Psych/Nuero Final: Lasilla Substance Use Disorders-Alcohol and Benzos (p1-54)

Characteristics of drugs that induce dependence:

-stimulate __ in the mesolimbic system

dopamine

Characteristics of drugs that induce dependence:

-___ absorption and distribution

-__ onset of action

rapid, rapid

Which drug affects all receptors involved in chemical dependence?

alcohol

If a drug works on ___ or ___ receptors, this means it can have potentially life-threatening withdrawal

GABA, glutamate

Substance Abuse Disorder Treatment

First = ___ (safely take pt off med)

Next = ___ (MAT)

detoxification, maintenance

Detoxification: __ duration treatment

MAT: ___-term treatment to enhance recovery

short, long

Detoxification

-utilized in withdrawal syndrome which is either __ or ___ __

painful, life threatening

Detoxification

-involves slowly tapering off drugs to decrease __ symptoms and ensure medical __ of patient

withdrawal, stability

NOT ALL DRUGS require ___

detoxification

MAT is NOT REQUIRED for drug __ treatment

abstinence

ASAM Principles of Detoxification

-when using medication regimens of other detoxification procedures, clinicians should only use protocols of ____ and _____ (providers ____ ____ patients if this is not the case)

establish safety, efficacy, must advise

ASAM Principles of Detoxification

-during detoxification, providers should control patient's ___ to _______ to the greatest extent possible (does not mean we withhold them)

access, medication

ASAM Principles of Detoxification

-initiation of ____ should be ___

withdrawal, individualized

ASAM Principles of Detoxification

-Whenever possible, clinicians should substitute a ___-acting medication for short-acting drugs of addiction.

long

ASAM Principles of Detoxification

-The intensity of withdrawal cannot always be ___ accurately.

predicted

ASAM Principles of Detoxification

-Every means possible should be used to ___ the patient's signs and symptoms of AOD (alcohol and other drugs) withdrawal.

ameliorate

Alcohol Withdrawal Syndrome

-alcohol suppresses ___ (stimulator), leading to enhanced ___ (inhibitor) transmission

NMDA, GABA

Alcohol Withdrawal Syndrome

-Withdrawal of alcohol in the dependent patient leads to

release of suppressed NMDA-inducing rapid release of ____ (norepinephrine, serotonin, and dopamine)

neurotransmitters

Alcohol Withdrawal Syndrome Treatment-we can either:

1. increase ___-ergic activity rapidly to prevent seizures and delirium tremens

2. We can decrease ___ release

GABA, NMDA

Alcohol Withdrawal Symptoms (Mild-Moderate)

-___, irritability, anxiety, agitation

-Anorexia, nausea, vomiting

-Tremor, elevated HR, increased BP

-Insomnia, intense ____ (about substance), nightmares

-Impaired concentration, memory, and judgment ("___")

-Elevated temperature

restlessness, dreaming, fog

Alcohol Withdrawal Symptoms (Severe)

-____ ____ and ____ ___!!

delirium tremens, generalized seizures

delerium tremens (DTs)

-acute confusional state involving disorientation to time, place, situation

-___ (visual, then auditory, olfactory, gustatory, or tactile)

-___ (usually paranoid)

hallucinations, delusions

Alcohol Withdrawal may be __ threatening

life

2 Scales Used to Measure Severity of Alcohol Withdrawal

1. Clinical Institute Withdrawal Assessment for Alcohol, Revised (___-__)

2. Withdrawal from Alcohol Scale (___)

CIWA-Ar, WAS

Scales Used to Measure Severity of Alcohol Withdrawal

-measures multiple domains of withdrawal

-higher score = ___ withdrawal

greater

Scales Used to Measure Severity of Alcohol Withdrawal

-If WAS or CIWA-AR score <__, patient may be able to withdraw without medications

10

Agents Used for Alcohol Detoxification

1. ___ or ___

2. ___ or ____

3. ____

chlordiazepoxide, diazepam, lorazepam, oxazepam, phenobarbital

1. Chlordiazepoxide or Diazepam

Advantages

-presence of __ acting metabolites (provides symptom management long after doses are completed)

long

1. Chlordiazepoxide or Diazepam

Advantages

-___ onset

slower

1. Chlordiazepoxide or Diazepam

Disadvantages

-should not be used if hepatic ___ (high ammonia) or ___ ___ ___ is present

encephalopathy, alcoholic liver disease

1. Chlordiazepoxide or Diazepam

Disadvantages

-___ ___ metabolism

oxidative hepatic

1. Chlordiazepoxide or Diazepam

Disadvantages

-Chlordiazepoxide is __ only

PO

1. Chlordiazepoxide or Diazepam

Disadvantages

-Diazepam cannot be given __; only PO or IV in detox (bc it is lipid soluble-so erratic absorption)

