Antipsychotics and Substance Abuse Meds (Exam 2: Mental Health, UTM Nursing)

First-Gen Antipsychotics (Typical)

block dopamine, noradrenaline, histamine, and cholinergic receptors

side effects = movement problems (EPS, TD)

Second-Gen Antipsychotics (Atypical)

block dopamine and serotonin receptors

side effects = more likely for weight gain and metabolic effects

Side Effect Profile (Antipsychotics)

-1st gen = more likely for movement (EPS, TD) ; typically dry a patient out

-2nd gen = more likely for weight gain/metabolic

- EKG changes can occur with any of these meds

Dry mouth (more common)

Hypersalivation - Clozaril

Blurred Vision

Constipation/Urinary Retention

Nausea

Skin Rash

Sedation

Orthostatic Hypotension

Chol/Trig - Ziprasidone (Geodon)

Photosensitivity

Decreased Libido/Retrograde Ejaculation/Gynecomastia

Amenorrhea

Weight Gain

EKG Changes - Ziprasidone (Geodon) = QT prolongation

Seizures

Agranulocytosis (sore throat/fever) = Clozapine (Clozaril) - fatal

Haloperidol (Haldol)

-1st gen

- Haldol Deconoate = long-acting

- Haldol Lactate = short-acting

Chlorpromazine (Thorazine)

-1st gen

- dry mouth, dizziness, urine retention

Fluphenazine (Prolixin)

-1st gen

Olanzapine (Zyprexa)

-2nd gen

-Zyprexa Zydis = dissolves

- Zyprexa Relprevv = long acting

Quetiapine (Seroquel)

-2nd gen

- good for mood disorder too

Ziprasidone (Geodon)

-2nd gen

- acute agitation, high potency

- QT prolongation, increased Cholesterol/Triglycerides (main SEs)

Aripiprazole (Abilify)

-2nd gen

- good for bipolar/depression

- Abilify Maintena = long acting

Clozapine (Clozaril)

-2nd gen

- CBC needed weekly, then bimonthly, and then monthly

- last line medication

- knocks out WBCs

- Agranulocytosis (fatal) ; CBC needed if flu-like sx start (main AE)

-hypersalivation (also on the slides)

Risperidone (Risperdal)

- 2nd gen

- acts slightly different by blocking less dopamine

- less sedation ; good for elderly

Asenapine (Saphris)

-2nd gen

- FDA schizo and bipolar- compound

Paliperidone (Invega)

-2nd gen

- Invega Sustenna = monthly (long-acting)

- Invega Trinza = q 3 months (longest-acting)

Iloperidone (Fanapt)

-2nd gen

Cariprazine (VRAYLAR)

-2nd gen

- also adjunct with antidepressant

- works well for bipolar

Lurasidone (Latuda)

- take with meals ; increases absorption (350 cal minimum)

- NMS, Seizures, Suicidal Thoughts (drug book has these as intense and common AEs)

Lumateperone (Caplyta)

-2nd gen

- one mg dosing, lesser SE profile

- interacts with Triple T = Trileptal, Tegretol, Topamax

Brexpiprazole (Rexulti)

-2nd gen

- common adjunct with antidepressant

EPS Drugs

Anticholinergics

- Benztropine (Cogentin)

- Trihexyphenidyl (Artane)

Antihistamines

- Diphenhydramine (Benadryl)

Dopaminergic Agonists

- Amantadine (Symmetrel)

- Bromocriptine (Parlodel)

VMAT Inhibitors (block VMAT 2, reduces uptake of dopamine; more effective against TD)

- Tetrabenazine (Xenazine)

- Deutetrabenazine (Austedo)

- Valbenazine (Ingrezza)

Benztropine (Cogentin)

- Anticholinergic (EPS drug)

- for tremors

Trihexyphenidyl (Artane)

- Anticholinergic (EPS drug)

Diphenhydramine (Benadryl)

-Antihistamine (EPS drug)

Amantadine (Symmetrel)

-Dopaminergic Agonist (EPS drug)

- low side effect profile

Bromocriptine (Parlodel)

-Dopaminergic Agonist (EPS drug)

- used in supportive treatment of Neuroleptic Malignant Syndrome

Tetrabenazine (Xenazine)

-VMAT inhibitor

Deutetrabenazine (Austedo)

-VMAT inhibitor

Valbenazine (Ingrezza)

-VMAT inhibitor

Herbal Medications

Black Cohosh

Echinacea

Evening Primrose (oil)

Feverfew

Garlic

Gingko Biloba

Ginseng

Goldenseal

Green Tea

Hawthorn

Saw Palmetto

St. John's Wart

Black Cohosh

Used for:

- menopause

- painful menstruation

- uterine spasms

- vaginits

Echinacea

Used for:

-colds/flu

- immune

Evening Primrose (oil)

Used for:

