Wk 6 only.docx

Week 6 Know the neural circuits and neurotransmitters associated with reward and addiction (Stahl)   Addiction medications- FDA-approved indications for each medication on your medication table which medications can precipitate withdrawal?  Are there any required actions prior to medication initiati...

Week 6 Know the neural circuits and neurotransmitters associated with reward and addiction (Stahl)   Addiction medications- FDA-approved indications for each medication on your medication table which medications can precipitate withdrawal?  Are there any required actions prior to medication initiation? Know the initiation time frame for each medication.   Review client education for the medications. Be prepared to educate a client.     Medications- know indication, mechanism of action, adverse effects or reactions, and starting dosing of the medications on your table. Know the client education for the medications.   Substances of abuse- know the mechanism of action of each substance know the associated signs and symptoms you would note on a physical exam. When a client presents to the ED it is essential to be able to swiftly identify which drug had been taken so appropriate treatment can be quickly initiated.    If given a clinical scenario, could you identify which substance was taken based on the client’s symptoms?  Review the pupillary response to the illegal substances.     Know when you can start medications.  Which medications can be started immediately and which medications require mild withdrawal?   Special populations Medication-associated pregnancy risks Lifespan considerations-which medications are safe in pregnancy?   Safe for use in the elderly?   Which medications should be avoided in pregnancy and the elderly?   Review lifespan considerations for these medications. Which medication can be increased in the elderly? Which medication should not be increased in the elderly?   Know the difference between impulsivity and compulsivity.   Week 6 quiz clinical pearls SSRIs are approved for 1st line treatment of OCD. Benzodiazepines are not the first-line treatment for OCD. Stahl p. 577 The primary action of hallucinogenic drugs such as LSD, mescaline, psilocybin, and MDMA are agonism of 5HT2A receptors. Hallucinogens may have additional actions at other serotonin Stahl p. 567-569 (Figure 13-27). Mechanism of hallucinogens at 5HT2A receptors Hallucinogenic Drugs Actions: Agonism of 5HT2A receptors, additional actions at other serotonin receptors (particularly 5HT1A and 5HT2C) and at other neurotransmitter systems, and MDMA in particular also blocks the serotonin transporter (SERT). Primary action NTM receptors LSD Blocks serotonin receptor (SERT) 5HT 2A, 1A, & 2C mescaline Blocks serotonin receptor (SERT) 5HT 2A, 1A, & 2C psilocybin Blocks serotonin receptor (SERT) 5HT 2A, 1A, & 2C MDMA Blocks serotonin receptor (SERT) 5HT 2A, 1A, & 2C The hypothalamus serves as the brain center that controls appetite by utilizing a complex set of circuits and regulators. One formulation of how the hypothalamus does this is the notion that there is a major appetite-stimulating pathway whose actions are mediated by two peptides (neuropeptide Y and agouti-related protein). Phentermine acts much like amphetamine, blocking both the dopamine transporter (DAT) and the norepinephrine transporter (NET) and, at high doses, the vesicular monoamine transporter (VMAT). Buprenorphine is approved for persons < 18 years of age. disulfiram-alcohol reaction may occur within 2 weeks of alcohol ingestion. Methadone is a full mu-receptor agonist with a long half-life, which can prevent withdrawal symptoms for 24 hours and provide steady control of cravings throughout the day. In addition to its opioid receptor activity, it is also an antagonist of the N-methyl-D-aspartate (NMDA) receptor. Stahl p.560 hallucinogen intoxication can cause what is perceived as a panic attack, often called a “bad trip.” As intoxication escalates, one can experience an acute state of confusion (delirium) where the abuser is disoriented and agitated.  