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The RATE of increases of dopamine levels.
Ex. IV cocaine reaches the brain faster and dopamine levels rise quicker than oral
What is the degree of reinforcement of drug use linked to?
Diagnostic criteria for SUD
Mild: 1-3
Moderate: 4-5
Severe: 6+
Alcohol
barbiturates
BZDs
Cannabinoids
Hallucinogens
Nicotine
Opioids
Stimulants
What are the drugs with potential for SUD?
Screening
-Helps assess the severity of substance use and aids to objectively identify a level of treatment for each patient
Brief intervention
Centers on behavioral changes by increasing awareness to the problem at hand.
Referral to Treatment (RT)
Provides patients the opportunity for an evaluation by trained personnel and referral to appropriate level of treatment.
1.) Reducing substance abuse or achieving a substance-free life.
2.) Maximizing multiple aspects of life functioning
3.) Preventing or reducing the frequency and severity of relapse.
What are the three generalized goals for all substance abuse treatment programs?
(initially, the patient needs to be detoxed from the substance → managed medically)
Alcohol
-Most common substance that Americans use to alter their state of mind
-Increases the risk of certain conditions:
Stroke
HTN
Depression
Esophagus cancer
Cirrhosis of the liver
-CNS depressant that has similar effect as barbituates and BZDs
-Increases the actions of GABA and inhibits the release of Ach.
Metabolic syndrome
Wernicke’s encephalopathy
What are two conditions that can arise from AUD?
Metabolic Syndrome
-Abdominal obesity, hyperglycemia, high cholesterol, and high blood pressure
Exacerbated by the cell damage and higher caloric intake in patients consuming large amounts of alcohol.
-Thiamine deficiency occurs due to decreased absorption and poor diet
Wernicke’s Encephalopathy
-Acute life-threatening neurological condition characterized by a triad of nystagmus, ataxia, and confusion. can result from administering glucose in the absence of thiamine.
-ALL heavy alcohol users need thiamine prior to any nutritional intervention.
-BANANA Bag → D5NS + Thiamine 100mg + Folate 1mg + MVI + Mag. Sulfate 2gm
Category of drinking
-Moderate drinkers → 1 drink/day for females, 2 for males
-Heavy Drinkers → 3 drink/day for females; More than 4 for males
2-4 drinks/hour → BAC 0.08-0.1% (legal limit is 0.08%)
Alcohol withdrawal
-Symptoms may appear 6-12 hours after discontinuation of alcohol but can start 1-3 days later and may last up to a week.
-Mild symptoms: (managed outpatient if no history of delirium tremens or seizures)
Anxiety, sweating, restlessness, insomnia
-Moderate Symptoms:
Mild symptoms + increased blood pressure/HR
Confusion
Mild hyperthermia
-Severe Symptoms:
Moderate symptoms + hallucinations
impaired attention
Seizures and delirium tremors.
Delirium Tremens (DT)
-Characterized by a rapid onset of psychological/neurological changes, hallucinations, and sympathetic overdrive.
-Considered the worst form of alcohol withdrawal, presents like delirium
Chlordiazepoxide
Diazepam
Lorazepam
Oxazepam
What are the BZDs that can be used to treat AUD?
Acamprosate
Disulfiram
Naltrexone
What are the 3 main drugs used for AUD?
Acamprosate (campral)
USE: moderate-severe AUD, decreases the severity of withdrawal symptoms.
MOA: GABA agonist/Glutamate antagonist.
-Three times daily dosing (compliance issues)
-Contraindicated in renal impairment and sulf allergies.
AE:
Diarrhea, nausea
Insomnia
Puritis, asthenia
Anxiety, depression
HTN
Naltrexone (REvia & Vivitrol)
-USE: AUD and OUD
MOA: pure opioid antagonist with high affinity for the mu opioid receptor which may block alcohol activity.
Blocks the euphoria of alcohol, making it less rewarding.
-Available PO (daily) or IM (every 4 weeks)
must d/c 30 days prior to surgery
AE:
Exacerbation of withdrawal (must be free for 7 days)
Nausea, headache
injection site reactions.
Contraindications:
Use of opioids/alcohol in the past 7 days
Acute opioid withdrawal
Failed naloxone challenge
Positive urine opioid screen
Acute hepatitis or liver failure.
Disulfiram (antabuse)
USE: AUD deterrent → produces unpleasant effects when taken with alcohol.
-Reaction can occur with even small amounts of alcohol (mouthwash, cough syrups, sauces)
-Metallic or garlic-like taste
Contraindications:
Cardiac disease
severe respiratory or renal disease
severe hepatic dysfunction
Poor impulse control
Metronidazole and ketoconazole
Varices
Enlargement of splanchnic vessels in the esophagus and stomach, risk of rupture and profuse GI hemorrhage.
Ascites
Buildup of fluid in the peritoneum
Spontaneous bacterial peritonitis (SBP)
Infection of the peritoneal space from most likely increased intestinal permeability → bacterial translocation from gut to peritoneal space.
Hepatorenal Syndrome (HRS)
Profound reduction of blood flow to the kidneys → Prerenal acute or subacute kidney injury
Hepatic Encephalopathy
Neuropsychiatric complication of cirrhosis from ammonia accumulation crosses BBB causing transient damage to astrocytes and neurons.
-Symptoms range from mild inattention and agitation to coma and death.
Nicotine replacement therapy
Varenicline (Chantix)
Bupropion (Zyban)
What are 3 approaches for treatment of tobacco use disorder?
Nicotine replacement therapy
-Chewing gum, lozenges and patches
-Mitigates nicotine withdrawal
Bupropion (Zyban)
-Atypical antidepressant
The ability to block the reuptake of dopamine may contribute to effectiveness.
-Decreases the urge to smoke, and reduces withdrawal symptoms.
-Start taking 1 week before your quit date.
AE:
Insomnia
Agitation
Dry mouth
Headache
Contraindications:
Seizures or taking meds that lower the seizure threshold.
Eating disorders
Anxiety disorders
Varenicline (Chantix)
-Partial nicotinic receptor agonist
Prevents withdrawal symptoms
Blocks nicotine reward pathway
-Most effective medication for smoking cessation.
-Choose a fixed, flexible, or gradual quit date; quitting in a few days is not unheard of.
AE:
Nausea
Insomnia
Abnormal dreams
HA, skin rash
Serous neuropsychiatric symptoms → (depression, SI, agitation) do NOT give to someone with a psych disorder!!