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neurology/psychiatry > substance use disorders > Flashcards

substance use disorders Flashcards

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1
Q

define illicit drug use

A

anything that is illegal (marijuana, cocaine, heroin) AND misuse of prescription drugs

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2
Q

define misuse

A

use in any way not directed by a doctor

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3
Q

define binge drinking

A

5 or more drinks for males
4 or more drinks for females
(12 oz beer, 5 oz wine, 1.5 oz liquor)

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4
Q

define heavy alcohol use

A

binge drinking on 5 or more days in the past 30 days

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5
Q

4 categories that define when substance use becomes a disorder

A

impaired control
social impairment
risky use
physical dependence

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6
Q

define addiction

A

a chronic, relapsing brain disease characterized by compulsive drug seeking & use, despite harmful consequences

considered a brain disease because drugs change the brain

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7
Q

true or false: opioid withdrawal is life threatening

A

false

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8
Q

general timeline of opioid withdrawal, depending on which opioids were used

A

short acting opioids: 6-12 hours after last dose
long acting opioids: 30 hours after the last dose
generally peaks at 72 hours

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9
Q

what are some symptoms of opioid withdrawal

A

n/v, stomach cramps, diarrhea, goosebumps, depression, drug cravings
can also include sweating/chills, shake/tremor, muscle ache, agitation/anxiety, more.

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10
Q

what is special about fentanyl

A

it is highly lipophilic, leading to its concentration in fat tissue and additional considerations during withdrawal management

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11
Q

what are some “comfort medications” used for opioid withdrawal

A

Pain: APAP, NSAIDs, diclofenac
anxiety: hydroxyzine
diarrhea: loperamide
insomnia: trazodone, melatonin

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12
Q

what do the ASAM national practice guidelines for OUD say about opioid withdrawal management

A
  1. methadone or buprenorphine recommended> abrupt cessation of opioids
  2. detoxification on its own, without treatment, is NOT a treatment method for OUD and is not recommended.
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13
Q

describe the role of alpha 2 agonists in opioid withdrawal

A

clonidine and lofexidine may be used for symptomatic relief during withdrawal management; they work by reducing sympathetic outflow from CNS, decreasing peripheral resistance/vascular resistance, heart rate, BP

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14
Q

what are the side effects seen from alpha 2 agonists

A

orthostatic hypotension, sedation, dizziness, somnolence, fatigue

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15
Q

describe which of the following are full or partial agonists, or antagonists:
methadone, buprenorphine, naltrexone, naloxone

A

methadone= FULL agonist
buprenorphine= PARTIAL agonist
naltrexone and naloxone= antagonists

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16
Q

what is the role of methadone in opioid withdrawal treatment

A

only given in specially licensed methadone clinics, unless
1. inpatient & admitted for something OTHER than opioid withdrawal
2. outpatient for 72 hours max to cover patient until they go to the clinic

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17
Q

what are the pearls to definitely know about methadone

A
  1. causes QT prolongation
  2. has drug interactions
  3. preferred agent in pregnancy (DOES NOT PRECIPITATE WITHDRAWAL!)
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18
Q

what is the difference in methadone dosing between withdrawal treatment, and maintenance treatment

A

withdrawal: 20-30 mg (NTE 40)
maintenance: higher; initial 20-30 but titrated 5-10 mgs every few days to 80-120 mg daily

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19
Q

methadone side effects

A

QT PROLONGATION
hypotension, dizziness, drowsiness, constipation, nausea/vomiting, respiratory depression

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20
Q

what is the most important thing to know about buprenorphine in opioid withdrawal treatment

A

given the HIGH BINDING AFFINITY, this drug will displace ANY opioids in the patient’s system causing PRECIPITATED WITHDRAWAL

MUST WAIT UNTIL PATIENT IS IN WITHDRAWAL TO GIVE! very unfortunate

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21
Q

which drugs are used for opioid withdrawal treatment, and which drugs are used for maintenance

A

withdrawal: methadone, buprenorphine

maintenance: methadone, buprenorphine, naltrexone

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22
Q

what is a disadvantage to consider when using methadone as a maintenance treatment?

A

patient has to present to the methadone clinic DAILY to ingest doses

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23
Q

which is the preferred drug in pregnancy and why

A

methadone– withdrawal leads to fetal harm and is not necessary to start methadone

