substance use disorder

person first language

Stigmatizing language	Non stigmatizing language	Reason:
Addict User Drug abuser Junkie Alcoholic Drunk	Person with substance use disorder Patient Person in recovery Person who previously used drugs	Person first language The patient “has” a problem instead of the person “is” a problem Terms avoid negative connotation, punitive nature, or blame.
Habit	Substance use disorder Drug addiction	Inaccurately describing the disease Undermines the seriousness of disease
Abuse	Use Misuse	Negative connotation Judgment
Opioid substitution therapy Medication assisted therapy	Opioid agonist therapy Medication for substance use disorder Addiction medication	Avoid the misconception that medications only substitute one drug for another or that medication is only supplemental to better treatments
Clean	Testing negative Abstinent, in remission	Only use clinically accurate terms (even if your patient uses slang)
Dirty	Testing positive Person who uses drugs	Only use clinically accurate terms (even if your patient uses slang)

DSM V diagnostic criteria chart

DSM V diagnostic mild score

2-3

DSM V diagnostic moderate score

4-5

DSM V diagnostic severe score

6+

physical dependance

• the body’s reaction to sustained exposure to a drug

• physical and observable withdrawal symptoms

• this process can be painful and consuming

psychological dependance

•Sustained mental need for the drug or substance

•Can occur with essentially any substance

•Hardwiring of the brain- we develop attachments or a need for the substance

•May last longer than a physical dependance 

SUD is a chronic condition

• SUD involves lapses and relapses

• SUD is estimated to be 40-60% genetic

• SUD responds to appropriate treatment

• defined by persistent use despite harmful consequences

brain area involved in SUD

• cortex - helps us make good choices

• amygdala - rules our emotions

• midbrain - controls our reward system

pathophysiology of SUD

• Repeated substance use overstimulates dopamine reward pathways.

• Brain begins prioritizing substance use over normal survival/reward activities.

• Tolerance develops over time.

• Withdrawal occurs when the substance is removed and the body is no longer in equilibrium.

why withdrawal happen

The body adapts to chronic substance exposure. When the substance is suddenly stopped, the body becomes overactive in the opposite direction.

alcohol withdrawal syndroms

• severe alcohol withdrawal can be associated with alcohol withdrawal delirium (delirium tremens)

  • if unmanaged, this can result in severe seizures and death

  • <5% of alcohol withdrawal cases

benzodiazepine withdrawal syndrome

• Benzodiazepine withdrawal can result in seizures that can be life threatening

  • High doses and chronic use increases the risk

  • More prevalent when the drug is quickly reversed

other withdrawal syndrome

• Other withdrawal syndromes rarely result in death

  • Of note: any prolonged situation where the body is deprived of a necessary element can result in death (i.e. prolonged dehydration)

opioid system affects what

• pain

• thirst

• mood

• hunger

medications for opioid use disorder (MOUD)

• methadone

• buprenorphine

• naltrexone

evidence based benefits of MOUD

•Improve survival

•Increase functioning and sustainability in treatment

•Decrease opioid use and criminal activity associated with Opioid Use Disorder

•Increase ability to gain and maintain employment

•Improve birth outcomes

naltrexone’s role in MOUD (compared to others)

• Naltrexone is considered MOUD and can be effective for patients

• However:

  • Lower treatment retention (detox schedule)

  • Decreases tolerance- adherence is really important

  • Lest robust evidence for primary outcomes

  • NOT recommended to begin in pregnancy. Only methadone and buprenorphine are first line and improve birth outcomes

methadone MOA and half life

full agonist

half life: 22-48 hours

methadone forms

dissolvable tablets or liquid

methadone BBW

• abuse

• respiratory depression

• QT prolongation

• cytochrome P450 interaction

methadone regulation

heavily regulated: only dispensed at a registered opioid treatment center (OTP)

methadone dose: starting and target

day 1: 5-10 mg with no or low opioid tolerance

day 1 maximum: 50 mg

typical target: 60 mg/day or higher associated with greater retention 80-120 mg/day (some require higher doses)

•Dosing is once daily, usually starts at 20-30mg based on tolerance then is titrated

methadone common adverse events

•constipation, lightheadedness, dizziness, sedation, nausea, vomiting, sweating  

methadone rare adverse events

• ECG abnormalities

• psychosis

• pruritis

• sexual dysfunction or decreased libido

• amenorrhea

• weight gain

• edema

• seizures

• hypotension  

methadone tests/considerations

• liver function tests (LFT)

