Substance use disorders

Goal of SUD treatment

• minimize withdrawal complications

• reduce cravings

• prevent relapse

Alcohol withdrawal onset

starts within 4-12 hours and can continue for 5-7 days

Alcohol withdrawal manifestations

• N/V

• tremors

• insomnia

• depression

• irritability

• increase in HR/BP/RR/temp

• delirium (can last 2-3 days, can be life threatening)

• seizures

Alcohol withdrawal meds

• benzodiazepines

• adjunct medications

Alcohol abstinence maintenance drugs

• disulfiram

• naltrexone

• acamprosate

Benzodiazepine examples

• chordiazepxoide

• diazepam

• lorazepam

Benzodiazepine use

• alcohol withdrawal

• decreases seizure risk and intensity of manifestations

Benzodiazepine interventions

• baseline and ongoing vitals and neuro exams

• seizure precautions

• can be PRN or around the clock

Benzodiazepine toxicity antidote

flumazenil

Adjunct medications for alcohol withdrawal

• carbamazepine (mood-stabilizing antieleptic)

  • decreases seizure risk

• clonidine (alpha 2 agonist)

  • depress autonomic response (decrease BP/HR)

• propranolol/atenolol (beta blocker)

  • depress autonomic response (decrease BP/HR)

  • decrease craving

Adjunct medications for alcohol withdrawal interventions

• monitor vitals and neurological status

• seizure precautions

Disulfiram uses

• aversion therapy for abstinence maintenance

• inhibits aldehyde dehydrogenase

Disulfiram manifestations

• causes severe reaction when alcohol ingested:

  • N/V

  • weakness

  • sweating

  • palpitations

  • hypotension

• can progress to:

  • respiratory suppression

  • seizures

  • death

• reaction can occur up to 2 weeks after last dose

Disulfiram education

• avoid ingesting any products that may contain alcohol

• be aware of potentially fatal reaction that could occur if alcohol consumed

Disulfiram interventions

monitor LFTs (hepatotoxic)

Naltrexone use

• opioid antagonist that suppresses craving and pleasurable effects of alcohol

• abstinence maintenance

• also used for opioid withdrawal

Naltrexone education

• must abstain from alcohol BEFORE initiating

• take with meals to prevent GI distress

• available in a monthly IV injection

Acamprosate use

• decreases glutamate activity, restores GABA function

• maintains abstinence

Acamprosate manifestations

• decreases unpleasant effects resulting from abstinence

  • dysphoria

  • anxiety

  • restlessness

Acamprosate education

• requires TID dosing with meals

• diarrhea can occur

• avoid in pregnancy

Opioid withdrawal onset

starts within 1 hour to several days lasting 1-2 weeks

Opioid withdrawal manifestations

• agitation

• insomnia

• flu-like s/s

• yawning

• abdominal cramping

• diarrhea

Opioid withdrawal medications

• methadone

• clonidine

• buprenorphine

Methadone uses

• full opioid agonist to replace illegal opioid

• prevents abstinence syndrome and removes need to obtain illegal substance

Methadone administration

• must be given from approved treatment center

• dosage monitored closely and slowly tapered down

Methadone side effects

respiratory depression (overdose risk)

Naloxone

opioid antagonist to reverse opioid toxicity

Clonidine use

• alpha 2 agonist

• assists with withdrawal effects (diarrhea, N/V)

• does NOT reduce cravings

Clonidine interventions

• baseline vitals

• do NOT discontinue abruptly (rebound HTN)

Clonidine side effects

• sedation

• dry mouth

• hypotension

• bradycardia

Buprenorphine uses

• partial opioid agonist

• decreases cravings

• prevents withdrawal manifestations

• effective for maintenance

• safer than methadone (decreased risk for resp depression and dependance)

Buprenorphine administration

• sublingual (tablets or films)

• surgical skin implant

• often combined with naloxone (prevent misuse)

• can be prescribed outpatient (no daily dosing required)

Nicotine withdrawal onset

starts within hours and slowly improves after 4 days

Nicotine withdrawal manifestations

• irritability

• nervousness

• restlessness

• insomnia

• difficulty concentrating

Nicotine withdrawal medications

• bupropion

• varenicline

• nicotine replacement therapy

Bupropion uses

• norepinephrine/dopamine reuptake inhibitor

• reduces cravings and manifestations of withdrawal

Bupropion contraindication

avoid in pts at risk for seizures

Bupropion side effects

• dry mouth

• insomnia

• N/V

• HA

• seizures

Varenicline uses

• nicotinic receptor agonist to stimulate pleasurable effects of nicotine (dopamine release)

• reduces cravings and severity of withdrawal manifestations

• reduces relapse by blocking desired effect of nicotine

Varenicline side effects

• N/V

• insomnia

• depression

• suicidal thoughts

Varenicline interventions

• monitor BP

• follow instructions for titration

• take after meal

Nicotine replacement therapy uses

• nicotine substitutes double the success rate of smoking cessation

• reduces withdrawal symptoms

• available as patches, gum, lozenges, nasal spray, and inhalers

Nicotine replacement therapy education

• follow product directions

• taper gradually

• e-cigs are NOT approved by the FDA