IM

2. Lorazepam or Oxazepam

Advantages

-used if alcoholic ____ ___ (increased total bilirubin) or in active ___ ___ or __

hepatic dysfunction, hepatitis B, C

2. Lorazepam or Oxazepam

Advantages

-metabolized via glucuronidation (___ eliminated)

renally

2. Lorazepam or Oxazepam

Advantages

-lorazepam is available as __ or __ formulation if this route is required

IM, IV

2. Lorazepam or Oxazepam

Disadvantages

-__ onset and __ elimination half life (violates ASAM principle that we want slow onset+long acting)

rapid, short

2. Lorazepam or Oxazepam

Disadvantages

-oxazepam is only available __

PO

3. Phenobarbital

Advantages

-used historically for seizures; anecdotal evidence

-enhances ___ centrally and peripherally

-presence of __ acting metabolites

-not affected by renal or hepatic dysfunction

GABA, long

3. Phenobarbital

Disadvantages

-NOT recommended as part of symptom triggered protocol (use for ___ ___ only)

dose taper

3. Phenobarbital

Disadvantages

-barbiturates can be __ at high doses

toxic

Methods of Detoxification

1. ___ ___ therapy

2. ___ __ therapy

3. combo of both

symptom triggered, dose taper

Goal for Detoxification = to prevent __ or ___ __

seizure, delerium tremens

1. Symptom Triggered Therapy

-employed as an ___ treatment for detoxification

inpatient

1. Symptom Triggered Therapy

-symptoms of withdrawal are treated if present according to observation and testing score on CIWA-Ar or WAS

-retesting with CIWA-Ar or WAS is required after each ___ of medication (usually q2-4 hours)

dose

1. Symptom Triggered Therapy

-according to ASAM, this is the ___ method of detoxification

preferred

1. Symptom Triggered Therapy

-drug is administered on __ basis if WAS or CIWA-Ar score >___

PRN, 10

1. Symptom Triggered Therapy

-example protocol involves administering huge dose of ___ or ___ PRN if WAS or CIWA-Ar score >10

chlordiazepoxide, lorazepam

2. Dose Taper Treatment

-WAS is not measured again after initial assessment

-usually employed as __ detoxification method (unless used in combo with symptom triggered)

outpatient

2. Dose Taper Treatment

-NOT the ___ method

preferred

Why is Dose Taper Treatment not the preferred method?

-less ___-___

-does NOT "limit access to medications"

cost-effective

Why is Dose Taper Treatment not the preferred method?

-more ___ used in dose taper treatment

-may be medicating symptoms that are not even ___ using another addictive substance

medication, present

The advantage of the Dose Taper Method = provides constant ___ of withdrawal symptoms

prophylaxis

Dose Taper Treatment

-drug is administered on __ basis

-__ acting drugs are highly preferred

scheduled

Dose Taper Treatment

-DOC for this protocol = ___

-can also use chlordiazepoxide, lorazepam, diazepam

phenobarbital

Dose Taper Treatment

-Example regimens are only 3-4 days long because evidence shows that initiating detoxification and achieving symptom control within the first ~___ hours significantly reduces the risk of withdrawal seizures and progression to severe withdrawal

72

3. Combination of Both Taper and Symptom Triggered

-used ONLY ___ in specific scenarios

inpatient

3. Combination of Both Taper and Symptom Triggered is used used in the following scenarios:

-___ (multiple alcohol detoxifications, each of which further lowers the seizure threshold)

-history of withdrawal ___ and/or ___

-patient is showing overt withdrawal signs and symptoms despite being ___

kindling, seizures, DTs, intoxicated

Off label treatment for alcohol withdrawal = IV ___ (NMDA antagonist)

ketamine

Ketamine

-NMDA antagonist-mimics what __ does in a controlled fashion

alcohol

Ketamine

-used off label for __ alcohol withdrawal (RAW), which is patients who continue to have withdrawal symptoms despite ___ GABA-ergic treatment

-given IN ADDITION to symptomatic treatment

resistant, maximizing

Ketamine

-can cause significant __ increase, increase in __ and ___ __

BP, CSF, intraocular pressure

Ketamine

-can cause ___ and/or ___ (memory loss, feeling of detachment from emotions, surroundings are perceived as distorted or unreal)

hallucinations, dissociations

Adjuvant Medications Utilized as Part of Alcohol Detoxification

What medication do you give to prevent Wenicke-Korsakoff encephalopathy?

thiamine

Adjuvant Medications Utilized as Part of Alcohol Detoxification

-hydration therapy is needed because nausea, vomiting, urination from drinking or withdrawal can lead to __ imbalances

electrolyte

Adjuvant Medications Utilized as Part of Alcohol Detoxification

-Replacement of lost electrolytes (___, ___, ___) given PO or IV

potassium, magnesium, phosphate

Adjuvant Medications Utilized as Part of Alcohol Detoxification

-"___ ___" is an IV fluid replacement with D5W, potassium, magnesium, thiamine, and multivitamin

banana bag

Why is it a bad idea to use NSS when rehydrating a patient?