Stahl p. 567-569 disulfiram irreversibly inhibits aldehyde dehydrogenase resulting in build of toxic levels of acetaldehyde Acamprosate reduces glutamate release associated with alcohol withdrawal, naltrexone blocks the enjoyment of heaving drinking through its action on reward circuitry, sedative hypnotics act at GABA A receptor sites in reward circuits. Stahl p. 556 Impulsive disorders are focused on reward and associated with the mesolimbic pathway. Stahl p.542 Opioid Use Disorder Opioid use disorder is defined as the “chronic use of opioids that causes clinically significant distress or impairment” (Dydyk et al., 2020, para. 1). Drugs of abuse may include illicit drugs, such as heroin, or prescription medications, including morphine, fentanyl, and oxycodone. Clients who present with opioid use disorder experience overwhelming cravings to use the drugs, dependence, increased tolerance, and withdrawal symptoms when the drug is ceased abruptly. Medication-assisted therapy (MAT) is an essential part of treatment for opioid use disorder and is considered first-line therapy. Opioid Overdose Overdose is a significant risk with opioid abuse. Fentanyl and carfentanyl are frequent impurities found in opioids sold on the street. These two drugs are thousands of times more potent than morphine and account for many overdoses across the country. Naloxone (Narcan), an opioid antagonist, is the drug of choice for an emergency opioid overdose. Narcan may be given for a known overdose of opioids or when the ingested substance is unknown. A series of small doses is preferred over 1 large dose to lessen antagonist-precipitated withdrawal symptoms. Withdrawal symptoms can occur in an individual who is chronically dependent on opioids. Acute withdrawal symptoms present within 3 minutes of injection, peaking in 10-20 minutes, and subsiding in about an hour. Symptoms of opioid withdrawal include: nausea/vomiting diarrhea runny nose tremor sweating irritability muscle spasms The psychiatric mental health nurse practitioner (PMHNP) may consider providing naloxone (Narcan) prescription for clients who are at high risk for an opioid overdose. Naloxone is also available without a prescription from some pharmacies.. For clients in the community, naltrexone may be provided as a nasal spray or an injection. Clients and their families, friends, and significant others should receive education on the administration of naloxone and the signs of opioid overdose, including: High Risk for Opioid Overdose Signs of Opioid Overdose High-dose, long-term pain/chronic pain management Inability to wake or respond to voice/touch Use of rotating opioid medications Slow or absent breathing (ex: RR<6 min) Previous opioid overdose Pinpoint pupils Uses extended-release opioids Blue lips Users who have had a period of abstinence Recently released from incarceration Clients who mix opioids and other drugs/alcohol & is on opioids after a MVA Special Considerations Pregnancy Buprenorphine is an acceptable treatment during pregnancy; however, there is an increased risk of a neonatal withdrawal syndrome in newborns. Suboxone (buprenorphine/naloxone) cannot be used in pregnancy. Naloxone increases the risk of neonatal abstinence syndrome. Pregnant clients must be switched to buprenorphine (Subutex) monotherapy. Methadone is approved in pregnancy for heroin-addicted women. Dosing requires adjustment. Short-term newborn withdrawal effects may be seen and may require neonatal intensive care unit (NICU) admission for treatment. Breast Feeding Naltrexone & buprenorphine are not recommended for breastfeeding mothers. Methadone can be prescribed with special consideration given to feeding intervals (breastfeed prior to or 2-6 hours after dose). Older Adult Buprenorphine use in the elderly may lead to confusion and drowsiness. Methadone has a high potential for drug interactions, associated with QT prolongation. It is difficult to titrate in the elderly and has a risk for accumulation due to the long half-life. Adverse Effects of Opioids Transcript Itching  Urinary retention  Respiratory depression  Constipation Sedation MAT is considered the 1st line therapy for opioid use disorder Initial Treatment Monitor Clonidine An antihypertensive agent, and Alpha2-Adrenergic Agonist produce analgesia at presynaptic and post junction alpha-2 adrenoceptors in the spinal cord, with pain transmission to the brain prevented Off Label: Adjunct for medically supervised opioid withdrawal.  0.1mg - 0.2mg, with ability to repeat up to 4 doses until symptoms resolve. Maintenance: q6-8 hrs depending on severity of symptoms BP HR Fentanyl This medication is the preferred opioid for those unable to tolerate morphine or hydromorphone and in those with severe hepatic and renal disease.  Almost immediate onset of action when given IV, with a duration of 0.5-1 hour.  