Substances of Abuse and Disorders

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1

Defined as reversible maladaptive behavior/psychological changes from the physiologic effects on the CNS due to recent ingestion of a substance

Intoxication

2

Defined as symptoms specific to a substance that occur in the absence of the substance

Withdrawal

3

Defined as the requirement of higher doses of a substance to achieve the same effect

Tolerance

4

List 4 components of dependence

  1. Tolerance/withdrawal
  2. Continued use despite harm
  3. Compulsive use
  4. 12 mo period of time
5

Defined as maladaptive pattern of a substance that is not considered dependence; also 12 mo period of time

Abuse

6

Defined as compulsive physiological and psychological need for a habit forming substance; continued despite negative consequences

Addiction

7

What are the 4 C's of addiciton?

  • Compulsive use
  • Cravings
  • Continued use despite harm
  • Inability to control quantity used (requires more for same effect)
8

Behavioral/psych changes w/ opioid intoxication:

Euphoria followed by apathy, dysphoria, psychomotor agitation/retardation, impaired judgement

9

S/S of opioid intoxication:

Pupillary constriction + one or more of the following:

  • Drowsiness/coma
  • Slurred speech
  • Impairment in attention/memory
10

Opioid withdrawal DSM-5:

Presence of either:

  • Cessation/reduction in opioid use that has been heavy and prolonged
  • Administration of an opioid antagonist after a period of opioid use
  • 3 or more flu-like symptoms developing w/in minutes-days
11

Flu-like symptoms of opioid withdrawal:

  • Dysphoric mood
  • N/V/D
  • Muscle aches
  • Lacrimation/rhinorrhea
  • Pupillary dilation, piloerection
  • Yawning
  • Fever
  • Insomnia
  • Sweating
12

Pharm therapy for opioid intoxication:

Naloxone (inpt: 0.4-2mg IV Q 3 min)

13

Describe Evzio

  • Naloxone autoinjector of 0.4 mg to be admin in upper outer arm/thigh
  • Comes w/ trainer; talks you through it
  • 5 min faster than "normal" syringe
14

Describe Narcan

  • Nasal spray; spray 1/2 syringe into each nostril
  • May repeat 1 time
15

T/F: Opioid withdrawal symptoms usually occur w/in 12-24 hours of opioid cessation and can take 2-3 days if DOC is buprenorphine or up to 7 days using methadone

True

16

When do opioid withdrawal symptoms usually peak?

7-10 d

17

Which opioid withdrawal symptoms may last for months?

  • Anxiety
  • Dysphoria
  • Anhedonia
  • Insomnia
18

Describe the scoring for the clinical opiate withdrawal scale (COWS)

  • ≤ 5 = very mild
  • 6-12 = mild
  • 12-24 = moderate
  • 25-35 = severe
  • >36 = very severe
19

What COWS score would you initiate meds?

12-24

20

Treatment for anxiety in opioid withdrawal:

  • BZDs (not best option)
  • Clonidine
  • Lofexidine
  • Hydroxyzine
21

Treatment for abdominal cramps in opioid withdrawal:

Dicyclomine

22

Treatment for general pain in opioid withdrawal:

  • NSAIDs
  • APAP
23

Treatment for sleep in opioid withdrawal:

  • Trazadone
  • BZDs (lorazepam Q 6-8 hrs)
  • Melatonin
  • Benadryl
24

Clonidine dosing:

0.1-0.2 mg Q 6-8 hrs

25

How does clonidine treat anxiety in opioid withdrawal?

Blocks peripheral response

26

Hold clonidine dose if BP is ____________

<85/55

27

Pros of Clonidine for anxiety in opioid withdrawal:

  • Non-narcotic
  • Non-addictive
28

Cons of Clonidine for anxiety in opioid withdrawal:

  • Cannot use in pregnancy
  • Does not treat other symptoms
29

Lofexidine brand

Lucymera

30

Lofexidine MOA:

α2 antagonist

31

Lofexidine dosing:

0.54 mg 4x daily during peak withdrawal symptoms (generally the first 5-7 d after last opioid use)

32

Max lofexidine dose:

0.72 mg/dose or 2.88 mg/day

33

Lofexidine AEs:

  • Orthostatic hypotension
  • Insomnia
  • Syncope
34

Lofexidine is contraindicated in who?

