SUDs: Barbiturates, Benzos, Opioids, Stimulants

Benzos: examples

• Short acting:

  • Ativan (Lorazepam)

  • Serax (Oxazepam)

  • Xanax (Alprazolam)

  • Rohypnal (Flunitrazepam): fast acting; date rape drug; memory loss under influence (anterograde amnesia)

• Long acting:

  • Klonopin (Clonazepam), Valium (Diazepam), Chlordiazepoxide (Librium)

Barbiturates examples

• phenobarbital (Solfoton) & Nembutal (Pentobarbital)

Benzos & Barbiturates Effects

• Increase synaptic transmission of GABA (inhibitory NT —> anti-seizure, sedation)

• CNS depression; reduces anxiety

• respiratory depression risks if take too much or combined w/ other sedative/CNS depressants → overdose, death

• Risks: Respiratory depression, tolerance, dependence esp. With prolonged use

  • > 3-4 weeks of sustained/regular benzo use increases risk for dependence

  • <2-3 weeks regular use = probably safe

Benzo Withdrawal

• treated the same as alc but longer (takes average of 10 days)

  • Generally the opposite of the drug’s effects; potentially fatal

  • Higher prevalence of labile mood states

  • Blurred vision, increased sensitivity to lights & sounds; muscle cramps & spasms; paresthesia

  • Confusion, psychotic reactions

  • Orthostasis, delirium (especially after bouts of insomnia); major motor seizures, CV collapse, death

Benzo detox

• 10 days or longer; benzo taper + supportive care

• the longer the drug is taken, or the higher doses increase the severity of withdrawal

• gradual taper; High to low

• IV fluids for hydration, frequent monitoring

Opioids

• Types:

  • Heroin

  • Oxycontin

  • Oxycodone

  • Fentanyl (synthetic; high OD risk)

  • Xylazine

Opioid Use Disorder: Epi-Risks

• route of use: infections, cut w/ toxins, other substances

• dependence, overdose (OD), withdrawal

• Risks: M>F: insecure employment, construction industry, burnout, workplace injuries, SEC

• prevalent in ages 15-26

• “Nodding out” = major sx

Xylazine

• horse tranquilizer drug and large animal sedative with pain killing & muscle relaxant properties that is mixed with heroin, cocaine, meth, and other street drugs

• ‘zombie drug’: can make a person go into psychosis and want to eat people

• leads to wounds / amputations

• When reversing the combo Xylazine + fentanyl O.D. with Narcan: harm reduction goal = just breathe; no need to wake person up

  • Xylazine is sedative → may stay asleep

Responding to the Heroin Epidemic

• Prevention

• Harm reduction

• Tx & recovery strategies

Heroin epidemic: prevention

Prevent people from starting heroin: reduce prescription opioid painkiller abuse by improving opioid painkiller prescribing practices and identify high risk individuals only

Reducing Heroin addiction

• ensure access to Medication-Assisted Treatment (MAT)

• combines use of medications (methadone, buprenorphine, or naltrexone) w/ counseling & behavioral therapies

Methadone Maintenance Therapy (liquid orange)

• federally regulated tx

• must go to clinic every day to take it in front of the nurse & be assessed

• cannot be under the influence of a sedative to take → OD risk

• prevents the effects of heroin; blocks heroin receptors

• clinically produced replacement opiate (safer)

• Methadone is the hardest detox → takes over a year

Buprenorphine

• another more accessible opiate

  • Buprenorphine: partial opioid receptor blocker + Naloxone (=Suboxone)

  • 2 drugs are used together d/t risk of abuse from buprenorphine & OD risks

• used for heroin & other short-acting opiate dependency

• Office-based option: if got extra training in this (allows to prescribe out of clinic)

• gives access in communities that lack methadone clinics

• newer approved therapy

• must be in withdrawal x 12-24 hrs

• pt. must be monitored during induction period (first 2-4 days) to find correct dose → improves withdrawal, reduces cravings, prevents OD

  • Withdrawal severity → increase risk of relapse & accidental OD

Reverse Heroin Overdose

• expand the use of naloxone → life-saving drug that can reverse the effects of an opioid overdose when administered in time

• RiVive: nasal spray of naloxone (narcan)

  • Will send person into immediate withdrawal when they come to

    • Agitated, vitals elevated, at risk for other-violence (opposite of normal drug effects)

Opioid pathophysiology

• drug attaches to opiate-mu receptors → reduces GABA (GABA normally reduces DA) but inhibiting inhibitory inter-neurons in VT area of the brain → increases DA released (euphoric effect)

Opioid effects

• pain suppression (analgesia)

• pinpoint pupils

• lowered HR, BP, resp. rate

• constipation

• cough suppression

• lax muscle tone

• dry mouth

• euphoria

Opioid Adverse Experiences

• infections

• abscesses

• endocarditis

• HIV/HCV

• Overdose(OD)