• EKG (QTc)

• pregnancy test for those of child-bearing potential

• serum concentrations

• interactions: CYP3A4 and 2C9

methadone hepatic impairment

lower starting doses

methadone renal impairment

lower starting doses

methadone adolescents

not FDA approved, can be provided to adolescents under special circumstances

buprenorphine MOA

partial agonist

• can be combined with naloxone, an antagonist

buprenorphine half life

• oral: 24-48 hours

• injection: 43-60 days

buprenorphine dosage form

• Available in buccal film, sublingual tablet, and sublingual film, patch, implant, injection

  • New reports the protentional for the severe tooth decay with orally dissolving buprenorphine. More than 300 case reports. Benefit still outweighs risk.

buprenorphine BBW

• addiction

• REMS

• respiratory depression

buprenorphine considerations and when to start

•Need to consider what type of opioid has been used (synthetic, long acting, etc.)

•Wait until the patient is past withdrawal or until they are clearly in withdrawal

buprenorphine buccal, sublingual dosing: initiation, targe, max

• initiation: 2-12 mg total on first day

• typical target: 16 mg/day

• maximum: 24 mg/day

  • *Doses up to 32mg/day have been studied but have not been demonstrated to provide any clinical advantage. Can consider up to 16mg on day 1 in people using fentanyl.

buprenorphine injectable dosing: monthly start and maintenance

•Monthly start: two doses of 300mg

•Monthly maintenance: 100mg*

buprenorphine injectable dosing: weekly start and maintenance

•Weekly start: 16 mg + 8mg in 3 days

•Weekly maintenance: 16-32 mg titrated as needed

buprenorphine common adverse effects

• sedation

• constipation

• nausea

• headache

• hyperhidrosis

• oral hypoesthesia

• glossodynia

• oral mucosal erythema

buprenorphine rare adverse effects

• hepatitis

• respiratory depression

• serotonin syndrome

buprenorphine test/considerations

• liver function tests

• UDS will show buprenorphine up to 12 months after discontinuation after chronic injectable buprenorphine

• injectables must be administered by professional

buprenorphine hepatic impairment

•combo products not recommended in moderate to severe impairment

•For single products: lower starting doses in severe impairment

buprenorphine renal impairment

no adjustments

buprenorphine adolescents

no FDA approved, but some studies show efficacy in 16 years and up

naltrexone MOA

full antagonist

naltrexone BBW

none

naltrexone dosage form

•Available in oral tablets an LA IM Injection

•HOWEVER oral tablets have not shown any benefit over placebo due to adherence issues

naltrexone half life

•IM injection has a peak in 2 hours (first peak) and 2-3 days (second peak) Duration of 4 weeks

•Oral half life is about 4-13 hours

naltrexone requirement

• patient NEED to be opioid free for at least 7-10 days

• can precipitate overdose with nonadherence

naltrexone dosing

Oral: 50 mg daily

Injection: 380 mg monthly

naltrexone common adverse effects

• nausea

• vomiting

• headache

• low energy

• anxiety

• depression

• rash

• decreased alertness

• injection site reactions

naltrexone rare side effects

hepatotoxicity

naltrexone monitor

liver function tests

naltrexone what can you not do

cannot treat acute or chronic pain with opioids while on this

naltrexone hepatic impairment

caution in severe impairment, but weigh risk and benefit

naltrexone renal impairment

use with caution in moderate to severe impairment

• extensive renal clearance

naltrexone adolescents

not studied

alcohol consumption mechanism

•Ethanol increases inhibitory (GABA) and decreases excitatory (glutamate) neurotransmission in many parts of brain

•Activates opioid receptors to release dopamine and serotonin

chronic alcohol use

• Regular alcohol use will result in increased tolerance

• To maintain homeostasis, the body will adapt to the effects of alcohol

  • This can cause or worsen withdrawal affects when stopping use

  • Can be more sensitive to alcohol in new environments

chronic alcohol use can lead to increased risk with

• dilated cardiomyopathy

• arrhythmias

• stroke

• cancers

• pancreatitis

chronic alcohol complications

• Liver disease

  • Steatosis → steatohepatitis → fibrosis → cirrhosis

• Wernicke Korsakoff Syndrome

  • Thiamine deficiency (B1)

  • Type of encephalopathy

first line for alcohol use disorder

naltrexone

naltrexone for alcohol use disorder

•Typically used first line due to dosing, cost, and flexible start

•Is also a treatment for opioid use disorder

•A lot of evidence for efficacy

• LAI and oral, but mostly LAI

naltrexone side effects - alcohol use

•LAI- injection site including the more serious abscess, necrosis, cellulitis and hematoma