Poor metabolizers of CYP2D6

35

Buprenorphine MOA:

μ agonist

36

Buprenorphine brand (alone)

Subutex, Probuphine (arm implant)

37

Buprenorphine brand (w/ naloxone)

Suboxone, Zubsolv

38

Methadone MOA:

μ agonist

39

Under US federal law, methadone prescribed for ____________ can only be done through a federally approved methadone detox program

Detoxification

40

T/F: Buprenorphine+Naloxone is a schedule IV drug of choice for opioid addiction (unless hypersensitivity) and can be used in pregancy.

False

41

Buprenorphine+Naloxone MOA

Partial agonist at μ receptor + opiate antagonist

42

Why was naloxone added to buprenorphine?

Block opioid effect if injected

43

BBW for Buprenorphine+Naloxone

QTc interval prolongation

44

When should Buprenorphine+Naloxone be initiated?

12-24 hours after last opioid dose

45

Dosing of Buprenorphine+Naloxone:

  • Day 1: 2 mg Q 2 hours (max 8 mg on 1st day)
  • Day 2: Additional 2 mg Q 2 hrs (max 16 mg)
  • Day 3: Additional 4 mg Q 2 hrs (max 32 mg)
  • Day 4-5: Maintain on dose required to alleviate withdrawal symptoms
  • Day 6+: decrease dose by 25% each day (or less depending on tolerance)
46

Buprenorphine+Naloxone metabolism and half-life:

3A4 and 20-44 hrs

47

Buprenorphine+Naloxone AEs:

  • Sedation
  • HAs
  • Constipation
48

There is a potential for Buprenorphine+Naloxone when used with ___________

BZDs

49

Regulations on Buprenorphine+Naloxone:

  • Obtain DATA 2000 waiver
  • Special DEA # (X)
  • 8 hrs training
  • Board certified in addiction medicine/psychiatry
  • no more than 30 pts at 1 time (275 after 1 yr)
50

Methadone MOA:

Synthetic opiate; μ agonist

  • NMDA antagonist
  • K and δ opioid receptor agonist
  • blocks 5HT and NET
51

Methadone brand:

Dolophine, Methadose

52

Methadone schedule:

II

53

Why does methadone half-life vary (8-59 hrs)?

Highly lipophillic = effects of drug may linger

54

How long does the analgesic effect of methadone last?

4-8 hrs

55

Counseling points for methadone:

  • Analgesic duration is increased w/ repeat doses
  • Unpredictable half-life
  • Lots of sedation, hard to titrate
56

Dose of methadone to treat withdrawal:

  • 20-80 mg/day (must document if over 120 mg/day)
  • Taper by 5-10 mg daily (different tapering options in literature)
57

Dose of methadone to treat chronic pain (i.e. cancer/neuropathic)

  • PO 2.5 -10 mg Q 3-4 hrs
  • IM 2.5 - 10 mg Q 8-12 hrs
  • PO 5-20 mg Q 6-8 hrs
58

Who can prescribe methadone for acute pain?

  • All physicians
  • if over 120 mg/day - pain specialist
59

Who can prescribe methadone for opioid dependence?

Certified psychiatrist working in a certified facility through SAMHSA or CSAT

60

What pharmacy can dispense methadone for acute pain?

Any pharmacy; document if dose over 120 mg/day

61

What pharmacy can dispense methadone for chronic pain?

Any pharmacy; must first verify reason for use

62

What pharmacy can dispense methadone for opioid dependence?

Cannot dispense

63

General guidelines for treating opioid withdrawal:

  • Symptoms peak at ~7 d
  • Symptoms can last 2 weeks
  • Explain SEs
  • Taper off opiate substitution
64

The DSM-5 for opioid use disorder is a problematic pattern of opioid use leading to impairment or distress manifested by ______ of the 9 symptoms

2

65

List the 9 symptoms of opioid use disorder:

  1. Opioids taken in larger amounts / over longer period
  2. Persistent desire/unsuccessful efforts to cut down/control use
  3. Great deal of time spent obtaining, using, or recovering from effects
  4. Craving to use
  5. Recurrent use resulting in failure to thrive (work/school/home)
  6. Continued use despite persistent/recurrent social / interpersonal problems made worse by opioids
  7. Social, occupational, recreational activities given up due to opioids
  8. Recurrent use in situations in which it is physically hazardous
  9. Continued use despite knowledge of having problems made worse by the substance
66

Which situations are not to be met for individuals taking opioids solely under appropriate supervision?

Tolerance and withdrawal

67

How would you taper off methadone treatment?

Reduce dose Q 7-14 days

68

What is the target dose of buprenorphine and how long does tx usually last?

