SUD: Opioids, Stimulants, Sedatives

3 biggest reasons for not receiving SUD treatment

1. belief that it can be handled alone

2. not ready to start treatment

3. not ready to stop or cut back use

Lofexidine: class, indication, limit on use

centrally-acting alpha-2 agonist to decrease sympathetic output

2nd line for opioid withdrawal

can only be used for 14-days

nalmefene: max duration of effect, warning, who needs test dose

lasts up to 4 hours

can precipitate severe opioid withdrawal

test dose for opioid-dependent patients

difference in methadone dosing for pain vs. OUD

dosed 3-4x/day for pain

dosed 1-3x/day for pain, most commonly 1-2x

methadone half life range, contraindications, BBW

range: 13-100, 24 hours

CI: respiratory depression, acute/severe asthma, GI obstruction

BBW: QTc > 500 msec, neonatal opioid withdrawal syndrome

what is the role of naloxone in buprenorphine-naloxone

the naloxone will become activated if the dosage form is tampered with, prevents “high” associated with buprenorphine’s opioid agonism in SUD

naltrexone: contraindications, population to avoid

contraindicated in opioid use in the last 7-10d (or 14d for buprenorphine or methadone)

avoid in acute hepatitis or severe hepatic impairment

avoid in pregnancy (risk of spontaneous abortion)

OUD special populations: pregnant, lactating, elderly

pregnant: prefer methadone > buprenorphine. AVOID opioid antagonists

lactating: methadone or buprenorphine, encouraged to breastfeed

elderly: buprenorphine/(naloxone) > methadone

role of flumazenil

approved for benzodiazepine overdose but NOT USED, increases risk of seizure and arrhythmia beyond benefits of reversing overdose

NO ROLE