Exam 4 New Content for Dr. G

What are the symptoms seen in a person going through an opioid OD?

Sedation (“nodding”), respiratory depression, pinpoint pupils, blue lips and nails

The routes of administration for naloxone for opioid OD are via ________ and ________. MOA? Do we need a prescription for naloxone (Narcan)?

• Naloxone instantly ________________ by ________ the opioids from interacting with the ________ receptors.

intranasal, intramuscular, reverses opioid overdoses, blocking, mu

If there is no response to Narcan in ________ minutes, you can administer another dose. It wears off in ________.

3, 30-90 minutes

List the FDA-approved treatments for opioids dependence and its MOA.

1. ________: opioid ________ 

2. ________: opioid ________ (helps with withdrawal symptoms, can be abused, ADR QT prolongation)

3. ________: ________ + ________ (sublingual). Buprenorphine is a ________ , naloxone = ________. Naloxone is not absorbed well sublingually. If the patient tries to abuse it by crushing it for IV, → naloxone will act as an ________ to ________ the buprenorphine.

4. Subutex: ________

Naltrexone, antagonist, Methadone, agonist, Suboxone, buprenorphine, naloxone, partial agonist and antagonist, antagonist, antagonist, block, buprenorphine w/o naloxone

Name the antidepressant FDA-approved for smoking cessation.

Bupropion

Name the drug of abuse that can be “cooked” from OTC pseudoephedrine (Sudafed).  

Methamphetamine

What is considered “legally drunk” DUI blood alcohol concentration (BAC) in California?

1. _____%- regular drivers

2. _____%-commercial license drivers

0.08, 0.04

List the treatments for alcohol w/d (inpatient) and rationale for their use.

1. ________: preferred treatment for withdrawal symptoms with ________ with alcohol through modulation of ________ receptors. Most commonly used are BZDs with ________ half-life: ________ (Librium), ________ (Valium). ________ (________) is for patients with liver impairment (________).

2. In situations of severe withdrawal sxs, ________ doses of BZDs → ________ 

3. Adjunct treatment with ________ → hypertension + to calm the sympathetic nervous system.

4. ________ (________) 100 mg → avoid Wernicke Korsakoff syndrome.

5. A banana bag (IV fluids containing vitamins and minerals) → contain ________ (________), ________ (________), and ________ → correct nutritional deficiencies or chemical imbalances in the body.

BZDs, cross tolerance, GABA, longer, chlordiazepoxide, Diazepam, lorazepam, ativan, LOT, large, phenobarbital, clonidine, Thiamine, B1, MVI, thiamine, B1, folic acid, B9, magnesium sulfate

Wernicke Korsakoff syndrome → Affect ________ → due to ________ (________) at ________ mg for ________. Alcohol abuse decreases ________. May not be hungry!

body and brain, thiamine, B1, 100, months, vitamin B1, hungry

Answer from Left to Right

Brand	Generic	MOA	Targets Cravings
	Disulfiram	________ --> accumulation of acetaldehyde --> deters alcohol use	________
Revia	Naltrexone _____	________ receptor --> decreases ________ of alcohol use --> reduce ________	X
Vivitrol	Naltrexone _____
Campral	________	________ receptors --> restoring ________ balance	X

inhibits aldehyde dehydrogenase, no effect, PO, blocks Mu, rewarding effects, cravings, IM, Acamprosate, blocks NMDA, GABA and glutamate

What is the most beneficial therapy for alcohol use disorder to attain long-term sobriety?

Alcoholics Anonymous

What is the MOA of flushing in some Asians after intake of alcohol AKA “Asian Flush”?  Describe the Antabuse reaction.

• Many Asian populations (30-50%) ________ (acetaldehyde metabolizer). ________ cannot be converted to ________ by ________.

• ________ blocks ________ → similar unpleasant sensation when they drink.

• Flushing → ________

lack aldehyde dehydrogenase, acetaldehyde, acetate, aldehyde dehydrogenase, disulfiram, aldehyde dehydrogenase, aldehyde dehydrogenase

How does Pepcid help with people with aldehyde dehydrogenase deficiency?

• Pepcid → ________ → for ________ 

slow breakdown, flushing

Which of the following are dissociative psychedelics drugs? (Dissociation from environment or self in a dream-like state or trance)

1. ________ (PCP) (AKA Angel dust)

2. ________ (AKA vitamin __)

3. High doses of ________ (can be ________ when you drink a whole bottle of it)

Phencyclidine, Ketamine, K, dextromethorphan, abused

Chronic alcohol abuse can ________ CYP____ enzyme. What is the effect the metabolism of acetaminophen?