16 mg/day; ~1 year

69

Naltrexone dosing:

Oral: 50 mg/d

LAI: 380mg/4wks

70

Naltrexone MOA:

μ antagonist

71

Naltrexone indication

Opiate and alcohol dependence

72

Naltrexone warnings:

  • Precipitate opioid withdrawal (admin 12hrs-2 days after last dose
  • Pts become vulnerable to opiate OD after use
  • Liver impairment
73

Which drug is on the REMS program and requires counseling and a medical alter bracelet/card

Naltrexone

74

Common SEs of naltrexone

  • Dizziness
  • HA, anxiety
  • N/V/D, anorexia
  • Increased ALT
  • CPK increase
  • injxn site rxn (LAI)
75

Symptoms of BZD intoxication

  • Memory impairment
  • Drowsiness
  • Visual disturbances
  • Confusion
  • GI disturbances
  • May appear intoxicated (slurred speech, poor coordination, swaying, bloodshot eyes, w/wo alcohol odor)
76

The intoxicated pt may be in acute distress in overdoses or when BZDs are combined w/ _________

alcohol

77

BZD intoxication treatment

FLumazenil 0.2 mg/min IV initially, repeat up to 3 mg max

78

Symptoms of BZD withdrawal

  • Agitation and restlessness
  • Dizziness
  • Flu-like symptoms
  • Impaired memory/concentration
  • N/V
  • Nightmares
  • Visual disturbances
  • Convulsions
  • Hallucinations
79

Signs of BZDs withdrawal

  • Hypotn
  • Nystagmus
  • Urinary retention
80

Pts experiencing bzd withdrawal may also be in acute distress and should be treated w/ a _____________ taper to prevent ______________

BZD, seizures

81

Pharmacologic tx for bzd withdrawal

Lorazepam 2 mg 3-4x/d; taper over 5-7d

82

DSM-5 for alcohol intoxication

  • Significant problematic behavior/psychological changes that developed during/shortly after alcohol ingestion
  • One or more of the following:
    • Slurred speech
    • Incoordination
    • Unsteady gait
    • Nystagmus
    • Impairment in attn/memory
    • Stupor/coma
83

DSM-5 for alcohol withdrawal

  • Two or more of the following, developing w/in several hours to a few days after cessation of/reduction in alcohol use:
    • Autonomic hyperactivity (sweating or pulse greater than 200 bpm)
    • Increased hand tremor
    • N/V
    • Transient visual, tactile, or auditory hallucinations/illusiong
    • Psychomotor agitation
    • ANxiety
    • Generalized tonic-clonic seizures
84

Tx for alcohol withdrawal

  • BZD taper (i.e. lorazepam 2 mg Q 6 hours x 6 doses, 1 mg Q 6 hours x 6 doses, 0.5 mg Q 6 hours x 6 doses);
    • Diazepam, oxazepam, and chlordiazepoxide also used
  • Vitamins and electrolytes (prevent Wernicke-Korsakoff syndrome
  • beta-blockers
  • Anticonvulsants
  • Antipsychotics (haloperidol for agitation)
  • IV ethanol
85

Which is the acute and which is the chronic phase of the neurological disorder Wernicke-Korsakoff syndrome (WKS)?

  • Wernike's encephalopathy (acute phase)
  • Korsakoff's psychosis (chronic phase)
86

What is WKS caused by

Deficiency in the B vitamin thiamine

87

Describe the clinical institute withdrawal assessment for alcohol (CIWA-A)

  • Pts placed on seizure precaution
  • Med used: Diazepam
    • CIWA >20: give 20 mg and assess Q 1 hr
    • CIWA 15-19: wait 1 hr and assess; if still 15-19 give 20 mg
    • CIWA 10-14: assess Q 2 hrs while awake
    • CIWA <10: assess Q 4 hrs
  • Continue CIWA for 48 hrs after time of first diazepam dose
88

DSM-5 alcohol dependence

At least two of the following w/in 12 months:

  • Alcohol taken in larger amts/over longer period than intended
  • Persistent desire/unsuccessful efforts to cut down/control alcohol use
  • Great deal of time spent in activities necessary to obtain/use/recover from alcohol
  • Craving to use
  • Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home
  • Continued use despite problems it causes / knowledge of the problems
  • Social/recreational/occupation activities given up/reduced due to alcohol
  • Recurrent use in situations where its hazardous
89

list 2 alcohol screening tools:

  • AUDIT
  • CAGE
90

Which alcohol screening tool:

  • Not diagnostic
  • Likely to be dependent if score is at least 2

CAGE

91

Which alcohol screening tool:

  • 8+ score = hazardous alcohol use
  • 1 + on question 2 or 3 = hazardous alcohol use
  • above 0 on questions 4-6 = incipience of alcohol dependence

AUDIT

92

What is the goal if the AUDIT score is b/w 8-15?

