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NUNP 543 > Substance use (including AUD, Smoking & Opioid) > Flashcards

Substance use (including AUD, Smoking & Opioid) Flashcards

1
Q

Substance use disorders

Substance abuse (C&G definition)

A

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more specific symptoms, occurring with a 12-month period.

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2
Q

Substance use disorders

Substance intoxication

A

A reversible substance-specific syndrome caused by ingestion

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3
Q

Substance use disorders

Substance dependence (C&G)

A

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) specific symptoms, occurring at any time in the 12-month period.

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4
Q

Substance use disorders

Substance withdrawal

A

A substance-specific syndrome caused by the cessation of (or reduction in) substance use that has been heavy and prolonged.

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5
Q

Substance use disorders

impaired control

A

Use of a substance in larger amounts or for longer time than originally intended.

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6
Q

Substance use disorders

Social impairment

A

Recurrent substance use leading to a failure to meet personal and social obligations.

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7
Q

Substance use disorders

risky use

A

Recurrent substance use leading to a failure to meet personal and social obligations

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8
Q

Substance use disorders

pharmacological criteria

A

Requirement for a markedly increased dose to achieve desired effect or markedly reduced effect at standard dose

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9
Q

Substance use disorders

Age (highest prevalence for substance use in general)

A

Youth age 15-24 years – highest report of illicit substance use and 5x more likely to report harm due to drug use.

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10
Q

Substance use disorders

Subjective Hx

A
  • Onset, duration, and course of presenting complaints
  • Question about relatives with hx of etoh, tobacco, or drug use problems.
  • Assess when started, amount of use, type etc…with least invasive questions first.
  • Start with past to present use (first to last use)
  • -past treatment interventions (pharm managment/OAT, A&D counselling, residential treatment programs, etc), past withdrawal management, past complications (seizures, OD), length of sobriety
  • OD hx,
  • Follow CAGE (cutdown, annoyed, guilty, eye-opener): 2/4 is highly predictive of addiction
  • Note usual weight and recent loss in what time frame.
  • Review suicidal ideation and/or past hx.
  • length of sobriety
  • drug costs/day, source of money
  • concurrent resp depressants (ETOH, benzo)

Trauma-informed social history:

  • housing
  • employment history
  • legal history, current legal issues
  • financial concerns
  • social/emotional supports
  • family history
  • safety: interpersonal violence, children
  • hx of trauma: ask about past trauma using ACE tool
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11
Q

Substance use disorders

Objective assessment

A

BP, RR, HR, WT
INSPECT:
-Gen appearance, dress, grooming, breath odour, wanted appearance, attitude, sad affect, impaired psychomotor ability, or tremors

  • Conduct a dermal examination for spider angiomas, bruises, track marks, colour, pallor, rash, jaundice, petechiae, gynecomastia in men (hallucinogens)
  • Examine the eyes for sclera colour and features, pupil size and reactivity
  • Inspect the nasal mucosa or erythema, oedema, spider telangiectasia, and discharge; look for septal lesions or perforation, deviation, and polyps.
  • Inspect the mouth/pharynx: oral lesions, poor dental hygiene, erythema, teeth for uneven surfaces and decay, and gum erosion.

PALPATE:

  • Neck and thyroid
  • Axilla and groin for lymphadenopathy
  • Abdomen; note hepatomegaly/tenderness

PERCUSS:
- Chest, note pulmonary consolidation
Abdomen for hepatosplenomegal

AUSCULTATE:
- Heart for murmur, new S4 gallop, single S2, and arrhythmias.
Lungs for rales, effusion, and consolidation.

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12
Q

Substance use disorders

Smoking cessation pharm management (in adjunct or instead of NRT)

A

Buproprion – 7 to 12 week treatment. Pt can smoke for first 2 weeks. Risk seizures.

**Varenicline – client chooses stop date and medication is started 1-2 weeks before. Warn patient of adverse effects: vivid dreams, aggression, anxiety. Preferred.

