M10A - Substance Use Disorders

Disulfiram

►Therapeutic Uses: AUD
►AEs:• Acetaldehyde syndrome (with alcohol)

• Mild: nausea, vomiting flushing, palpitations, HA, sweating, thirst, chestpain, weakness, blurred vision, hypotension
• Severe: respiratory depression, CV collapse, dysrhythmias, seizures, death•
  Without concurrent alcohol
• Rash, drowsiness, liver dysfunction (rare), peripheral and optic neuritis(rare)
  ► Individual variation: heart disease, hepatic dysfunction,
  psychiatric disorders
  ► DDIs: alcohol, metronidazole, warfarin
  ► Safety: avoid alcohol‐containing products
  ► Nursing Implications:
  • Administer no sooner than 12 hours after last drink
  • High quality patient education is crucial
• Discuss hazards of treatment
• Effects of disulfiram persist for 2 weeks after stopping medication
• Wear medical alert bracelet
• Avoid alcohol‐containing products (e.g., mouthwash, cough syrup, cologne )
• Warn patients of DDI risk

Naltrexone for AUD

►Therapeutic Uses: AUD, OUD (after detoxification)
►Individual variation: contraindicated in acute hepatitis orliver failure; high risk if actively using opioids
►Dosage forms:• Tablets administered daily (ReVia)• IM injection administered once monthly (Vivitrol)
►AEs: GI effects (abdominal pain, nausea, diarrhea), HA,
sedation, anxiety, injection‐site reactions (IM form), liver
toxicity
►DDIs: opioids
►Nursing Implications:
• Administer after patients stop drinking
• Do not administer if patient also taking opioids (may precipitate
withdrawal)
• Educate patient to watch for and report s/s liver injury
• Explain to patient that medication effectiveness improves with
concurrent counseling
• Pain mgmt. may be difficult given drug properties

Acamprosate

►Therapeutic Uses: AUD
►Dosage forms: tablets three times daily
►Individual variation: ESRD or CrCl < 30 mL/min; avoid inpregnancy
►AEs: diarrhea (17%), suicide‐related events (rare)
►Nursing implications:• Give with meals three times daily• Patients should start after detoxification is over (~ 5 days afteralcohol stopped)• Renal function must be evaluated• Explain to patient that medication effectiveness improved withconcurrent counseling

Methadone

►Therapeutic Uses:• OUD withdrawal/detoxification•
OUD maintenance and suppressive therapy
• Pain management
►PK: long half‐life and duration of action, cross tolerance toother opioids
►Individual variation: PMH or FH of QT prolongation syndrome, may be used in pregnancy
►AEs: Standard opioid AEs (see opioid lecture), QTprolongation, Respiratory depression, Hepatic injury
►DDIs: CNS depressants, QT‐prolonging drugs, CYP3A4inhibitors
►Safety:
• Repeated dosing can lead to accumulation and respiratory depression
• Only prescribed for OUD through opioid treatment program(OTP), exception for inpatient use for 72 hours
►Nursing Implications:
• Controlled substance (CII) - requires nurse to maintain chain ofcustody considerations
• Obtain baseline ECG before starting medication, routine thereafter (ifcardiac history)
• Educate patient to watch for and report s/s liver injury
• Monitor VS and also observe that dose is sufficient to suppress withdrawal
• Warn patient about potential DDIs• Warn that after discontinuation, if patient relapses at greater risk foropioid‐related death
• Explain to patient that medication effectiveness improved with concurrent counseling

Buprenorphine

►Therapeutic Uses:
• OUD withdrawal/detoxification
• OUD maintenance and suppressive therapy
• Pain management
►Individual variation: PMH or FH of QT prolongationsyndrome, buprenorphine alone preferred in pregnancy
►AEs: HA, GI upset, anxiety, sleep disturbances, lowerextremity edema, sweating
► DDIs: Strong inducer/inhibitors of CYP3A4, CNS depressants
►Safety:
• Ceiling effect ‐ lower abuse potential, lower risk of respiratorydepression compared to full agonist
• Although risk increases with concomitant CNS depressants
►Nursing Implications:
• Controlled substance (CIII)

• requires nurse to maintain chain ofcustody
  • Administer tablets and film sublingually
  • Warn that after discontinuation, if patient relapses at greater riskfor opioid‐related death
  • Explain to patient that medication effectiveness improved withconcurrent counseling

Naltrexone for OUD

►Therapeutic Uses: AUD, OUD (after detoxification)
►Individual variation: contraindicated in acute hepatitisor liver failure; not used in pregnancy
►Dosage forms:• IM injection administeredonce monthly (Vivitrol )preferred in OUD
►AEs: GI effects (abdominal pain, nausea, diarrhea), HA,sedation, anxiety, injection‐site reactions (IM form), livertoxicity
►DDIs: opioids (no other DDIs)
►Nursing Implications:
• Patient MUST be opioid‐free (negative urine screen); Do notadminister if patient also taking opioids
• Use manufacturer‐provided customized needles intramuscularly togluteal muscle (alternate each month)
• Educate patient to watch for and report s/s liver injury
• Warn that after discontinuation, if patient relapses at greater risk foropioid‐related death
• Explain to patient that medication effectiveness is improved withconcurrent counseling

Naloxone

► Therapeutic use: reversal agent for opioid overdose, post‐opopioid effects, neonatal respiratory depression (after birth)
► PK:• Half life is short, effects begin within 2 - 5 minutes, persist for several hours
• Strong mu receptor binding capacity
• Cannot be given PO because of high first pass effect
► Dosage forms:• Solution (SubQ/IM/IV) and Auto‐injector (SubQ/IM)• Nasal spray (intranasal)
►AEs: reversal of pain control and/or withdrawal if physicallydependent on opioids
►DDIs: opioids (of course!)
►Nursing Implications:
• Dose needs to be titrated carefully to prevent withdrawal or loss of paincontrol
• Monitor for a minimum of 4 hours after overdose (maybe longer if long‐acting medication)
• Teach patient proper administration technique based on productprescribed