Reduce drinking

93

What is the goal if the AUDIT score is b/w 16-19?

Suggest counseling

94

What is the goal if the AUDIT score is above 20?

Needs further diagnostic evaluation

95

Which medication for treating alcohol dependence is indicated for deterrence?

Disulfiram (Antabuse)

96

T/F: Naltrexone blocks the euphoric feeling of drinking alcohol and reducing the craving of alcohol

True

97

Naltrexone brand name

Vivitrol, Revia

98

Special consideration w/ naltrexone

  • Pt should be opioid free for 7-10 d PRIOR to starting
  • Monitor liver fxn
  • Do not use w/ acute hepatitis/liver failure
99

Naltrexone SEs:

  • N/V
  • Decreased appetite
  • HA/dizziness
  • Fatigue
  • Somnolence
  • Anxiety
  • Acute hepatotox (rare)
100

T/F: Acamprosate reduces the craving of alcohol and the dose is two 300 mg tablets daily

False

101

Acamprosate SEs

Diarrhea and somnolence

102

Acamprosate caution:

Renal impairment

103

Disulfiram dosing:

500 mg once daily x 1-2 weeks, reduce to 250 mg/day

104

Disulfiram SEs

  • Flushing
  • Palpitations
  • Nausea
  • Drowsiness
  • Hepatic tox
  • Metallic aftertaste
105

Disulfiram contraindications

  • Alcohol
  • Metronidazole
  • CAD
106

Disulfiram caution in

  • DM
  • Epilepsy
  • Renal impairment
  • Cirrhosis
107

Disulfiram interactions:

  • 3A4 inhibitors
  • Warfarin
  • EtOH
  • Metronidazole
  • OTC cough syrups
108

Treatment pearls for alcohol dependence

  • Course of tx: 6-12 mo
  • Relapse is part of tx
  • Praise the small steps
  • Define cutting down vs abstinence
  • Always review th ebenefits of abstinence
  • Address adherence to meds
  • Refer: 800-662-HELP
109

First line therapy for nicotine cessation:

  • Bupropion SR
  • Nicotine Replacement Therapy (NRT)
  • Varenicline
110

What are the 5 As for treating tobacco use and dependence?

  • Ask "do you currently use tobacco?"
  • Advise to quit
  • Assess willingness to quit
  • Assist in quitting
  • Arrange follow up
111

Important counseling for nicotine gum:

Acidic beverages (coffee, juice, soda) interfere w/ absorption; avoid eating and drinking for 15 min before/during chewing

112

Nicotine gum is available in 2 and 4 mg doses. If a pt smokes less than 25 cigarettes per day, which dose should they use?

2 mg

113

Chewing technique for nicotine gum

  • Chew until flavor emerges, then park b/w cheek and gum
  • Gum should be slowly and intermittently chewed and parked for ~30 min until taste is gone
114

T/F: Dosing for nicotine lozenge is based on how may cigarettes a person smokes in a day.

False

115

When should a pt using a nicotine patch initiate tx?

As soon as they wake up on quit day

116

T/F: All NRT are considered 1st line, but the patch is more effective than the gum or lozenge due to increased compliance.

False

117

When should a pt begin bupropion SR?

1-2 weeks before quitting

118

Bupropion max dose:

300 mg/d

119

Bupropion AE:

  • Insomnia
  • Dry mouth
  • Anxiety
  • HA
  • Seizures
120

Bupropion contraindications:

  • Seizure hx
  • Eating disorders
  • MAOI use in past 14 d
121

Varenicline dosing:

  1. 0.5 mg/d for 3 days
  2. 0.5 mg BID for 4 days
  3. Quit on day 8
  4. 1 mg BID for 3 mo
  5. Can use up to 6 mo
122

Varenicline MOA

nACh partial agonist

123

Varenicline warnings:

Changes in behavior

124

Varenicline AEs

  • abnormal/vivid/strange dreams
  • Nausea
  • Trouble sleeping
125

Drug interactions w/ smoking:

  • Theophylline
  • Clozapine
  • Caffeine
  • Fluvoxamine
  • Olanzapine
  • Warfarin