Behavioral Med Pharmacotherapy: Substance Abuse, Sleep, and ADHD

sleep

The following are medications used for...?:

- melatonin

- trazodone

- remeron (mirtazapine)

- TCAs

- hypnotics (prescribe with caution)

ADHD

The following are meds used for...?:

- stimulants (prescribe with caution)

- strattera

- wellbutrin

disulfiram

this drug interferes with ethanol metabolism by blocking oxidation of acetaldehyde to acetic acid

flushing, tachycardia, hyperventilation, n/v

What AEs can be expected from a disulfiram rxn?

yes

Do you need to monitor LFTs for patients taking disulfiram?

12 hours

Do not administer disulfiram if ethanol has been consumed within ______________.

acamprosate

What drug is used for maintaining alcohol abstinence by restoring balance to GABA/glutamate activities?

CIs: CrCl < 30

AEs: suicidal ideation

What are CIs and AEs of acamprosate?

naltrexone - 1

What is one of the first line meds for moderate to severe alcohol use disorder that is available both in IM and PO formulations?

- reduces alcohol consumption through modulation of opioid systems

- reduces the reinforcing effects of alcohol

How does naltrexone work?

acute, uncomplicated alcohol withdrawal (lorazepam)

alcohol withdrawal seizures (IV benzos: diazepam or lorazepam; IV MgSO4; IV/IM thiamine)

delirium tremens (DTs) (IV benzos)

How do you treat alcohol withdrawal?

disulfiram

acamprosate

naltrexone

What drugs help treat alcohol abuse?

mu (major receptor for pain relief and resp depressant effects)

kappa (sedative actions)

delta (many actions)

The major effects of opioids occur on 3 major receptor families, and all have some effect on analgesia. What are those 3 receptor families?

buprenorphine

What drug is a partial agonist at mu opioid receptors and is available in sublingual, implant, and injection forms?

This drug is used to treat opioid abuse (reduces dependence).

suboxone (buprenorphine/naloxone)

What is a sublingual tablet often used after buprenorphine therapy has been used for awhile to aid in the reduction of opioid dependence?

naloxone

This drug is used for opioid OVERDOSE mainly via IV or intranasal. The effects occur in as little as 30 seconds after IV, but it has a short duration of action and may require multiple dosing, depending on when the opioid was taken.

naltrexone

This drug can be used for both alcohol abuse and opioid use disorder. It blocks mu opioid receptors, preventing exogenous opioids from binding there which prevents pleasures of opioids.

opioid antagonists

These drugs quickly displace opioids from receptors and occupies receptors and are used for reversal of CNS depression from opioid overdose (complete or partial reversal of opioid depression).

methadone

What drug has similar potency to morphine but less euphoria and longer duration of action but is used for opioid abuse?

- QTc prolongation

- respiratory depression

What AEs are concerns of methadone (a synthetic opioid agonist)?

- anxiety

- drug craving

What s/sx can be expected from someone having an opioid withdrawal within 8 hours?

- anxiety

- insomnia

- GI disturbance

- rhinorrhea

- mydriasis

- diaphoresis

What s/sx can be expected from someone having an opioid withdrawal within 8-24 hours?

- tachycardia, HTN

- GI disturbance: n/v/d

- fever/chills

- tremors

- muscle spasms

- seizures

What s/sx can be expected from someone having an opioid withdrawal within 1-7 days?

bupropion

This drug is an atypical antidepressant that blocks the reuptake of dopamine and NE to treat nicotine abuse.

vareniCline (chantix)

This drug blocks nicotine binding to receptors and partially stimulates nicotinic receptors to decrease Craving and withdrawal sxs.

upon initiation of NRT

When should you stop smoking if you plan on using nicotine replacement therapy (NRT)?

