Substance use study guide (3).docx

Opioid intoxication Common signs Pupillary constriction Slow or slurred speech Signs of dangerous levels of intoxication/ overdose Respiratory depression (shallow breathing)V Comatose state Pinpoint pupils Biot’s breathing Groups of quick shallow inspirations followed by periods of apnea Diagnosis P...

Opioid intoxication Common signs Pupillary constriction Slow or slurred speech Signs of dangerous levels of intoxication/ overdose Respiratory depression (shallow breathing)V Comatose state Pinpoint pupils Biot’s breathing Groups of quick shallow inspirations followed by periods of apnea Diagnosis Prompt recovery with Naloxone Positive urine toxicology test Medication to use in overdose Naloxone (Narcan) Opioid withdrawal Symptoms: pruritus, nausea, vomiting, abdominal cramping, diarrhea, sweating, joint pains, myalgias/ flu-like symptoms, dysphoria, restlessness, craving for opioids. Signs Piloerection, pupillary dilation, hypertension, tachycardia, diaphoresis, lacrimation, rhinorrhea, yawning Management Symptomatic control Clonidine (decreases sympathetic response) Loperamide (immodium for diarrhea Dicyclomine for abdominal cramps NSAIDs for arthritis/ myalgia Management of severe symptoms Methadone or Buprenorphine + above measures Relapse prevention Medication Mechanism of Action Buprenorphine (Subutex) Partial opioid receptor agonist Buprenorphine/ Naloxone (Suboxone) Partial opioid receptor agonist + opioid receptor antagonist Methadone Opioid receptor antagonist Naltrexone Competitive opioid antagonist Cocaine Adverse effects At high levels or prolonged use causes agitation, paranoia, pressured speech, nausea, vomiting, seizures and chest pain Tachycardia, which can trigger refractory tachydysrhythmias and re-entry ventricular arrhythmias Hypertension and coronary vasospasm Higher risk of thrombosis Physical Exam findings common with cocaine intoxication Abnormal vitals: Hyperthermia, hypertension, tachycardia Tremor Flushing Diaphoresis Cold sweats Pupillary dilation Agitation Aggression Signs of severe intoxication Respiratory depression Arrhythmias Seizures Hallucinations Paranoia Repetitive behaviors (like picking at skin) Treatment of severe cocaine intoxication Benzodiazepines are first line treatment Cooling blankets if hyperthermic, possibly ice baths Antihistamines if very agitated or combative Alpha blockers (Phentolamine) are preferred for treatment of HTN Nitroglycerin is second line Beta Blockers and calcium channel blockers are third line Cocaine withdrawal Symptoms Craving, dysphoria, apathy, irritability, post-intoxication depression, anhedonia, hypersomnia, disorientation, increased appetite, nightmares, headache, suicidal ideation Signs Constricted pupils PCP Mechanism NMDA glutamate receptor agonist Intoxication often leads to bizarre and often violent behavior Signs of acute intoxication Delusions (including delusions of physical prowess), violent behavior, diminished perception of pain, severe agitation, hyperthermia, hypoxia, hypertension, tachycardia, confusion, hallucinations. Multidirectional nystagmus Management Physical restraints If needed (for shortest duration necessary) Chemical sedation with paternal benzodiazepines Diazepam, Lorazepam, Midazolam Antipsychotics if agitation / psychosis continues after administering Benzodiazepines Haloperidol or Droperidol Marijuana Adverse effects Anxiety, dry mouth, increased appetite, motor impairment Occasionally fear, psychosis Chronic use can lead to cognitive performance issues, conjunctivitis, tachycardia and hypotension Hyperemesis syndrome: Chronic severe emesis in chronic users. Withdrawal sx: irritability, insomnia, depression, restlessness, diaphoresis, diarrhea, twitching Alcohol Mechanism of action CNS depressant – depresses inhibitory control mechanisms Symptoms of Alcohol withdrawal Increased CNS activity – Hand tremors, anxiety, irritability, agitation (usually minor), restlessness, insomnia, diaphoresis, palpitations, headache, nausea, vomiting, diarrhea, alcohol craving. Signs of alcohol withdrawal: Uncomplicated alcohol withdrawal Tachycardia, Hypertension (usually systolic), hyperactive reflexes, tremor Complicated alcohol withdrawal Seizures Delirium tremens (48-72 hours after the last drink) Delirium: Rapid onset, fluctuating disturbance of attention and cognition Hallucinations (Alcoholic hallucinosis) – generally visual, often insects or animals in the room Abnormal vital signs – tachycardia, hypertension, fever, drenching sweats Treatment of complicated alcohol withdrawal Needs to be hospitalized due to risk of seizures, unstable vitals and cardiac arrhythmias Treatment Benzodiazepines Generally Lorazepam, Chlordiazepoxide or Oxazepam Tapered off after the patient is stabilized Beta Blockers if elevated blood pressure or tachycardia present. Alcohol use disorder Screening CAGE Questionnaire Treatment (prevention of relapse) Medications Disulfram (Antabuse) Naltrexone (Vivitrol, Revia) Acamprosate (Campral) Topiramate (Topamax) Psychotherapy Individual or group (Alcoholics anonymous, etc) No single option officially considered superior Relapse prevention medications Disulfram (Antabuse) Mechanism of Action: Inhibits Aldehyde dehydrogenase (an enzyme needed to metabolize alcohol) leading to increased levels of acetaldehyde when drinking alcohol. causes uncomfortable symptoms: hypotension, palpitations, flushing, hyperventilation, dizziness, nausea, vomiting and headache Contraindicated if cardiovascular disease, diabetes mellitus, hypothyroidism, epilepsy, kidney or liver disease present. Naltrexone (Vivitrol, Revia) Mechanism of Action: Mu-receptor opioid antagonist Blocks the euphoric effects of alcohol Reduces alcohol craving & reduces alcohol induced euphoria Nicotine Dependence Smoking cessation should be discussed with all smokers at every clinical contact Treatment Options: Counseling, support therapy, cognitive behavioral therapy, medical management Most effective approach is ‘combination therapy’, generally medication and one of the other options First line pharmacotherapies: Nicotine replacement therapy Varenicline (Chantix) Bupropion (Zyban) Varenicline (Chantix) Mechanism of Action: Blocks nicotine receptors, reducing nicotine activity Adverse effects: Nausea, headache, insomnia Increased neuropsychiatric conditions Increased suicidality Bupropion (Zyban) Mechanism of Action: Dopamine and norepinephrine reuptake inhibitor Adverse effects: Anxiety Increased risk of seizures and psychosis at high doses Contraindicated in epilepsy or conditions with increased seizure risk including patients with eating disorders such as Bulimia and Anorexia or patients undergoing abrupt discontinuation of alcohol