More potent than morphine, but short duration of action Fentanyl has the same indications as morphine and is also used frequently in procedural sedation and general anesthesia (pre-induction, induction, and maintenance and in pre-treatment of rapid sequence intubation). Conversion between fentanyl products is NOT mcg for mcg. Heroine Safe in pregnancy Hydromorphone Similar opioid agonist as morphine but more potent.  Oral and parenteral doses are not equivalent (parenteral doses up to 5 times more potent). Hydromorphone is an opioid agonist that is more potent than morphine. Ketamine Useful in general anesthesia & procedural sedation Off label usage as infusions for acute pain, as both a stand-alone treatment. Adjunctive option with opioids, as well as an intranasal formulation. Meperidine No longer recommended as an analgesic, and not widely available. Has numerous concerning adverse effects such as seizures and delirium. Methadone This is a long-acting opioid that binds to and occupies mu-opioid receptors, reducing craving for opioids and prevents withdrawal symptoms for 24 hours. Over time, with high levels of opioid tolerance maintained, the euphoric effects of further illicit opioid use are decreased.  Utilized in detoxification and maintenance treatment of opioid addiction and heroin addiction, with high variability among patients. Discontinuation requires a wean to avoid withdrawal. Safe in pregnancy Safe in breast-feeding in special feeding intervals. In pregnant females, in methadone treatment programs, a risk benefit ratio is necessary as fetal outcomes are improved as compared to illicit drug use, however infants born to opioid addicted mothers treated with methadone during pregnancy can have decreased birth weight, length, head circumference and fetal growth. This medication still has the potential for abuse, with only licensed opioid treatment programs or licensed inpatient hospital units permitted to order and dispense this medication.  State law will determine the AGACNP’s ability to continue this medication during inpatient hospitalization, but this is highly regulated. Methadone has potential for life threatening respiratory depression and QT prolongation.   Equianalgesic conversion ratios between methadone and other opioids are individually variable, with deaths occurring during conversion from chronic high dose opiate history or opioid abuse to methadone. Morphine Prototype opioid agonist. Binds to opioid receptors in the central nervous system (CNS), inhibiting ascending pain pathways, and altering the perception and response to pain.  Produces CNS depression and potentially respiratory depression which may be life-threatening, especially if utilized with benzodiazepines, CNS depressants, or alcohol.    Morphine is indicated for acute pain, including acute coronary syndrome, refractory ischemic chest pain, breakthrough cancer pain (for those on chronic opioid therapy), as well as postop pain, sickle cell disease and Vaso-occlusive pain, and in critically ill patients in the intensive care unit (ICU) necessitating analgesia and sedation.  Onset of action: (IR): patient-dependent, with variable absorption. (IV): 5-10 minutes, with a duration 3-5 hours. (CR): (MS Contin) and extended-release morphine (Avinza). Morphine can cause respiratory depression if utilized with BZO & can also be used during acute coronary syndrome or refractory ischemic chest pain. Naloxone pure antagonist treatment of acute opioid overdose NOT safe in pregnancy IV naloxone can dramatically reverse opioids, even in comatose states, with recent widespread community availability of intramuscular and intranasal administration options available given the prescription and recreational opiate crisis, and related deaths.  Given the short duration of action, patients can relapse into coma or previous overdose state, and may need continued monitoring and potentially further doses or constant infusion. Oxycontin Tramadol Opioid agonist Blocks reuptake of serotonin and norepinephrine. Indicated for acute pain management, with added benefit for patients with neuropathic pain and nociceptive pain.   