-arthritis

- PMS

- CV disease

- hyperactivity in kids

Feverfew

Used for:

-pain

-migraines

-menstrual cramps

Garlic

Used for:

- CV conditions

- Cholesterol/Triglycerides

- Colds/flu

Gingko Biloba

Used for:

- aging conditions

- poor circulation

- memory loss

Ginseng

Used for:

- tonic for body tone

- energy

- resistance to stress

Goldenseal

Used for:

- antiseptic properties

- colds/flu

- inflamed nose

Green Tea

Used for:

- combat fatigue

- prevent arteriosclerosis

- cancer

- lower cholesterol

- reduce tooth decay

- weight loss

Hawthorn (heart)

Used for:

- angina

- atherosclerosis

- CHF

- HTN

Saw Palmetto

Used for:

- enlarged prostate

St. John's Wart

Used for:

- mild to moderate depression

Neuroleptic Malignant Syndrome (NMS)

- rare but fatal complication of neuroleptic drugs ; medical emergency

- temp increase / parkisonian sx

- Sx can appear similar to other things = hyperthermia, tachycardia, diaphoresis, cramps, HTN/hypotension, seizure activity, neuromuscular hypoactivity (rigidity- resistance through ROM), hyporeflexia

- Blood Test = elevated CK and WBC

- Onset is hours/years after drug initiation ; progression is rapid over 24-72 hours

Tx = supportive, stop caustive factor (antipsychotic)

- dantrolene helps relax muscles, reduce hyperthermia

- bromocriptine increases dopamine levels

Alcohol

- Legal limit = 0.08 or 80

- Intox = 100-200

- Death (possible)= 400-700

-Withdrawal Sx begin around 4-12 hours of last use

- Thiamine Deficiency in abuse

- Vivitrol (Naltrexone) and Disulfiram can help recover

Alcohol Withdrawal Sx

-Tremors

- N/V

- Malaise

- Weakness

- Tachycardia

- Increased BP

- Sweating

- Seizures

- Hallucinations (DTs)

Tx of Alcohol Abuse

Vivitrol (Naltrexone) = helps maintain alcohol abstinence

- blocks effects on CNS

- used for alcohol abuse (mainly), also heroin/morphine/codeine

- Deep IM in gluteal once a month

- Pts must have 7-10 days sober time before injection

Disulfiram = helps not to drink alcohol

- causes unpleasant effects = flushing, vomiting, dizziness

CAGE ?'s

- Have you felt you should CUT your drinking?

- Have others ANNOYED you about your drinking?

- Have you ever felt GUILTY about your drinking?

- Have you ever had a drink first thing in the morning as an EYE-opener?

Benzodiazepines (CCC MOLDA)

- Alprazolam (Xanax) = short-acting

- Diazepam (Valium) = long-acting

- Lorazepam (Ativan) = intermediate

- Phenibut

- Chlordiazepoxide ("greens and whites", "roaches") = long-acting

- Clonazepam = long-acting

- Clorazepate = long-acting

- Oxazepam = short-acting

- Meprobamate ("dolls, dollies")

BEERS Criteria

Benzos meet these criteria

- over 65 and not on hospice/palliative care

- avoided in certain health conditions

- avoid with certain medications due to increased likelihood of interactions

- avoid if side effects outweigh benefits

- limited due to effects on renal function

Benzo Withdrawal Sx

- increased anxiety/depression

- sweating

- N/V

- seizures

- hallucinations

- agitation

-tremors

- insomnia

- dry mouth, dizzy, increased HR

- illusions

- Short-acting withdrawal (alprazolam, lorazepam) begin between 12 and 24 hours of last dose (peaks 24-72) and subside in 5 to 10 days.

- Longer half-life drugs (diazepam, phenobarbital[not one of our drugs], chlordiazepoxide) may begin within 2 to 7 days, peak 5-8 days, subside 10-16 days.

Tx of Benzo Abuse

- Withdrawal is treated with Valium (high as 40 mg at start) and/or Baclofen Taper

- Reversal Agent for OD = Flumazenil

Stimulants

- Methamphetamine

- Cocaine

- Nicotine

- Caffeine

- Dextroamphetamine (Adderall)

- Atomoxetine (Strattera)

- Bath Salts (synthetic hallucinogen)

Intoxication of Stimulants

- Euphoria, anxiety, impaired judgment, anger, psychosis, violent aggression

- Hypervigilance, tension, memory loss

- Tachy/Bradycardia, chest pain, arrhythmias, increased BP

- Pupil DILATION

- sweating, N/V, wt loss

- respiratory depression

- seizures, muscle movement issues

Stimulant Withdrawal Sx

- increased anxiety/depression

- hallucinations

- tremors

- paranoia

- irritability

- N/V/D

- increased appetite

- HA

- nightmares/insomnia

- dysphoria (increased suicide risk)