CBT-I (Insomnia)

What is the 1st line tx for chronic insomnia?

sleep onset insomnia

What is melatonin used for?

ramelteon

This drug is a melatonin agonist used to promote sleep and help maintain circadian rhythms (NL sleep-wake cycle). It is used for sleep onset insomnia.

trazodone

mirtazapine

doxepin (TCA)

What antidepressants are used for sleep?

sleep onset & sleep maintenance

*use lower dose than you would for depression tx

What is trazodone used for in terms of sleep?

- priapism

- sedation

- orthostatic hypotension

What AEs can be expected from trazodone?

mirtazapine

What drug is off-label for sleep onset and maintenance has AEs of increased appetite, and is often used in depressed pts with insomnia/anxiety/panic/weight loss/low appetite/elderly?

doxepin (a TCA)

should take 30 min before bedtime and on empty stomach

What drug is used in low doses for sleep maintenance? What should administration be like for this drug?

- zolpidem

- zaleplon

- eszopiclone

What are examples of non-benzo hypnotics?

non-benzo hypnotics (zolpidem, eszopiclone, etc.)

Do benzos or non-benzo hypnotics have less potential for rebound insomnia and withdrawal effects?

ambien (zolpidem)

This is one of the most population NON-benzo sedative hypnotics that is used short term to treat insomnia (onset or maintenance). Patients taking this medication should IMMEDIATELY go to bed after taking it.

zoleplon

This drug has hypnotic actions very similar to zolpidem but has a shorter half life and is better for sleep latency.

eszopiclone

*AE: unpleasant taste

This drug is a non-benzo hypnotic that has rapid absorption (peaks in 1 hour) and is effective for up to 6 months of continuous use.

What AE can be expected with this drug?

triazolam

temazepam

What drugs are examples of hypnotic benzos?

temazepam

This drug is used for short term tx of insomnia and has a delayed onset of action which makes it useful for noctural awakening tx.

suvorexant

This drug is used for sleep onset and maintenance by blocking the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R and is thought to suppress the wake drive.

- atomoxetine

- bupropion

- clonidine

- guanfacine

What are some NON-stimulant ADHD meds?

stimulants > non-stimulants

Meta-analysis show effect sizes in short term trials of adult ADHD greater for ___________________ than _______________.

stimulants

What is the 1st line med for ADHD in school age children and adolescents?

those with motor tics or Tourette's Syndrome (can worsen tics)

What patients should we NOT prescribe stimulants?

controlled duration of action -> effects last ~1-3 hours after patch is removed

Daytrana is a long-acting stimulant that comes in a patch form. What happens if you remove the patch early?

up to 9 hours

Daytrana takes 2 hours to start working and may be worn for _____________ hours. The effects continue for 1-3 hours after removing it!

methylphenidate (ritalin, methylin tablets or oral suspensions)

dexmethylphenidate (focalin)

dextroamphetamine (dexedrine, zenzedi, procentra)

amphetamine-dextroamphetamine (adderall)

What are some immediate-release stimulant preparations for children with ADHD?

atomoxetine

This is a non-stimulant that has no known abuse potential, generally less effective than stimulants, takes longer to work than stimulants, contraindicated with MAOI, pheochromocytoma hx, severe CV d/o, angle closure glaucoma

clonidine

This is a non-stimulant alpha2 agonist that can help concentration and motor hyperactivity, extened-release version FDA approved for children 6-17 years of age, DOES NOT WORSEN TICS, takes longer to work than stimulants, CI w/ proven allergy to it

guanfacine

This is a non-stimulant alpha2 agonist that is FDA approved for ADHD in kids 6-17 years old and is CI if proven allergy to it

bupropion

This is a non-stimulant med that is off-label for ADHD tx.

CIs include: seizures, eating disorders, recent head injury, nervous system tumor, abruptly stopping alcohol/sedative use/anti-convulsant, if taking thioridazine, allergy to it

disulfiram

acamprosate

naltrexone

How can we treat alcohol abuse?

buprenorphine

naltrexone/naloxone

methadone

How can we treat opioid abuse?

bupropion

varenicline

nicotine replacement therapy

How can we treat nicotine abuse?