Has a lower risk of constipation and dependence than other opioids but does have risk of serotonin syndrome. Drugs to Treat Overdose buprenorphine Cannot be used in breast feeding women Not recommended in elderly, may lead to confusion & drowsiness. Buprenorphine /naloxone (Buprenex, Probuphine, Suboxone) Naltrexone (Revia, Vivitrol) Cannot be used in breast feeding women   Dual Diagnosis and Substance Use Disorders The prevalence of substance use disorders is one of the most pressing mental health issues facing practitioners today. Substance use disorder occurs when the recurrent use of a substance, such as alcohol or drugs, causes clinically significant impairment, including health problems, disability, or failure to meet responsibilities at home, work, or school (Substance Abuse and Mental Health Services Administration [SAMHSA], 2022b). Substance use disorders affect clients across the lifespan. While substance use disorders can be debilitating, treatment options, including pharmacologic interventions, are available. Psychiatric mental health nurse practitioners (PMHNPs) are instrumental in providing pharmacologic and therapeutic support to clients with substance use disorders. Drug use, either illicit or prescription medications, commonly begins in adolescence. Early drug use is a risk factor for the later development of a substance use disorder. A substance use disorder diagnosis may be seen alone or in combination with other mental health diagnoses. Dual diagnoses are common in addiction medicine. For example, up to 60% of adolescents in community-based substance use disorder treatment programs may meet the diagnostic criteria for another mental health condition (National Institute on Drug Abuse, 2020). Clients may self-medicate to treat distressing symptoms of other conditions. Alcohol use commonly begins during early adulthood, when times of stress & emotional fatigue are more common. Early drug use is a risk factor for the later development of substance abuse disorder Common comorbidities include: Anxiety disorders Psychotic illness Bipolar disorder Depression Borderline personality disorder Antisocial personality disorder Mental health comorbidities impact the course, prognosis, and treatment of both the substance use disorder and the comorbid condition.  Substance Use Disorder Terms Tolerance - With repeated ingestion of a drug, the drug shows decreased effect. Increasing doses are required to achieve the effects noted with the original administration. Dependence - State of adaptation produced with repeated administration of certain drugs so that physical symptoms occur when the drug is discontinued abruptly. Addiction - A change in behavior caused by biochemical changes in the brain after continued substance use characterized by preoccupation with and repeated use of a substance despite negative outcomes. Withdrawal - Physiological and psychological reactions that occur when the use of a substance is stopped abruptly. Intoxication - Condition following the ingestion of a substance resulting in changes in level of consciousness, cognition, perception, judgment, and behavior. Treatment When assessing clients for substance use disorder, the PMHNP must ascertain: What substance is the client using? How much and how often the substance is used? When was the substance last ingested to determine the most appropriate course of treatment? Treatment, when a client is actively using a substance, differs from treatment during withdrawal, following detoxification, and during abstinence. Tolerance and dependence impact treatment decisions, sometimes necessitating increased medication dosing.  Medication-Assisted Therapy (MAT) During medication-assisted therapy (MAT), clients use prescription medications as part of a treatment plan for substance use disorders. MAT substitutes the drug of abuse for a prescribed medication that targets the same receptor as the preferred substance. (MAT) can reduce cravings, improve relapse rates, reduce mortality from overdoses, and increase the likelihood of abstinence either alone or in combination with psychosocial interventions. MAT is most prescribed for opioid use disorder but may also be used for clients with alcohol or tobacco use disorder. SAMHSA (2022a) identified the goals of MAT to include: decreased illegal activity improved treatment retention improved birth outcomes in people who use substances while pregnant increased quality of life reduced human immunodeficiency virus (HIV) and Hepatitis B & C infections  improved survival Medications for Substance Use Disorder Impulsive/ Compulsive Disorders Other mental health disorders share similar neurobiological characteristics with substance use disorders. Disorders with impulsive and compulsive components, such as obsessive-compulsive disorder (OCD) and eating disorders have comparable neurobiological involvement, including alterations in reward pathways. For example, studies indicate dopaminergic activity in the activation of the right ventral striatum in response to images of food in individuals with binge-eating disorders (Duong et al., 2020). Pharmacologic management