• ________ with the toxic metabolite of ________ can be damaging to the ________ if used ________ grams a day

• If the pt has been drinking alcohol the max dose should NOT be ________ gm/day (increased risk of ________).

induce, 2E1, APAP, NAPQI, liver, more than 4, more than 2, hepatotoxicity

Your patient is taking Percocet 2T q6hr after surgery. In addition, she takes Tylenol extra strength 2T q 12 hr for pain relief for over 6 months. Any issue in this case?

• Percocet (________) 

• 2TQ6 hr = APAP 2.6/day + 2 gm OTC = ___ gm/day (________)

already has Tylenol, 4.6, exceeds 4 gram limit

Is naloxone effective in treating other types of overdoses other than opioids?

No

Can pregnant patients with opioid OD be given naloxone?

Yes

Which medication is FDA-approved for AUD and OUD? 

Naltrexone (Revia)

What is Vivitrol and its indication?

• ________ injection for ________________

Naltrexone monthly IM, opioid and alcohol use disorders

What is the difference between Suboxone and Subutex? Why is naloxone added in Suboxone?

1. Both have ________. 

2. Suboxone has ________ 

3. Adding ________ prevents ________

buprenorphine, buprenorphine and naloxone, naloxone, IV drug abuse

What are the FDA-approved treatments for OUD?

• ________, ________, ________, ________ (________ DRUG, ONLY IN ________)

Buprenorphine, Methadone, Naltrexone, Naloxone (rescue, overdose)

What is the street name for MDMA (3,4-methylenedioxy-methamphetamine)?  

1. Ecstasy —> ________

2. 5-HT and ________ (________, ________)

Molly, oxytocin, lovey dovey, touchy

What NT imbalance causes alcohol withdrawal symptoms?

Glutamate and GABA

What are the symptoms of alcohol w/d (AIMS)?

Anxiety, insomnia, muscle tremor, seizures, and increases BP

The most commonly used benzodiazepines with ________ half-lives are ________ (________, ________) and ________ (________). Use ________ (________) for patients with liver impairment (________)

longer, chlordiazepoxide, Librium, emergency, Diazepam, Valium, Lorazepam, Ativan, LOT

1. ________ can be seen in babies with mothers with ________. What are sxs of FAS?

• Fetal alcohol syndrome can be ________.

Fetal Alcohol Syndrome (FAS), alcohol use disorder, prevented

Which OTC drug is abused in supratherapeutic doses to act on the mu opioid receptors (AKA poor man’s methadone)?

1. ________ → hits ________ receptor at ________ doses

Lopiramide, Mu, high

What is Kratom? Is this abused? MOA?

• Kratom: ________, it’s ________, used for ________

Mu agonist, abused, pain

Delirium treatments usually peak around day __ after alcohol cessation. What are the usual treatments for DTs?

1. 2-3 days after alcohol. Peak at day 5, lasts up to 7 days

2. Symptoms: agitation, disorientation, tachycardia, HTN, fever, diaphoresis, tremor

3. Banana bag: ________, ________, ________, ________

4. Treated with ________ and/or ________ (inpatient settings)

5, folic acid, thiamine, multivitamins, magnesium, phenobarbital, BZDs

Substance abuse frequently coexists with and complicates other ________, and it is a common and often unrecognized cause of ________. IV drug abuse is a major factor in the spread of  ________.

psychiatric disorders, physical morbidity, HIV and Hepatitis C

What are the most abused drinks in college students?

Coffee and Alcohol

Which is a rescue drug for opioid OD?

Naloxone

Naltrexone is FDA-approved for which disorders?

AUD and OUD

Your patient is doing well on naltrexone but often misses their daily doses. What can you recommend?

Vivitrol (Naltrexone) IM injection monthly

What is the most common ADR for Campral (acamprosate) for the treatment of AUD? Management? (333mg 2T po TID to 1T po TID)

Diarrhea and use lower doses

Which class of medications contributes to the most fatalities with OD? Name the drug with the most OD death.

Synthetic opioids, such as Fentanyl

The most likely cause of opioid OD fatalities is from ________ (stop ________) death

respiratory depression, breathing

Higher risk of respiratory depression from opioid OD is higher with concurrent use of what other meds?

BZDs (alprazolam, diazepam) and Gabapentin

Explain why it takes approximately 3 weeks for Valium (diazepam) to be cleared from the body?

• ________-acting, highly ________, and forms ________ metabolites with very ________ half-lives. These metabolites ________ and are slowly released from ________, ________. As a result, urine drug screens can remain positive for 2–3 weeks even after the drug is stopped.

long, lipophilic, active, long, stay in the body, fat tissue, prolonging elimination