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24
Q

what is a good maintenance dose for buprenorphine

A

16-24 mg/day, but 24 is better

lower doses associated with a greater risk of treatment discontinuation

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25
counseling for buprenorphine
typical ADEs associated with opioids; requires proper administration technique (SL/buccal) and mouth should be rinsed after use to prevent long term dental decay.
26
true/false: buprenorphine prescribing requires an X waiver?
false; it previously did but now you just need a regular DEA number
27
talk about the pros/cons of buprenorphine formulations?
1: monoproduct: contains only BUP, may increase risk of diversion/misuse 2: combination: contains BUP and naloxone to act as a deterrent for misuse 3: injectables Sublocade and Brixadi: contain only BUP; increased adherence and decreased diversion
28
what is the role of naltrexone in maintenance OUD treatment?
the long acting injectable Vivitrol is used (no PO form for OUD) A must higher risk for opioid relapse & overdose, making it only for super stable patients.
29
how does the combo of buprenorphine/naloxone deter misuse?
naloxone is minimally absorbed PO; meaning in the combo product it is not pharmacologically active. It's purpose in the combination is to discourage injection use because it would then become active and cause withdrawal
30
compare/contrast Sublocade and Brixadi
Sublocade: lower tolerability, forms a palpable depot/lump, higher plasma concentrations above what is achieved by SL BUP, not allowed in pregnancy Brixadi: higher injection tolerability, no lump, lower plasma concentrations/similar levels to SL BUP, weekly formulation is allowed in pregnancy
31
what is the duration of therapy in OUD
generally as long as the patient sees benefit or until they desire to discontinue
32
what is the evidence behind higher doses of naloxone?
no difference in survival 8 mg products had a significantly higher prevalence of opioid withdrawal signs & symptoms than the 4 mg products
33
naloxone side effects?
withdrawal very safe & effective: very rarely anaphylactic reactions, pulmonary edema is related to the opioid used and not the narcan
34
what is the MOA of alcohol
GABA agonist: inhibitory NMDA antagonist: additional inhibitory net result being CNS depression
35
what is the kinetic order of alcohol
zero order elimination (NOT concentration dependent) so it takes TIME to clear from the body
36
true or false: alcohol withdrawal is life threatening
true!
37
what are some risk factors for complicated alcohol withdrawal
heavy use history of delirium tremens comorbid conditions seizure disorder age 65+ long duration of use VERY SERIOUS RISK FACTOR: patient is conscious/coherent at a BAC 0.30
38
what is delirium tremens?
hallucination, disorientation, tachycardia, fever, hypertension, diaphoresis, agitation
39
risk factors for delirium tremens
history of sustained drinking history of previous DT age >30 concurrent illness significant alcohol withdrawal with an elevated alcohol level LONGER period since last drink
40
patients who present with alcohol withdrawal more than ___ hours after their last drink are more likely to develop DT than those who present sooner.
48 hours
41
when is delirium tremens onset?
48-72 hours after last drink
42
first line drug of choice for alcohol withdrawal
benzodiazepines (because they are GABA agonists similar to alcohol)
43
dosing for benzodiazepines in alcohol withdrawal
can be "fixed dose taper" or "symptom triggered"
44
pros/cons of fixed dose taper vs symptom triggered for benzo dosing for alcohol withdrawal
symptom triggered: reduces amount of benzo use, reduces length of stay, maybe more appropriate if uncomplicated withdrawal fixed dose: increased benzo requirement, increased length of stay, but maybe more appropriate if complicated withdrawal
45
which benzos are short acting
OLA oxazepam lorazepam alprazolam
46
which benzos are long acting
CDC clonazepam diazepam chlordiazepoxide
47
when to choose a short acting benzo for alcohol withdrawal
lower amount of alcohol use or lower amount of benzo use/low potency benzo
48
when to choose a long acting benzo for alcohol withdrawal
significant use of alcohol, presentation with high BAC, significant use of benzos or high potency benzos or longer acting benzos
49
which drug is reserved for severe withdrawal, failed benzo therapy, or history of complicated withdrawal
phenobarbital
50
what are some of the inferior options for treating alcohol withdrawal
gabapentin dexmedetomidine ketamine carbamazepine baclofen
51
what are (4) long term complications of alcohol use
wernicke encephalopathy korsakoff syndrome liver disease and cirrhosis depression
52
define wernicke encephalopathy
acute, reversible neurologic complication of thiamine (vitamin B1) deficiency that is commonly associated with alcohol use disorder
53
what is the triad of symptoms of wernicke encephalopathy
Encephalopathy: altered mental state oculomotor dysfunction: nystagmus, provoked by horizontal gaze to both sides gait, ataxia: unsteady when walking
54
dosing of thiamine for alcohol withdrawal vs dosing for suspected wernicke encephalopathy
patients being treated for alcohol withdrawal: give thiamine 100 mg IM/IV x 3 days then 100 mg PO daily thereafter suspect wernicke: thiamine 500 mg IM TID x 2 days, then 500 mg IM daily x 5 days, then 100 mg PO daily thereafter
55
do you wait for confirmation of wernicke encephalopathy diagnosis before giving thiamine
NO!! a delay in treatment risks permanent damage. if untreated it can lead to coma, death
56
what is korsakoff syndrome
an IRREVERSIBLE neuropsychiatric manifestation of wernicke encephalopathy which develops later if under treated or not treated. prognosis is poor and there is no effective treatment
57
what are some symptoms of korsakoff syndrome
confabulation, memory deficits, apathy, intact sensorium and long term memory
58
how is korsakoff syndrome prevented
parenteral thiamine
59
what are the 3 main drugs used for alcohol use disorder maintenance treatment
naltrexone acamprosate disulfiram
60
mechanism of naltrexone
mu opioid receptor antagonist
61
adverse effects of naltrexone
GI upset, headache, dizziness, insomnia, increased LFTs improve compliance with vivitrol IM every 4 weeks
62
when is naltrexone contraindicated
liver impairment
63
mechanism of acamprosate
modulates glutamate transmission
64
when is acamprosate contraindicated
CrCL<30
65
mechanism of disulfiram
inhibits aldehyde dehydrogenase, causing buildup of acetaldehyde: a disulfiram reaction then ensues reaction: sweating, headache, dyspnea, hypotension, flushing, palpitations, nausea, vomiting
66
what should you counsel patients about when dispensing disulfiram
hidden forms of alcohol (mouthwash, cooking ingredients, etc)
67
side effects of disulfiram
besides the intended side effects: severe and sometimes fatal hepatic failure
68
drugs for cocaine use disorder
non-psychostimulants: bupropion, topiramate psychostimulants: modafanil, ER mixed amphetamine salts
69
drugs for amphetamine-type stimulant use disorder
non-psychostimulants: bupropion +/- naltrexone, topiramate, mirtazapine psychostimulants: ER Methylphenidate

neurology/psychiatry (22 decks)

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