Drug Therapy for Substance Abuse Disorders

A maladaptive pattern of substance use, leading to clinically significant impairment or distress. Involves self-administration of drug for prolonged periods or in excessive amounts; there is no “cure” for addiction.

Substance abuse

Overwhelming desire to repeat drug use: either to produce pleasure or avoid discomfort

• Intoxication – reversible substance-specific syndrome caused by recent ingestion/exposure to a substance

Psychological dependence

Chronic use of a drug to avoid withdrawal symptoms (body has adapted to receiving substance on a regular basis)

• Withdrawal – “unpleasant” symptoms when drug is stopped

Physical dependence

Reversible substance-specific syndrome caused by recent ingestion/exposure to a substance

Intoxication

Increased doses are required to achieve desired effects (higher dose is needed to achieve similar effect compared to earlier with lower doses)

Tolerance

CNS depressants (that can be abused)

• Alcohol

• Antianxiety (ie benzos)

• Sedative-hypnotics (e.g. Ambien)

• Opioid analgesics (including heroin)

What drugs are most likely to be abused?

Drugs that affect the CNS

• CNS depressants

• CNS stimulants

CNS stimulants (that can be abused)

• Nicotine

• Stimulants (cocaine, meth)

• Marijuana

• Hallucinogens

  • Lysergic acid diethylamide (LSD)

  • MDMA aka “Molly” or “Ecstasy” (date-rape drug)

  • Dextromethorphan

Hallucinogens

• Lysergic acid diethylamide (LSD)

• MDMA aka “Molly” or “Ecstasy” (date-rape drug)

• Dextromethorphan (an OTC cough ingredient)

General S&S of withdrawal

• Flu-like symptoms

• Body aches and tremors

• HA

• GI: NVD, dehydration

• CNS: irritability, anger, confusion, decreased attention span, unconsciousness

Drug that treats alcohol withdrawal

Benzodiazepines

Prodrug of benzos

Chlordiazepoxide (Librium) & Diazepam (Valium)

Benzo MOA

Sedative and anti-convulsant effects

• Binds to and stimulates GABA receptors (increases channel opening frequency) → sedating effects

• Enhances inhibitory effect of GABA

Benzo indication

• Anxiety – acute/short-term (acute anxiety attacks)

• Preprocedural/preoperative sedation

• Insomnia

• Seizures

• Alcohol withdrawal

• Serotonin syndrome/NMS management

Benzo nursing considerations 

• Goal is to take drug while abstaining from alcohol to reduce withdrawal symptoms (substitute alcohol with this drug)

• BBW for combined use w/ opioids (respiratory depression)

• Schedule IV

Drugs have BBW for combined use w/ opioids (respiratory depression; can be fatal)

Benzodiazepines

Prodrug of BZD reversal agent

Flumazenil (Romazicon)

MOA of flumazenil (BZD reversal agent)

Inhibit BZD at receptor sites

Flumazenil

Antidote that reverses the effects of BZD OD

Drug has a BBW for r/o seizures (be aware of if patient has past hx of epilepsy)

Flumazenil

Enzyme inhibitor for maintenance of alcohol sobriety

Prodrug = Disulfiram (Antabuse)

MOA of disulfiram (enzyme inhibitor of maintenance of alcohol sobriety)

Prevents normal metabolism of alcohol, resulting in unpleasant reaction when consumed with alcohol

Disulfiram (Antabuse) indication

Maintain state of sobriety (threaten patient with death)

Nursing considerations for disulfiram 

• Patient consumes alcohol, SEs may include:

  • HA, seizures, NV

  • Chest pain, HF, MI, death

• BBW

  • Patients MUST know they are taking this med

  • Not for patients/CI who consumed alcohol in past 12 hrs; or patients with heart conditions

  • Educate patient about mouthwash/OTC products that contain alcohol

Drug has BBW for:

• Patients legally MUST know they are taking this med (drug can kill them if they consume alcohol)

• Not for patients who consumed alcohol in past 12 hrs; or patients with heart conditions

Disulfiram

Educate patient about mouthwash/OTC products that contain alcohol due to BBW

Disulfiram

Opioid agonists for treatment of opioid abuse

Prodrug: methadone (Methadose)

Methadone MOA

Same as other opioids, but works slower and produces less euphoria (patient will not lack pain relief, and avoid euphoric effects of stronger opioids)

Methadone indication

Detoxification/maintenance therapy for opioid addiction

Nursing considerations for methadone (Methadose)

BBW

• Only for use with an approved opioid addiction treatment program

• Monitor for QT prolongation

Drug has a BBW for

• Only for use with an approved opioid addiction treatment program

• Monitor for QT prolongation (methadone can increase QT interval)

Methadone

Opioid antagonist/agonist for treatment of opioid abuse

Prodrug: buprenorphine-naloxone (Suboxone)

MOA of buprenorphine-naloxone (Suboxone; opioid antagonist/agonist)

Buprenorphine blocks opiate receptors to reduce urges; naloxone reverse effects of opioids (buprenorphine has stronger binding than naloxone; only opioid naloxone cannot reverse); buprenorphine provides weak opioid/pain therapy while naloxone reverse all other opioids (prevents abuse of other opioids during therapy)

Buprenorphine-naloxone (Suboxone) indication

Maintenance therapy for short-acting opioid dependence (not as strong as methadone; used when withdrawal symptoms comes on fast)

Nursing considerations for buprenorphine-naloxone (Suboxone)

BBW → Buccal and transdermal routes have higher r/o addiction, abuse, and misuse leading to respiratory depression

Drug has BBW for buccal and transdermal routes having higher r/o addiction, abuse, and misuse leading to respiratory depression

Buprenorphine-naloxone (Suboxone)

There are few proven pharmacologic treatments to treat abuse and dependence on the following:

• CNS stimulants

  • Methamphetamine

  • Cocaine

• Marijuana

• Hallucinogens

  • LSD

  • MDMA