-can cause ___ to shift out of brain cells, leading to central pontine myelinolysis

water

Other Meds Utilized as Part of Alcohol Detoxification

-____ (Zofran) is a 5HT3 antagonist used PRN for severe vomiting and withdrawal

Ondansetron

Other Meds Utilized as Part of Alcohol Detoxification

-___ PRN used for fever and pain

ibuprofen

AVOID ibuprofen if patient presents with alcohol induced ___

thrombocytopenia

alcohol induced thrombocytopenia = platelets < ____/mL

100,000

Other Meds Utilized as Part of Alcohol Detoxification

-___, ___, __ ___ PRN used to treat GERD from excessive vomiting from drinking

antacids, PPI, H2 antagonists

RULE OUT ___ ___ before starting antacids, PPI, H2 antagonists (bc they can mask symptoms)

esophageal varicies

___ are not used for alcohol detoxification because by the time the medication reaches steady state, its too late for efficacy

anticonvulsants

____ are not used except for in severe delerium tremens, because they lower the seizure threshold

antipsychotics

____ ___ are not used because they may mask the important symptoms of withdrawal

beta blockers

Benzodiazepine/Sedative Withdrawal may be __ threatening

life

Benzodiazepine/Sedative Withdrawal

-seen with chronic use (3-4 months )

-due to rapid withdrawal of GABA agonist

-receptor ___, unlike alcohol

-allows NMDA activity to predominate

-drug induced over-stimulation by __ release

specific, NE

Benzodiazepine/Sedative Withdrawal

-HIGHEST ___ risk

seizure

Benzodiazepine/Sedative Withdrawal

-risk of ___ ___

delirium tremens

Benzodiazepine/Sedative Withdrawal

-following detoxification, there is a MUCH ___ drug craving syndrome (protracted) vs alcohol

longer

Benzodiazepine/Sedative Withdrawal

-same protocols as alcohol, but treatment duration may last __ based on the ___ ___ of the abused BZD

longer, half life

Benzodiazepine Withdrawal Syndrome

Key Point: Whether short or long-acting, the protracted withdrawal symptoms (rebound anxiety) can last up to ___ days!

40

Benzodiazepine/Barbiturates Overdose Scenarios

-Pure benzodiazepines

-Mixed __ __ with benzodiazepines (deadly!)

-barbiturates

CNS depressants

Benzodiazepine/Barbiturates Overdose Treatment

-mainly just __ ___

supportive care

reversal agent for Benzodiazepines = ____

Flumazenil

We do NOT want to use Flumazenil in a benzodiazepine ___ patient (can induce seizure) (we only really use in surgery)

dependent

What are the 3 MAT Medications for Alcohol Dependence?

disulfuram, naltrexone, acamprosate

What is the brand name of Disulfuram?

Antabuse

Disulfuram (Antabuse)

-inhibits ___ ___ to produce an __ effect if alcohol is consumes (N/V, flushing, throbbing headache, chest pain, hypotension)

-DOC in active duty

aldehyde dehydrogenase, unpleasant

Disulfuram (Antabuse)

-used less frequently, but employed in conjunction with ___ treatment program (not as monotherapy)

comprehensive

What is the brand name of Naltrexone?

ReVia

Naltrexone (ReVia)

-endorphin (opiate) receptor blocker

-start taking 7-10 days after last __ to avoid seizures

-ADRs = nausea, vomiting, anxiety, insomnia, depression

drink

Naltrexone (ReVia)

-healthcare workers should ___ if patient is taking this drug

know

Why should healthcare workers know if patient is taking naltrexone?

-if patient gets in accident and receives ___ management, it will not work and the patient could end up in respiratory distress

-if patient has ___ ___ ___ __ (due to hepatotoxicity risk)

pain, end stage liver disease

Naltrexone (ReVia)

-shown to decrease alcohol ___

-should be used in conjunction with comprehensive treatment program

cravings

Naltrexone also comes in LAI formulation (brand name is ___)

Vivitrol

What is the brand name of Acamprosate?

Campral

Acamprosate (Campral)

-indicated for maintenance of alcohol abstinence

-if relapse, this medication decreases the __ of drinks consumed

number