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13
Q

Substance use disorders

Follow-up

A

weekly, then monthly

screen suicidality every visit

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14
Q

Substance use disorders

5 A’s of smoking cessation

A

Ask- Identify use

Advise- recommend reduction/cessation

Assess- readiness

Assist- non-pharm & pharm interventions

Arrange- Schedule follow-up

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15
Q

Substance use disorders

TWEAK

A 
Tolerance
Worry
Eye-opener
Amnesia
K(cut-down)
  • Use in pregnancy
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16
Q

Substance use disorders

5 A’s integrating substance use knowledge

A

Acquire knowledge

Anticipate harm that may be caused by your practices, reactions, judgements

Analyze the impact of policies

Avoid social judgements about SU

Approach all pt/s respectfully

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17
Q

Substance use disorders

CAGE

A

Cut down
Annoyed
Guilty
Eye-opener

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18
Q

Substance use disorders

SWIGECAPS

A 
• Sleep
	• Worthlessness
	• Interest
	• Guilt
	• Energy
	• Concentration
	• Appetite
	• Psychomotor changes
Suicidal/Safety
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19
Q

Substance use disorders

What is OUD?

A

Chronic relapsing problematic use of and addiction to opioids

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20
Q

Substance use disorders

Opioid use disorder Age and Sex

A

OD deaths
80% Age 29-49yrs
80% male

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21
Q

Substance use disorders

Risk factors for opioid OD

A
  • social isolation (3/5 OD deaths were using alone)
  • Indigenous (intergenerational trauma from colonization) over-represented in OD deaths
  • untreated psychiatric conditions
  • high ACE scores
22
Q

Substance use disorders

Opioid patho

A
  • dopamine reward pathway dysfunction
  • Increased dopamine release in nucleus accumbens (responsible for motivation and goal-directed behaviour)
  • dopamine is needed for memory to associate positive and negative emotions –> reinforces positive reward
  • drugs (amphetamines, cocaine, nicotine, opioids) cause 2-10x amt of dopamine compared to naturally rewarding stimuli)
23
Q

Substance use disorders

Tolerance

A

need for increased amount of drug to achieve effect

24
Q

Substance use disorders

Time for moderate to severe withdrawal from pharmaceutical grade opioids

A
  • Short acting opioids (heroin, morphine, IR oxycodone): 12-16 hours
  • Intermediate acting opioids (SROM, CR HM, SR oxycodone); 17-24 hours
  • Long acting opioids (methadone): 30-48 hours
25
Q

Substance use disorders

How have fentanyl analogues complicated Suboxone inductions?

A

precipitated withdrawal can occur 24+ hours after stopping

26
Q

Substance use disorders

What is a long term complication of opioid OD?

A

anoxic brain injury

27
Q

Substance use disorders

Two-Item Conjoint Screen (TICS)?

A
  • have you ever drunk/used drugs more than you meant to?

- have you felt you wanted/needed to cut down your drinking/drug use?

28
Q

Substance use disorders

Screening for substance use, ask all patients:

A

“how many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?”

29
Q

Substance use disorders

Opioid withdrawal symptoms

A 
HR 
Sweating 
GI upset (N/V/D/cramps)
Tremor 
Restlessness
Yawning
Pupil dilation 
Anxiety/irritability
Piloerrection 
Bone/joint aches
Rhinorrhea/lacrimation 
Cravings
30
Q

Substance use disorders

Opioid OD Signs

A
  • Respiratory depression (RR<10-12/min is best clinical predictor of opioid intoxication)
  • Gurgling/snoring
  • Minimally responsive –> unresponsive
  • Constricted pupils
  • Slow erratic HR
  • Cyanosis and cool/clammy skin
31
Q

Substance use disorders

atypical opioid toxicity

A
  • chest wall rigidity
  • dyskinesia: involuntary muscle movement (ranging from twitching to chorea)
  • decorticate posturing
  • anisocoria (unequal pupils)
32
Q

Substance use disorders

DSM criteria for opioid use disorder

A

Two or more of the following (* if only two are tolerance/withdrawal, excludes those using Rx’d opioids for chronic pain)

  • often take > amts than intended
  • persistent desire or attempt to control use
  • ++ time spent securing substances
  • cravings
  • recurrent opioid use resulting in failure to fulfill social/professional/academic obligations
  • continued use despite social consequences
  • giving up social/work/rec pursuits
  • physically hazardous use
  • continued use despite physical/psych consequences
  • tolerance
  • withdrawal
33
Q

Substance use disorders

Labs when initiating OAT

A

Labs: CBC, Cr, LFT (esp ALT, GGT), HIV, Hep A/B/C, syphilis, chlamydia, gonorrhea
• Preg test for women of childbearing age
• Repeat LFTs 4 weeks after initiation esp if pre-existing liver disease

Lab based urine drug screen: covers methadone, opiates, BZD, cocaine/cocaine metabolites, amphetamines
*fentanyl and synthetic opioids (eg buprenorphine, oxycodone, HM) must be specifically requested when ordering UDS