• CNS, resp. depression

• Krokodil → flesh eating infection

• Tranq: painful wounds, amputations

Opioids w/ short half lives

• morphine, heroin, hydromorphine

• withdrawal develops in 8-12 hrs

• peaks 2 days lasts 7

Opioids with long half lives

• methadone

• withdrawal develops in 36-48 hrs

• peaks 4-6 days, lasts up to 2 wks+

Opioid Withdrawal sxs

• r/t heavy & prolonged use:

  • yawning

  • fever

  • muscle aches, pain

  • insomnia

  • dysphoric mood

  • N/V/D

  • lacrimation, rhinorrhea

  • pupillary dilation

  • diaphoresis, piloerection

COWS Scale

• determines severity of opiate withdrawal & needed supportive care

• focuses on 11 sxs:

  • elevated resting pulse → antihypertensives (Clonadine/Catapres)

  • diaphoresis (cooling blanket)

  • increased restlessness: Trazodone, benadryl → benzo if panic lvl

  • dilated pupil size

  • bone or joint aches: Tylenol, mindfulness activities, topical pain management

  • rhinorrhea or eye tearing: benadryl

  • GI upset: peppermint tea, anti-emetics

  • tremor

  • yawning

  • anxiety/irritability

  • gooseflesh skin

Opioid detox

• medically supported detox is not usually required but is helpful

• Supportive care:

  • Tylenol PRN for pain

  • benadryl for restlessness and rhinorrhea

• OTC antidiarrheal and anti-emetics

• Clonidine (Catapres)

• Chronic methadone use requires a long taper (of about a year)

Post Opioid Detox

• Naltrexone (Revia)

• antagonist blocker; decreases cravings management

Opioid Overdose Management

• naloxone (narcan): antagonist

• kicks out opiate from receptor; opiate reversal agent

Harm Reduction Strategies

• aim to minimize risks of bxs such as offering support for safer use, manage use through safer replacement therapies, meeting ppl who use “where they’re at” in recovery process and addressing relapse an opportunity for improvement

Stimulants

• cocaine, crack

• methamphetamine

• amphetamines

• mild-caffeine

• nicotine

• Ritalin (Methylphenidate): ADD/ADHD Rx meds

• ecstasy/MDMA: rapidly reduces 5HT, induces damage to 5HT nerve fibers & cell loss/death

Stimulant Physiological Effects

• release NE, E, DA; excess use → tolerance, NT depletion

• CNS, systematic activation; increase DA

• increased energy, decreased appetite, thirst

• increased reflexes, HR, BP, breathing w/ cardiac risks

• Neuro risks with methamphetamines

• hypersensitivity

• dilated pupils

Psychological Effects

• ‘high’ activation, increased energy, alertness, restlessness, anxiety, excessive talking, increased DA

• Over confidence, feelings of supremacy

• euphoria/extremely elevated mood, or irritability, paranoia

• route of use: risks (smoking or injecting → faster & shorter “high” vs. intranasal/snorting)

Stimulant Withdrawal

• occurs in 12-96 hrs, usually mild

• immediate effects wear off in 30 min-2hrs

• “Crash” occurs 1-4 hrs after binge

Withdrawal Sxs

• depression, irritability, anergia, anhedonia

• high risk for depression, SI, or bx—common during crash phase

• euphoric recall of positive experience r/t cocaine use dominate thinking, dreams, thoughts → increased psychological need (addiction)

  • cues usually subside in 6-18 wks if abstinent

Vasoconstrictors

Caffeine and tylenol: vasoconstrictors → calms vasospasms → minimizes headache pain → can also vasoconstrict blood vessels for heart and leading to brain → cardiac event or stroke

Cocaine or Meth Intoxication

• Cardiac Risks

• cardiac artery constriction → damage to vessels, heart → arrythmias

• → cardiac arrest/MI (esp. if underlying CVD)

• → increased myocardial O2 demand → increased HR → acute chest pain & severe vasoconstriction →

  • increased MI risks

  • ventricular fibrillation

  • sudden death

Meth

• most neurotoxic drug: sig. damage to striatum & affects DA nerve endings

  • Causes holes in brain from apoptosis

  • Parkinson’s sxs

  • more chronic use → less restoration of activity (abstinence can restore some but not all)

  • can lead to permanent psychoses

• can cause nutritional issues, dental issues

• Meth use is common in men having sex with men → increased risk for HIV transmission

Meth ST effects

• nausea

• bizarre and sometimes violent bx

• hallucinations

• panic & psychosis

• convulsions

• seizures

Meth Tx: mainly supportive care

• Wellbutrin (Buproprion) antidepressant

• trigger management

• 12-step recovery model

• dental

• nutrition

• infections (complications r/t route of use, esp. skin, liver)

• No FDA-approved tx for meth. use disorder

Meth Detox

• meds not required; 3-7 days

• Initial abstinence: 1st week thru. 3 mos.

• Long-term abstinence: 3-18 mos.; can be 5+ yrs

• Recovery: lifetime