PHARMACOTHERAPY OF SUBSTANCE USE DISORDERS

Question 1

substance use disorder

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 happens at the legal BAC level

Answer 2

Moderate impairment, legal definition of intoxication in most states

Question 3

what is stage 1 alcohol withdrawal

Answer 3

~ 6 – 8 hours Moderate autonomic hyperactivity (anxiety, tremulousness,
tachycardia, insomnia, nausea, vomiting, diaphoresis) and a craving
for alcohol

Question 4

what is stage 2 of alcohol withdrawal

Answer 4

~ 24 hours Autonomic hyperactivity with auditory or visual hallucinations lasting
~ 1 – 3 days – most remain lucid and oriented

Question 5

what is stage 3 of alcohol withdrawal

Answer 5

~ 1 – 2 days ~ 4% of those untreated develop grand mal seizures ~ 7 – 48 hours
after drop in BAC

Question 6

what is stage 4 of alcohol withdrawal

Answer 6

3 – 5 days Delirium tremens (DTs) in ~5% of patients (confusion, illusions,
hallucinations, agitation, tachycardia, hyperthermia)
Mortality associated with DTs ~5 – 15% attributable to arrhythmias, shock, infection, trauma or aspiration

Question 7

what are the risk factors for delirium tremens

Answer 7

proior history of DTs

Question 8

What is the prophylaxis/fixed dosing for tx alcohol withdrawal

Answer 8

Advantage: prevent withdrawal Disadvantage: unnecessary BZD dosing
Chlordiazepoxide 25mg TID x 2 days, BID x 2 days, daily x 2 days, then d/c
May also see PRN use of lorazepam to supplement

Question 9

What is individualized dosing for tx of alcohol withdrawal

Answer 9

Use BZD if symptoms warrant: Use CIWA-Ar Scale
CIWA < 8-10, CIWA 8 – 15CIWA > 15
Nonpharmacologic tx Medicate Risk of complications if untreated
Reduces treatment duration, decreased benzodiazepine dosing

Question 10

T of F: if a pt being treated for alcohol withdrawal has liver dysfunction you should not use diazepam/chloridazepoxide,

Answer 10

T should only use them if there is no liver dysfunction

Question 11

T or F if a pt has liver dysfunction you can use oxazepam and lorazepam

Answer 11

T can also use without liver dysfunction

Question 12

What is another tx consideration

Answer 12

Thiamine

Question 13

T or F Phenytoin is effective to treat withdrawal seizures

Answer 13

False they are not effective

Question 14

What is wernicke Korsakoff syndrome

Answer 14

Result of thiamine deficiency
Give before dextrose-containing fluids
Thiamine is co-factor in glucose metabolism, Wernicke’s can be precipitated by high glucose loads

Question 15

What is Disulfiram

Answer 15

Aversive therapy
Irreversible inhibitor of aldehyde dehydrogenase
Unpleasant effects if alcohol is used (flushing, nausea, vomiting, tachycardia)
Monitor LFTs
Disulfiram reaction for up to 14 days after medication discontinuation

Question 16

What is Acamprosate

Answer 16

Maintenance of abstinence
Renal elimination, monitor renal function, avoid in severe renal
impairment
Suicidality warning, side effects also include diarrhea, nausea, depression,
anxiety

Question 17

T or F Naltrexone

Answer 17

Decreases binge drinking, helps to increase time between drinking days

Question 18

Naltrexone

Answer 18

Elevated LFTs common, must monitor at baseline and routinely
Need to evaluate pain management needs, patient should have wallet card or be able to tell emergency providers that they are taking this
Warning for injection site reactions

Question 19

Buprenorphine should not be initiated until BLANK hours after the last use of a short-acting opioid (heroin or oxycodone) and BLANK hours after the last use of
methadone

Answer 19

12-18hrs
24 – 48

Question 20

What are symptoms of Opioid Withdrawal

Answer 20

Muscle Aches/Tension
Agitation/Anxiety/Insomnia
Abdominal Cramping/Nausea/Vomiting
Diarrhea
Sweating/yawning/increased tearing/runny nose

