[PSYC] SUD: Sedatives (Alcohol + BZD)

Alcohol Use Disorder

Screening Tools: (What do the following tests screen for)

1) AUDIT-C

2) PAWSS

3) CIWA-Ar

4) According to Canada’s Guidance on Alcohol + Health, ≤ __ drinks/week is considered “safe”

1) Screens high-risk drinking

2) Predicts severe withdrawal risk

3) Monitors withdrawal severity

4) ≤ 2

Alcohol Use Disorder: ACUTE WITHDRAWAL MANAGEMENT

PAWSS (Predicts severe withdrawal risk)

1) What PAWSS score is considered mild-moderate

2) What PAWSS score is considered severe

3) Which medications can you give for mild-moderate withdrawal (4) **ALWAYS GIVE ELECTROLYTE RESTORATION

 

4) Which medications can you give for severe withdrawal AND WHY 

5) What are 3 things you should ALWAYS supplement with

ACUTE ALCOHOL WITHDRAWAL
1) Alcohol ___ the action of NMDA receptors [glutamate] (excitatory) and ___ activity of GABA receptors (inhibitory) 

2) Chronic alcohol use can lead to ___ of NMDA receptors and ___ of GABA receptors

3) Alcohol WITHDRAWAL leads to ___ NMDA function and ___ GABA transmission

4) Potentially life threatening things that can happen (4)  

1) <4

2) ≥4

3) Carbamazepine, Clonidine, Gabapentin, Valproate

4) Benzodiazepines 

• Strong evidence for preventing seizures and DT

5) Folate, magnesium, thiamine 

Acute Alcohol Withdrawal

1) Inhibits NMDA; Enhances GABA

2) Upregulation of NMDA; Downregulation of GABA

3) Withdrawal = Enhanced NMDA; Reduced GABA

4) Seizures, HYPERthermia, arrhythmias, DT (delirium tremons)

1) What are the 5 medications used for AUD maintenance

2) What are the first line ones (2)

1) Acamprosate, naltrexone, gabapentin, topiramate, disulfiram

2) Acamprosate and naltrexone

Naltrexone (AUD)

1) MOA

2) How does it help in AUD / most effective option for management of what

3) Who do you want to avoid this in / dose adjust this in what population

4) What should you always be aware of 

1) Mu opioid receptor ANTAGONIST

2) Decreases euphoric / rewarding effects of alcohol

• Decreases amount of drinking

• Effective for CRAVING management

3) Hepatic impairment

4) Opioid use (CI in opioid use)

Acamprosate (AUD)

1) MOA (2) + How it helps

Structurally similar to ___

2) Most effective option for ____

3) Who do you want to avoid this in / dose adjust this in what population 

4) CI in whom (2)

5) Good option for those with ___ impairment 

1) MOA:

• Modulates glutamate (decreases enhanced/upregulated NMDA)

  • Decreases neuronal hyperexcitability that can trigger a return to use during periods of abstinence

• Increases GABA (that was downregulated)

Structurally similar to GABA

2) Goal of abstinence (stopping completely)

3) Renal impairment (CrCl <30)

4) Hepatic impairment is ok

Gabapentin (AUD) 2nd line

1) MOA

2) Target dose

3) Who needs adjustment (2)

4) Caution with risk of ____/____

5) DDI (2)

1) Binds to Ca channels (alpha-2-delta-1 subunits); modulates release of excitatory transmitters

2) 600 mg TID

3) Renal impairment, Elderly

4) Diversion / Misuse 

5) CNS depressants + antacids

Topiramate (AUD) 2nd line

1) MOA (3)

• Does what in response to alcohol ingestion (decreases ___ by decreasing ___ release in response to alcohol ingestion)

• Enhances what

• Blocks what

2) CI in whom

3) Why is use limited

4) DDI (1)

1) Decreases cravings by decreasing dopamine release in response to alcohol ingestion

• Enhances GABA (agonist)

• AMPA/Kainite glutamate receptor blocker

2) Pregnancy / child bearing potential

3) Significant ADRs

4) CNS depressants

Disulfiram (AUD)

1) MOA: Inhibits ____ _____ leading to ___ build-up which in turn ____

2) CYP 450 metabolism of pro drug indicates what 

3) How is it cleared

4) DDI (2) 

5) Examples of ADR if alcohol is consumed 

6) How long can this last for 

1) Inhibits ALDEHYDE DEHYGROENASE , leading to ALDEHYDE buildup, which in turn leads to unpleasant effects when alcohol is consumed

2) Multiple active metabolites

3) Renally 

4) CYP450 substrates, any alcohol containing product 

5) Bad effects:

• Sweating

• Headache

• Dyspnea

• Hypotension

• Flushing

• Tachycardia

• Palpitations

• Nausea

• Vomiting 

6) Can last up to 2 weeks 

Benzodiazepines

1) Withdrawal symptoms (most fatal 3)

2) 3 common withdrawal symptoms

3) How long does it take for withdrawal symptom onset

4) Tapering principles

• Do you switch to any med?

• Reduce dose ___ to ___ % every 1-4 weeks as tolerated 

• Who should get a slower taper (2)

5) What’s a hint that benzodiazepines may be mixed in illicit opioids 

1) Seizure, hallucination, paranoia

2) Anxiety, headache, nausea

3) 1-2 days for short acting; 2-7 days for long acting 

4) Tapering principle:

• Switch to long acting (Diazepam, Clonazepam)

• 5-25% every 1-4 weeks

• Elderly or seizure risk 

5) OD not fully reversing with naloxone (Atypical withdrawal)

Symptoms of Wernickes encephalopathy

Opthalmoplegiam ataxia, confusion

• Give thiamine

Symptoms of Korsakoffs syndrome

Delirium characterized by memory loss with confabulation but preservation f other intellectual function

—> Unintentionally fills in gaps in memories with false events

** Give thiamine