SE?(3) * What schedule drug?
Adverse effects: * Sedation * Memory loss * Impaired cognitive function Schedule IV controlled substance
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Insomnia Pharmacologic treatments: Dual orexin receptor antagonists * Orexins arise from what?
Orexins arise from the neurons of the hypothalamus and promote wakefulness / arousal
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Insomnia Pharmacologic treatments: Dual orexin receptor antagonists * Blocks what? * What are the examples and what are for? * All metabolized by what?
Block orexin A and orexin B receptors * Lemborexant (DayVigo) – get to sleep * Suvorexant (Belsomra) – stay asleep * Daridorexant (recently FDA approved) All metabolized by CYP3A4 – avoid strong inhibitors or inducers
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Insomnia Pharmacologic treatments: Dual orexin receptor antagonists * Appropriate for what? * Suvorexant robust effects on what? * What type of schedule?
* Appropriate for sleep onset and sleep maintenance insomnia * Suvorexant robust effects on sleep onset and at last third of night without significant morning sedation * Schedule IV controlled substance
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Insomnia pharmacologic treatments * What are the different examples of benzos? Do not seem to develop what?
Benzodiazepines * Triazolam * Flurazepam * Temazepam – sleep onset only Do not seem to develop dependence or tolerance per short-term studies
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What are the SE of benzos? What type of schedule?
Adverse effects: * Sedation * Psychomotor impairment * Abuse potential Schedule IV controlled substance
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Insomnia pharmacologic treatments * What are the antidepressants, antipsychotics, anticonvulants?
Antidepressants * Trazodone * Mirtazapine Antipsychotics * Quetiapine * Olanzapine Anticonvulsants * Gabapentin * Pregabalin (more sedation)
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What is the alcohol withdrawal timeline?
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# , Alcohol withdrawal treatment * What is the acute treatment?(3)
Fluid replacement * Thiamine (B1) * Folic acid * Magnesium * Multivitamins * Saline Antiemetics Benzodiazepines – serves as alcohol substitute at the GABA receptors; decreases severity of withdrawal symptoms
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CIWA-Ar * Each category scored on what?
* Nausea and vomiting * Paroxysmal sweats * Headache * Auditory disturbances * Visual disturbances * Anxiety * Tremor * Tactile disturbances * Orientation and clouding of sensorium * Agitation
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CIWA-Ar * What is the score range? * What needs and does not need intervention?
Score range: 0 to 67 * Score < 8 usually requires no pharmacologic intervention * Specific follow-up and treatment depends on CIWA score
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CIWA-AR * What is the gold standard txt for alcohol intox? What are some considerations?
Benzodiazepines gold-standard treatment for alcohol intoxication * Specific BDZ dependent on patient organ function – especially liver * BDZ dose and frequency dependent on CIWA score
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CIWA-AR
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All drug therapy should be combined with evidence-based structured psychotherapy
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Fill in covered
All drug therapy should be combined with evidence-based structured psychotherapy
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Fill in covered part
All drug therapy should be combined with evidence-based structured psychotherapy
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What is the Opioid withdrawal timeline? | *
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What are the Opioid acute withdrawal sxs? | FYI
* Pulse * GI upset * Sweating * Tremor * Restless * Yawning * Pupil size * Anxiety/irritability * Gooseflesh skin * Bone or joint aches * Running nose or tearing
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Opioid acute withdrawal * What is the scoring system and what is the score interpretation? | FYI
Cows Score interpretation * 5 to 12 mild * 13 to 24 moderate * 25-36 moderately severe * 37 to 48 severe
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Opioid Withdrawal * What is required? * Specific prescribing privileges are needed tp what?
Medical supervision generally required Specific prescribing privileges are needed to prescribe controlled substances for purposes of addition medicine * Medications for Addictions Training (MAT training)
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Opioid Withdrawal * What are the primary agents used to decrease withdrawl sxs?(3)
* Buprenorphine * Methadone * Clonidine: Usually used as adjunct with opioid agonists to decrease autonomic symptoms including sweating, nausea, diarrhea, anxiety, irritability
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Fill in covered part?
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Opioid withdrawal / OUD * What are two alternative treatments?
Buprenorphine + naloxone (Suboxone) and Naltrexone
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Buprenorphine + naloxone (Suboxone) * What is special about this?
* Naloxone has no effect when Suboxone given at correct doses * Poorly absorbed orally; if given parenterally will trigger withdrawal symptoms
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Naltrexone * What is special about this?
* Long-acting opioid antagonist * Used to prevent relapse in patients after opioid withdrawal complete * Oral tablets or long-acting injection(LAI) * Improves abstinence rates short term; long-term benefits
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What is the benzo withdrawal timeline?
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Benzodiazepine withdrawal * Change patient to what? * Monitor for what? * Continue BZD therapy with what?
* Change patient to long-acting benzodiazepine at dose that eliminates withdrawal symptoms * Monitor for respiratory depression * Continue BZD therapy with long taper over several months
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Benzodiazepine withdrawal * What can you give for OD? * What is hte BBW?
* Antidote: flumazenil * Rarely needed * BBW: can precipitate seizures
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# Withdrawal from other drugs Most substances without specific antidotes – supportive care * Give what to decrease agitation/anxiety? * what are the stimulants? * What are the hallucinogens? * What other drug?
* Benzodiazepines often indicated to decrease agitation / anxiety * Stimulants – cocaine, methamphetamine, amphetamines * Hallucinogens – LSD, PCP * Cannabinoids
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Most substances without specific antidotes – supportive care * With cocaine. avoid what?
avoid beta-blockers as antihypertensives; concerns of coronary artery vasoconstriction and systemic hypertension, which can result from unopposed alpha-adrenergic stimulation
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Smoking cessation * What is the general approach? * What is the first line pharm?
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Pharm III (14 decks)

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