Question 21

What is used to tx muscle aches and tensions in opioid withdrawal

Answer 21

Acetaminophen or NSAID

Question 22

what is used to tx Agitation/Anxiety/Insomnia in opioid withdrawal

Answer 22

Hydroxyzine/benzodiazepines

Question 23

what is used to tx AbdominalCramping/Nausea/Vomiting in opioid withdrawal

Answer 23

Ondansetron

Question 24

what is used to tx Diarrhea in opioid withdrawal

Answer 24

Loperamide

Question 25

What is used to tx Sweating/yawning/increased tearing/runny nose inopioid withdrawal

Answer 25

Clonidine or Lofexidine

Question 26

T or F Treating noradrenergic symptoms can serve as an entry to longer-term treatment with MOUD and psychosocial treatment

Answer 26

T

Question 27

What is clonidine dosing

Answer 27

0.3 – 0.6 mg/day (mild withdrawal) Up to 1.2 mg/day (severe withdrawal) Divided doses (0.1 – 0.2 mg/dose given up to hourly hypotension most common SE less likely to lofexidine

Question 28

What is Lofexidine dosing

Answer 28

0.54 mg (3 tablets) four times daily x 5 – 7 days Maximum dose = 2.88 mg/day (16 tablets) No single dose > 0.72 mg (4 tablets) May continue for up to 14 days dosing adjustments in renal and hepatic impairment

Question 29

T or F pregnant women should not take buprenorphine or methadone

Answer 29

False they can take

Question 30

T or F methadone must be gicen in a licensed tx program

Answer 30

T

Question 31

T or F Buprenorphine is usually given in combination with naloxone in a sublingual tablet or film strip dosage form

Answer 31

T poor bioavailability when swallowed, must be sublingual

Question 32

What are methadone tx pearls

Answer 32

P450 2B6, 3A4, 2C19, 2D6 substrate – use with caution in patients also taking moderate to strong inhibitors or inducers (largest concern for 3A4 inhibitors) QTc prolongation is a serious concern – ECG monitoring is recommended

Question 33

Buprenorphine Clinical pearls

Answer 33

Given with naloxone in the same dosage form to decrease misuse – naloxone is not absorbed through the GI tract, so no effect if taken sublingually; but if injected, will block opiate effect of buprenorphine. must be dosed sublingually due to lack of gastric absorption Monitor LFTs with serotonergic drugs

Question 34

T or F to avoid precipitating withdrawal, initiate buprenorphine therapy when there are no signs of withdrawal; administer in divided doses on day 1

Answer 34

False need to initiate when there are clear signs of withdrawal

Question 35

What Cyp substrate is buprenorphine

Answer 35

3A4 monitor closely when given with inducers or inhibitors

Question 36

T or F the for buprenorphine the risk of respiratory depression in overdose is much less than with opioids, including methadone, due to partial agonist effect

Answer 36

T

Question 37

Extended-Release Injection (Sublocade®, Brixadi®)

Answer 37

buprenorphine ER injection For Moderate-severe opioid use disorder, patients initiated on sublingual buprenorphine and dose adjustment for at least 7 days prior to first injection Monitor for use with serotonergic drugs – risk for serotonin syndrome

Question 38

NALTREXONE LONG-ACTING INJECTION (VIVITROL)

Answer 38

Given in same dose as that used for alcohol use disorder Is the “abstinence” treatment, patients must be ready for this, discuss with patient about readiness to encourage adherence with ongoing dosing. Risk for overdose if patient discontinues treatment, must tell patient of this risk

Question 39

What is a Naloxone kit

Answer 39

FDA approved OTC naloxone nasal spray (Narcan, 4 mg)

Question 40

Whar is OPVEE (nalmefene)

Answer 40

Nalmefene has a longer half-life than naloxone (11.4 hours) Half-life of fentanyl used as an anesthetic is 7.5 hours Made available to combat increasing fentanyl found in drug supply  Prescription only