is often used in combination with psychotherapy to address eating disorders. Examine the image below to learn more. Obesity (Know which drugs can be used in obesity) Mneumonic: On Tuesday Pam & Barb Left for New Zealand Phenterine or phentermine/ Topiramate Bupropion or Bupropion/naltrexone lorcaserin zonisamide Anorexia Nervosa (Avoid bupropion in individuals with anorexia nervosa as bupropion lowers the seizure threshold- increased risk for new-onset seizures (Stahl, 2020; Stahl, 2021). olanzapine May lead to modest weight gain. Bulimia Nervosa (Avoid bupropion in individuals with bulimia nervosa as bupropion lowers the seizure threshold- increased risk for new-onset seizures (Stahl, 2020; Stahl, 2021). Fluoxetine (high dose) Binge Eating Disorder lisdexamfetamine topiramate bupropion Alcohol Use Disorder Alcohol use and abuse are common. Alcohol intake above recommended guidelines is associated with increased mortality, significant medical morbidities, and health effects. Alcohol abuse may affect cardiovascular health (hypertension, peripheral vascular disease, and stroke) and is associated with an increased risk of several types of cancer (especially, liver and pancreatic). Other system morbidities include diabetes, gout, renal dysfunction, hematological complications, osteoporosis, and dementia. Alcohol use is frequently associated with trauma and accidents. Many individuals report wanting to reduce or eliminate alcohol intake without success (Knox et al., 2019). Although psychosocial interventions are effective in the treatment of alcohol use disorder, most individuals return to heavy drinking after treatment. MAT for Chronic Alcohol Use Disorder Pharmaceutical agents demonstrate some efficacy in reducing heavy drinking (Chukwueke & LeFoll, 2019). Medication selections for MAT should be based on clinical presentation, history of alcohol use/abuse with comorbid liver disease or renal impairment, concurrent opioid use disorder, and other unique client characteristics. Acamprosate (Campral) Treats withdrawal symptoms Modulates glutamine transmission & resembles GABA Good option for clients who must take opioids for chronic pain Abstain prior to tx Chlordiazepoxedine (Librium) Benzodiazepine for acute & chronic alcohol use Can cause benzodiazepine (BZO) withdrawal symptoms when stopped abruptly Avoid in older adults Chlorpromazine (Thorazine, Largactil) Best for elderly patients Disulfiram (Antabuse) Blocks oxidation of alcohol Creates unpleasant symptoms when pt. drinks while taking medication: Palpitations HA N&V Flushing Abstain prior to tx to avoid a reaction Naltrexone (Revia, Vivitrol) Used to treat concurrently for opioid use disorder Given monthly long-acting injections (Vivitrol) Start while still drinking Contraindicated in liver dz Topiramate (Topamax) Anticonvulsant Blocks sodium channels & enhances GABA Reduces craving for alcohol Alcohol Withdrawl When clients who regularly consume alcohol abruptly stop drinking, they may be at risk for alcohol withdrawal. The PMHNP must be alert for signs and symptoms of withdrawal in clients admitted to inpatient settings; clients may not always disclose heavy alcohol use. The Clinical Institute Withdrawal Assessment- Alcohol, shortened version (CIWA-Ar) is a highly regarded standardized instrument used to assess the severity of withdrawal symptoms (as shown below) and directs pharmacotherapy. Mild Moderate Severe Anxiety Increased BP Hallucinations Irritability Increased HR Seizures Headache Confusion Disorientation Insomnia Mild HTN Impaired attention Tremors Rapid breathing Delirium tremors Nausea/vomiting Death The use of pharmacologic interventions should be considered for individuals with moderate to severe withdrawal symptoms due to the risk of increased morbidity and mortality during withdrawal. The use of benzodiazepines on a symptom-triggered regimen is the preferred approach. Symptom-triggered therapy is derived from objectively measured symptoms on the CIWA-Ar standardized instrument as seen below. Special Considerations Pregnancy Teratogenic effects of alcohol on the developing fetus are well known; however, there is limited data on the safety of withdrawal medications in pregnancy. Naltrexone is commonly used to treat alcohol use disorder in pregnant women, but its effects on the fetus remain largely unknown. Acamprosate is not recommended in pregnancy but may be necessary if the mother cannot stop drinking alcohol. Disulfiram's safety in pregnancy is not established. Older Adult Frequent monitoring is necessary when