lecture 85/86

Question 1

what is the definition of SUD according to the DSM-5?

Answer 1

a problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by two of the following, occurring in a 12 month period?

Question 2

what could be the manifestations of SUD?

Answer 2

taken in larger amounts or over a longer period than intended
persistent desire or unsuccessful efforts to cut down or control use
great deal of time spent in activities necessary to obtain substance or recover from use
craving, strong desire, or urge to use
recurrent use results in failure to fulfill major role obligations
continued use despite consistent or recurrent social or interpersonal problems caused by or exacerbated by use or effects of use
important activities are given up or reduced
recurrent use in situations in which it is physically hazardous
continued use despite knowledge of having a persistent or recurrent physical or psychological problem related to use
tolerance
withdrawal

Question 3

what is the definition of tolerance?

Answer 3

needing increased amounts to achieve effect or diminished effect with continued use of the same amount

Question 4

what is the definition of withdrawal?

Answer 4

characteristic syndrome OR substance is used to relieve or avoid withdrawal symptoms

Question 5

how does a BAC of 50 mg/dL present?

Answer 5

motor function impairment observable

Question 6

how does a BAC of 80 mg/dL present?

Answer 6

moderate impairment, legal definition of intoxication in most states

Question 7

how do BACs of 450 mg/dL and 500 mg/dL present?

Answer 7

450 – respiratory depression
500 – LD50 for ethanol

Question 8

what are the characteristics of stage 1 of alcohol withdrawal?

Answer 8

onset around 6-8 hours
moderate autonomic hyperactivity (anxiety, tremulousness, tachycardia, insomnia, NV, diaphoresis) and a craving for alcohol

Question 9

what are the characteristics of stage 2 of alcohol withdrawal?

Answer 9

onset around 24 hours
autonomic hyperactivity with auditory or visual hallucinations lasting around 1-3 days
most remain lucid and oriented

Question 10

what are the characteristics of stage 3 of alcohol withdrawal?

Answer 10

onset around 1-2 days
around 4% of those untreated develop grand mal seizures which appears around 7-48 hours after drop in BAC

Question 11

what are the characteristics of stage 4 of alcohol withdrawal?

Answer 11

onset around 3-5 days
delirium tremens (DTs) in around 5% of patients (confusion, illusions, hallucinations, agitation, tachycardia, hyperthermia)

Question 12

what are the risk factors for delirium tremens?

Answer 12

prior history of DTs No 1 factor
number of detoxifications
consuming the equivalents of 1 pint of whiskey per day for 10-14 days prior to admission
early symptoms of withdrawal
hepatic dysfunction

Question 13

how should alcohol withdrawal be treated?

Answer 13

benzodiazepines –> specifically diazepam/chlordiazepoxide (no liver dysfunction) or lorazepam/oxazepam (liver dysfunction possible)
then thiamine

Question 14

what is unique about the usage of diazepam/chlordiazepoxide in treating alcohol withdrawal?

Answer 14

causes no liver dysfunction
longer half life and decreased risk of breakthrough symptoms

Question 15

what is the medicate threshold for CIWA?

Answer 15

8

Question 16

how is phenytoin used for alcohol withdrawal syndrome?

Answer 16

is not effective to treat withdrawal seizures
consider d/c but maybe not

Question 17

what is wernicke’s encephalopathy?

Answer 17

result of thiamine deficiency, precipitated by high glucose loads
so important to give thiamine before dextrose-containing fluids as it is a cofactor in glucose metabolism

Question 18

what are the counseling points of disulfiram (antabuse)?

Answer 18

unpleasant effects if alcohol is used like flushing, NV, tachycardia
monitor LFTs
reaction for up to 14 days after medication discontinuation

Question 19

what is the moa of disulfiram?

Answer 19

aversive therapy
irreversible inhibitor of aldehyde dehydrogenase

Question 20

what are the counseling points of acamprosate (campral)?

Answer 20

maintenance of abstinence
renal elimination, monitor renal function
suicidality warning
SE also include ND, depression, anxiety

Question 21

what are the counseling points of naltrexone?

Answer 21

decreases binge drinking, helps to increase time between drinking days
elevated LFTs common –> monitor baseline and routinely
need to evaluate pain management needs, pt should have wallet card or be able to tell emergency providers that they are taking this
warning for injection site reactions

Question 22

what are the symptoms of opioid withdrawal and what drug(s) should be used to treat them?

Answer 22

muscle aches/tension –> tylenol/NSAID
agitation, anxiety, insomnia –> hydroxyzine, benzodiazepines
abdominal cramping, NV –> ondansetron
diarrhea –> loperamide
sweating, yawning, increased tearing, running nose –> clonidine or lofexidine

Question 23

how should buprenorphine be used for opioid withdrawal?

Answer 23

initiate 12-18 hours after last use of short-acting opioid (heroin or oxycodone) OR 24-48 hours after last use of methodone

Question 24

what is the role of alpha-2 agonists in opioid withdrawal syndrome?

Answer 24

treating noradrenergic symptoms can serve as an entry to longer-term tx with MOUD and psychosocial tx
clonidine and lofexidine used

Question 25

what are the drugs used for maintenance treatment?

Answer 25

methadone --> needs to be given with a licensed treatment program buprenorphine --> in combo as su oxone in SL or film strip due to poor oral bioavailability

Question 26

what are the important counseling points of methadone?

Answer 26

P450 2B6, 3A4, 2C19, 2D6 substrate -- use with caution in pts also taking moderate to strong inhibitors/inducers (largest concern is 3A4) QTc prolongation is serious concern -- ECG monitoring is recommended

Question 27

how does naloxone work when combined with buprenorphine?

Answer 27

given with naloxone to decrease misuse when absorbed SL, no effect is taken because it is not absorbed through the GI tract if buprenorphine/naloxone was injected, the naloxone would block opiate effects

Question 28

what are the counseling points of buprenorphine?

Answer 28

available in SL films and tablets, must be dosed SL due to lack of gastric absorption 3A4 substrates (monitor) monitor LFTs, use with serotonergic drugs may cause SS risk of respiratory depression in overdose is much less due to partial agonist effects

Question 29

what are important counseling points of buprenorphine XR injection?

Answer 29

used for moderate-severe opioid use disorder with pts initiated on SL buprenorphine and dose adjustment monitor for SS

Question 30

what are the counseling points of naltrexone long-acting injection (Vivitrol)?

Answer 30

given in same dose as that used for alcohol use disorder used for abstinence treatmentso pt must be ready for this (discuss readiness to encourage adherence with ongoing dosing) risk for overdose if pt d/c tx (tell pt this)