•Oral- nausea, headache, dizziness (but tends to go away with continued use)

disulfiram

•Causes undesirable effects to alcohol (dose dependent)

•Recommended to be used under supervision

•No alcohol for minimum of 12 hours prior to start (really need 2 days abstinence)

•CYP substrate and inhibitor

•Has been used off label for cocaine use disorder

•Counsel on what products have alcohol: toothpaste, mouthwash, some tonics and mixers

disulfiram contraindication

patients with coronary artery disease, psychosis

disulfiram dosing

250-500 mg/day oral

disulfiram common side effects

• abnormal taste

• headache

• sedation

• allergic dermatitis

• impotence

disulfiram rare side effects

• hepatotoxicity

• optic neuritis

disulfiram monitoring

• liver function tests

• CBC

• electrolytes

• cardiac function

acamprosate how long to take

•Takes 5-8 days for full effect

acamprosate

•Appears to work through its GABA-ergic activity

•Takes 5-8 days for full effect

•Used after naltrexone or can be used to supplement Naltrexone

•Patient must be fully abstinent and already gone through withdrawal

•Studies show some consistent efficacy

acamprosate contraindications

severe renal dysfunction

acamprosate dosing

666mg oral TID

acamprosate common side effects

diarrhea

acamprosate rare side effects

attempted and completed suicides

acamprosate monitoring

renal function

alcohol use disorder drug chart

stimulant use

•Stimulants increase the amount of monoamines in the brain including dopamine, norepinephrine, and serotonin. It also inhibits reuptake of monoamines and inhibits monoamine oxidase.

•Increased extracellular monoamine levels impact our reward pathways and addiction potential

•Causes increased motor activity, increased alertness, increased energy, decreased appetite, a heightened sense of well-being and euphoria.

chronic stimulant use

•Neuropsychologic impairment

•Exacerbated mental health conditions

•Malnutrition

•Weight loss

•Insomnia

•Pruritus

•Risk of seizures, arrythmias, stroke, heart attack

methamphetamine medications

• bupropion and naltrexone

• bupropion

• mirtazapine

cocaine use disorder medications

• topiramate

• naltrexone

• disulfiram

• modafinil

• dopamine agonists (Adderall)

• TA-CD vaccine

evidence based treatments in stimUD

• contingency management

• cognitive behavioral therapy

• peer support

• matrix model

discontinuing medications for substance use disorder

• different for all patients

• patient centered care model

• lifestyle modifications - like any other chronic condition

prescription monitoring program

• also known as PMP or PDMP

• electronic database that tracks controlled substances by state

  • can be combined with other states

  • typically tracks the medication, date prescribed, date recieved, quantity, day supply, prescriber and dispenser

what does PMP not required to include

• inpatient services

  • including day surgery clinic

• pharmacies operated by the department of corrections

• veterinarians

• substance use treatment programs such as opioid treatment programs

needle and syringe exchange programs

•Goal: minimize infection transmission risks by supplying sterile equipment and other support services at little or no cost

•Many programs also provide information on accessing treatment and other health care services

needle and syringe exchange program do not…

•Many studies have clearly shown that needle/syringe exchange programs are effective in reducing infectious disease transmission and do not increase rates of community drug use

drug testing strips

•Example: Fentanyl testing strips are used to identify the presence of fentanyl in unregulated drugs

•Increased awareness = decreased overdose risk

•Others: Xylazine testing strips, Rohypnol test strips

•Used in patients using ANY illicit substance due to contamination

nalaxone and nalmefene

• 3 types of intranasal naloxone

  • Brand name Narcan

    • Naloxone 4 mg per dose

  • Generic Naloxone nasal spray

    • Naloxone 4 mg per dose

  • Brand name Kloxxado

    • Naloxone 8 mg per dose

• 1 type of intranasal nalmefene

  • Brand name Opvee

    • Nalmefene 2.7 mg per dose

flumazenil

• Noncompetitive antagonist of the benzodiazepine (BZD) receptor

• Use of flumazenil is highly controversial due to ability to cause seizures in withdrawal

  • “only reverse if you caused it”

  • Really need to have a good patient history to accurately assess risk vs benefit

• If overdose is combined with opioids- Treat the opioid overdose!

• Not first line in BZD overdose

  • Supportive care: oxygen, monitoring, glucose levels, etc.