prescribing benzodiazepines for alcohol withdrawal in older adults. Acamprosate should be used with caution in older adults. Points to Ponder: Alcohol misuse is associated with stigma and discrimination, which may lead clients to minimize drinking behaviors. Providers must be alert to signs of alcohol withdrawal. What strategies might the PMHNP use to reduce the stigma associated with alcohol misuse and encourage open communication about drinking behaviors? Tobacco Use Disorder Tobacco use and exposure should be addressed by all providers. Illnesses and the resulting complications that lead to death from tobacco use are preventable. The likelihood of dying from a tobacco-related disease such as cancer, cerebrovascular disease, or cardiovascular disease decreases by 90% if the client quits before the age of 40 (Centers for Disease Control and Prevention [CDC], n.d.) Identifying the physiological and psychological processes associated with substance abuse will help providers understand the rationale for MAT for tobacco use disorder. Tx goal is complete discontinuation of tobacco. Nonpharmacologic treatment of nicotine addiction Individual or group counseling Support via a telephone hotline or online support group Interventions should include problem-solving, skills training, relapse prevention, and stress management Nicotine Replacement Therapy (NRT): Not used in Children. Adolescents- early identification & support for quitting, patch has some evidence for use (RX needed). Monitoring: Withdrawl symptoms & Nicotine toxicity Education: Proper dosing Advise on OTC products Removal of patch at appropriate time Monitor for ADRs Proper dosing of gum and inhaler Nicotine Act on nicotine receptors in the brain and central nervous system Rapidly absorbed Each puff maintains blood levels Tolerance develops Withdrawal syndrome if discontinued Tx goal: Complete discontinuation of tobacco Nicotine Replacement Therapy (NRT) Gradual, controlled reduction of nicotine to avoid withdrawal symptoms. Use for pt. who smoke > 20 cig/day. Contraindicated immediately after MI or after stroke. Not recommended in pregnancy bupropion (Zyban) Unknown action but believed to enhance the noradrenergic and dopaminergic release Start 1 to 2 weeks before quit date Dose: 150 mg daily for 3 days then increase to 150 mg twice daily Tobacco free by therapy 7 to 12 weeks, may need longer Not recommended in pregnancy Tobacco-free by 7 to 12 weeks of therapy May use with nicotine replacement products Precautions & Contraindications Seizure disorders, bulimia, & anorexia Nervosa Neurological disorders Reduce dose in renal dysfunction Avoid in pregnancy Monitor for adverse drug reactions Insomnia (40%) Dizziness (10%) Dry Mouth (10%) Important: Wellbutrin SR is the antidepressant version of bupropion & is identical to Zyban. Clients may be prescribed either one but should not be on both. varenicline (Chantix) Nicotine receptor partial agonist. Highly selective to the Alpha-4 beta-2 nicotinic receptor & moderately selective to the 5-HT3 receptor. Start a week before quit date Dosing: 0.5 mg by mouth daily for the first 3 days; then 0.5 mg twice daily on days 4 to 7; increase to 1.0 mg twice daily on day 8 Continue therapy for 12 weeks Adult use only (18 yrs or >) Not recommended in pregnancy Tobacco-free by 12 weeks Monitor for adverse drug reactions: Nausea Sleep disorders (insomnia, vivid dreams) Stop medication if rare neuropsychiatric symptoms (hostility, depression, SI) Combining with other nicotine replacement products does not improve results. bupropion Antidepressant Nicotrol Inhaler Nicotrol Nasal Spray Puff inhaler x 20 min. Wean down gradually over 12 weeks Monitor for adverse drug reactions (cough, mouth irritation), & dyspepsia). (NS) Rapid onset & peak Proper administration education Monitor for adverse drug reactions Abuse potential Over the Counter drugs Gum: Nicorette Dosing: For people who smoke within 30 minutes of awakening: the 4 mg dose is recommended. For people who wait more than 30 minutes after awakening to smoke: the 2 mg dose is recommended Client weans dose after 2 to 3 months of abstinence Gum: Pregnancy cat C Improves cessation success Buccal absorption Needs to follow directions or nicotine will release too quickly, increasing adverse drug reactions. Patch: Nicotrol, Nicoderm, Habitrol Dosing: 16 hr & 24 hr patches Dose determined by # of cig/day Dose is decreased gradually Transdermal Patch: Pregnancy cat D Slow onset, steady state once at peak Pt. cannot smoke while using patch Monitor for