34
Q

Substance use disorders

COWS/SOWS score to start Suboxone

A

COWS > 11
SOWS > 16
(moderate to severe withdrawal)

35
Q

Substance use disorders

Refer to addiction’s specialist for OAT tx when:

A
  • pregnant/breastfeeding
  • concurrent chronic pain, complex comorbidities
  • switching from another type of OAT
  • previous unsuccessful inductions
  • youth
  • complex polysubstance use
  • consideration for iOAT (injectable OAT: hydromorphone, diacetylmorphine)
36
Q

Substance use disorders

Opioid harm reduction resources

A
  • Take home naloxone kit: free for all patients, caregivers, practitioners. For all patients at risk of OD.
  • Harm reduction supplies (sterile needles, pipes, etc)
  • Access to supervised consumption sites
  • Safer supply (prescription opioids): risk mitigation during dual public health emergency
  • Drug testing, toxic supply reporting
  • Education on safer use: where to inject, switch to intranasal/smoking, do not use alone
  • Link to Overdose Outreach Teams
  • Lifeguard app
37
Q

Substance use disorders

Contraindications and precautions for Suboxone

A

Contraindications:
severe resp distress, delirium tremens, acute ETOH intoxication, severe liver failure

Precautions: caution with other sedating meds (increase risk of resp depression with BZD, ETOH, other sedatives), CYP medications
Monitoring:

38
Q

Substance use disorders

Suboxone MOA

A

buprenorphine partial opioid agonist w/ high binding affinity –> binds rapidly to opioid receptors (knocks off full opioid agonists eg heroin/fentanyl that may be present)
naloxone helps to prevent diversion

39
Q

Substance use disorders

Suboxone adverse reactions

A

1) Headache
2) Nausea, vomiting, constipation, abdominal pain
3) insomnia
4) hyperhidrosis

40
Q

Substance use disorders

Methadone adverse rxn

A

overdose/resp depression (no ceiling, full opioid agonist)

prolonged QT!

41
Q

Substance use disorders

naloxone duration of action

A

20-90 min

42
Q

Substance use disorders

BCCSU/Canada Low Risk Drinking Guidelines: definition risky drinking

A
  • Males 3+ drinks/day or 15+ drinks/week

- Females 2+ drinks/day or 10+ drinks/week

43
Q

Substance use disorders

C&G definition of binge drinking:

A
  • males 5+ drinks on at least 1 day in last 30 days

- females 4+ drinks on at least 1 day in last 30 days

44
Q

Substance use disorders

AUD prevalence

A
  • age: 15-49 ETOH is leading cause of death/disability
  • 18% of all Canadians age 15+ meet clinical criteria for AUD in their lifetime
  • 20% of Canadians 12+ drink in excess of recommended limits
  • Higher prevalence in sexual minority (LGBTQ)
45
Q

Substance use disorders

AUD patho (C&G?)

A
  • Brain disorder caused by combination of genetics and environment
  • ?impaired metabolism, insensitivity to alcohol, alterations in brain wave
46
Q

Substance use disorders

Complications of AUD

A 
anemia 
HTN
cardiomyopathy
hepatitis/AFLD/Cirrhosis
Gout
DM
CA
gastritis/varices/UGIB
pancreatitis
polyneuropathy
dementias 
psychosis
47
Q

Substance use disorders

What is the PAWSS?

A

Prediction of alcohol withdrawal severity scale

Score < 4 –> low risk, manage without pharm or with gabapentine as outpatient

Score > 3 –> hospital admission, benzo for withdrawal management

48
Q

Substance use disorders

2 first - line pharm management for AUD and their contraindications?

A

naltrexone –> contraindication in severe liver dysfunction or concurrent opioid use (best choice is patient wants to reduce drinking but isn’t necessarily planning abstinence)

acomprosate –> contraindicated in severe renal failure, breastfeeding A = abstinent (best choice if patient would like to stop altogether)

49
Q

Substance use disorders

What are two 2nd line pharm options for AUD and their contraindications?

A

topiramate –> contraindicated pregnancy, narrow angle glaucoma, nephrolithiasis

gabapentine –> contraindicated in renal impairment, pregnancy, teens or > 65 yrs, concomitant CNS depressants, poor resp function, cognitive impairment

50
Q

Substance use disorders

Supplements for AUD

A

Thiamine (100 mg)
folic acid (1 mg)
B6 (2 mg)

NUNP 543 (22 decks)

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