- poor concentration

**within a few hrs to days after prolonged use/ peak 2-4 days after abstinence

Opioids

- Hydrocodone (Norcos, Vicodin)

- Oxycodone (Oxycontin, Roxicodone, Percocet)

- Fentanyl (Dirty 30's)

- Meperidine (Demerol)

- Morphine (MS Contin, Roxanol)

- Heroin

- Kratom (opioid and stimulant effects)

Intoxication of Opioids

- Initial euphoria followed by apathy, dysphoria, psychomotor agitation/retardation

- Pupil CONSTRICTION (dilation if OD)

- Drowsy/slurred speech

- Respiratory Depression/Coma/Death

Opioid Withdrawal Sx

- Muscle and joint pain

- N/V/D/ABD cramps

- Sweating/Restlessness

- Goosebumps

- Runny nose/watery eyes

- Malaise

- Increased BP/HR

- Dysphoria

- Pupil DILATION

Tx of Opioid Abuse

- Naloxone (Narcan) = reversal agent for OD

- Methadone = eliminates withdrawal and reduces cravings by fully activating the opioid receptors (heroin, morphine, opioids)

- Suboxone (Buprenorphine/Naloxone) = used during stabilization of withdrawal and maintenance stages of recovery (opioids)

- Sublocade (Buprenorphine ER) = lessens withdrawal sx and controls cravings (opioids)

- Vivitrol (Naltrexone) = used mainly for alcohol abuse but can also be used for heroin, morphine, and codeine

Methadone

- synthetic opioid that eliminates withdrawal sx and decreases cravings

- used for heroin, morphine, opioids

- fully activates opioid receptors (abuse potential)

Suboxone (Buprenorphine/Naloxone)

- used during stabilization of withdrawal and maintenance stages of recovery

- preferred over Methadone (partially activates receptors instead of fully)

- Treat opioids

- pill or dissolvable film

- Pt must have 5-7 days sober time and must pass the Naloxone test

Sublocade (Buprenorphine ER)

- lessens withdrawal sx and controls cravings

- opioids

- viscous liquid injection ; SubQ ; once a month

- Pt must have 7-10 days sober before injection

Vivitrol (Naltrexone)

- helps pt maintain alcohol abstinence

- blocks effects on CNS

- alcohol abuse (main use), also for heroin, morphine, codeine

- viscous injection ; Deep IM in gluteal ; once a month

- Pt must have 7-10 days sober before injection

- Possible OD risk due to blocked effects (pt takes more trying to get that "high")

Disulfiram

- can help pts not to drink

- when taken with alcohol, causes unpleasant effects = flushing, vomiting, dizziness

Hallucinogens

Naturally Occuring:

- Mescaline (peyote cactus)

- Psilocybin and Psilocin (mushrooms)

- Ololiuqui (morning glory seeds)

Synthetic Drugs:

- LSD (lysergic acid diethylamide)

- DMT (dimethyltryptamine) and DET (diethyltryptamine)

- PCP (Phencyclidine) - angel dust

- Ketamine (ketalar)

- Bath salts, Ecstasy

Effects of Hallucinogens

doesn't lead to a physical dependence or withdrawal symptoms

develop a psychological dependence

- N/V

- chills

- Increased HR, BP, Temp

- Increased Libido

- Dizzy, trembling, decreased appetite, sweating

- Insomnia

- Decreased respirations

- Pupil Dilation

- Peace, paranoia, fear, magnified feelings, derealization, depersonalization

- Distorted vision

Cannabis Intoxication

- impaired motor coordination

- euphoria

- anxiety, tachycardia

- increased appetite, dry mouth

- red eyes

Synthetic Cannabinoids:

- agitation

- HTN

- seizures/shaking

- increased HR

- paranoia/hallucinations

- violence

- N/V

Cannabis Withdrawal

**usually occur within 7 days of heavy use

- Irritable, aggression, nervous, restless, anxiety

- Insomnia, disturbing dreams

- Decreased appetite, wt. loss

- Depression

- Abdominal pain, tremors, sweating, fever, chills, HA

COWS

Clinical Opiate Withdrawal Scale

- 1. Resting Pulse Rate

- 2. GI Upset

- 3. Sweating

- 4. Tremor

- 5. Restlessness

- 6. Yawning

- 7. Pupil Size

- 8. Anxiety or Irritability

- 9. Bone or Joint Aches

- 10. Gooseflesh Skin (goosebumps)

- 11. Runny Nose or Tearing

A score of 12 or more = ER

CIWA

Clinical Insitute Withdrawal Assessment of Alcohol

- can also be used for benzos

- Nausea and Vomiting

- Tremor

- Paroxysmal Sweats

- Anxiety

- Tactile Disturbances

- Auditory Disturbances

- Visual Disturbances

- Headache, Fullness in Head

- Agitation

- Orientation and Clouding of Sensorium