nicotine toxicity Advise to dispose of patch safely Commit lozenge Dosing: 1 lozenge q 1-2 hours. Use 4 mg if pt. smokes within 30 min of waking. Weak after 6 weeks of abstinence Lozenge: Lozenge slowly dissolves in mouth. Advise not to chew lozenge Do not eat/drink while lozenge is in mouth Combination Therapy Long Term (> 14 weeks) Nicotine patch + other nicotine replacement therapy (gum & spray) Nicotine patch + nicotine inhaler Nicotine patch + bupropion sustained-release Practice Questions Bernita is a 64-year-old who has been using heroin for 6 years. She is currently unemployed and lives with her daughter in the city center. She does not have health insurance. Rationale: Methadone is a full μ-receptor agonist with a long half-life, which can prevent withdrawal symptoms for 24 hours and provide steady control of cravings throughout the day. It is only administered in methadone federally regulated opioid treatment programs (OTP). Methadone clinics incorporate psychosocial interventions and require daily attendance for the first several months, so this is a good option for a client that has the flexibility to attend daily meetings. The use of methadone in MAT for opioid use disorder helps extend client survival. When clients stop methadone, they have a high likelihood of relapsing, even 10 years after starting treatment. Antoine is a 34-year-old who has been abusing prescription oxycodone. He is employed but is on probation at work for increased absenteeism. He desires MAT but is concerned about his roommates stealing his medication to get high. Rational: Buprenorphine in combination with naloxone (Suboxone): naloxone is a mu-opioid receptor antagonist and can therefore block the effects of buprenorphine; however, because naloxone has poor sublingual bioavailability, it does not interfere with buprenorphine's effects when used properly. Naloxone does have good parenteral bioavailability; thus, if one tries to administer the buprenorphine/naloxone formulation intravenously, naloxone will prevent any rewarding effects from buprenorphine, making this drug a less desirable street drug. Suboxone is a good option for a client who may not be able to leave work for medication dosing, as it does not need to be taken under direct observation. Lisa is a 29-year-old who admits to using "pills, heroin, and booze" regularly. She lives in a rural area and is employed part-time. She has a history of poor compliance with past treatments. Rational: Naltrexone blocks mu-opioid receptors, preventing exogenous opioids from binding there and thus preventing the pleasurable effects of opioid consumption. This medication also reduces alcohol consumption through the modulation of opioid systems, thereby reducing the reinforcing effects of alcohol. For those clients with alcohol use disorder, who have poor adherence to a regimen, and are unable to maintain abstinence, a long-acting injection of naltrexone (Vivitrol) administered monthly can be efficacious. Miranda is a 20-year-old who is 18 weeks pregnant and uses heroin. She wants to get clean "for her baby." Rational: Buprenorphine is a partial opioid agonist which binds with a strong affinity to the mu-opioid receptor, preventing exogenous opioids from binding at the receptor site, and preventing the pleasurable effects of opioid consumption. While either methadone or buprenorphine may be prescribed in pregnancy, buprenorphine does not require daily visits to an opioid treatment program and requires less need for dosage adjustments during pregnancy (The American College of Obstetricians and Gynecologists [ACOG], 2017). John is a 56-year-old with a history of seizure disorder who has smoked 1 pack-per-day (PPD) for 30 years. He has tried to quit using nicotine gum without success. He is committed to quitting smoking but feels he would benefit from medication to help. Rationale: Varenicline is an appropriate medication option for clients who want to quit using tobacco products. Bupropion is contraindicated in clients with seizure disorder. Ellen is a 35-year-old who has a history of drinking 4-5 alcoholic beverages per day. She was admitted to the hospital for a respiratory infection and was treated with benzodiazepines using the CIWA-Ar scale. She has abstained from alcohol for 8 days and is committed to maintaining abstinence but would like to take a medication to help her stay away from alcohol. Rationale: Disulfiram creates unpleasant physical symptoms when taken with alcohol. This mild negative stimulus can help reinforce the client's abstinence from drinking alcohol. Nori is a 24-year-old who has a history of abusing opioid medications and binge drinking. She is not committed to abstain from using at this time. Rationale: Since Nori is not committed to abstaining at this time, it is important to provide naloxone along with education to help her remain safe from overdose. Juan is a 19-year-old who has a history of using oxycodone that he has taken from his grandfather and drinking occasional alcohol. He wants to stop using both substances. Rationale: Naltrexone is a good option for clients who use opioids and alcohol and are committed to abstinence. A 40-year-old male presents to your emergency department (ED) with severe anxiety, generalized tremors, complaints of dizziness, diaphoresis, and agitation. He was incarcerated 2 days ago and is brought to the ED today by the police due to the development of acute symptoms. His social history is significant for heavy alcohol use. A Clinical Institutes Withdrawal Assessment Scale for Alcohol (CIWA) score is 39. Question 1) The client tells you he has had withdrawal seizures in the past when he stops drinking. Which medication should you order? lorazepam (Ativan)  Rationale: Benzodiazepines are the first-line treatment for clients having psychomotor agitation associated with alcohol withdrawal. This client has an increased risk of an alcohol-related withdrawal seizure, especially since he had one in the past.  carbamazepine, levetiracetam, and phenytoin are not routinely used for alcohol withdrawal due to the lack of evidence demonstrating increased efficacy. Additionally, these drugs may potentially mask hemodynamic signs of withdrawal. Question 2) You are discharging this client from the hospital following admission for alcohol withdrawal syndrome. He has no further withdrawal symptoms and he would like to abstain from alcohol use. He informs you that has abused opioids in the past, but he has not used them in the last several months. He is concerned that he is at risk of abusing opioids again. Which of the following is the best pharmaceutical option for this client? naltrexone (ReVia)  Rationale: Narcan is the common initial treatment for alcohol use disorder. Can be initiated while the client is still drinking. Can also be utilized in those with opioid use disorder, as the drug can treat both conditions. However, the client should be opioid-free for at least 7-10 days to avoid withdrawal. Acamprosate is used in the treatment of alcohol use disorders but does not have a similar effect to opiates. Disulfiram is utilized for resistant treatment, but this medication should not be administered to clients until they have abstained from alcohol for at least 12 hours, as a disulfiram reaction can occur for up to 14 days after alcohol has been consumed. Diazepam is not indicated at this time, given this client has already gone through acute withdrawal. Question 3) The PMHNP is rounding on patients on the post-surgical floor in the hospital. Upon entering a pt.’s room, the PMHNP notices the patient is not responding to voice, has pinpoint pupils, & a respiration rate of 6 breaths per min. The PMHNP suspects opioid overdose. Which action is correct at this time? Rationale: Naloxone is the reversal agent for opioids! It does not matter which opioid was given; the important thing is administering the naloxone as quickly as possible. Romazicon (flumazenil) is the reversal agent for BZOs. If the patient does not wake up after small dose naloxone administration and is therefore unable to protect their airway, then emergency intubation may be necessary. But administering a reversal agent should come first. An expecting mother who is to be prescribed medication for heroine use disorder tells the PMHNP that she plans on breastfeeding her baby after it is born. Which teaching does the PMHNP need to provide to this patient? Rationale: “ I am going to start you on methadone, but you will need to breastfeed prior to taking the dose every day.” Methadone can be used in pregnant women who plan to breastfeed, however, feeding intervals are required. The patient will have to either breastfeed prior to taking the dose or breastfeed 2-6 hours after taking the dose. A patient with depression & tobacco use disorder is to be prescribed Zyban. Which question must be asked before starting the pt. on this medication? What medication do you currently take for your depression? Make sure they are not currently taking Wellbutrin SR as it is an antidepressant version of bupropion & pt. cannot be on both at the same time.