Patient Cases
Mechanism of Action
PotPourii
Clinical Effects
Potpourrii II
100
A 68 yo man with MDD, ETOH use disorder, hep C and hepatic steatosis was discharged after 6-day ETOH detox. Which long term treatment would be most appropriate long term treatment for ETOH use disorder?
Acamprosate is renally eliminated and preferred treatment in patients with significant hepatic impairment
100
Nicotine?
α4β2* nicotine ACh receptor agonist
100
What is the most commonly abused illict drug?
Marijuana - it is still illegal at the federal level regardless of state regulations/laws
100
When do DT's start?
3-5 days after last drink
100
What is the PMP Interconnect?
National database of controlled substance prescribing (>40 participants/applicants) - state regulations vary on this so know the state regs where you will practice.
200
PBM has a long history of opioid abuse. He is admitted for acute opioid detox. He last used oxycontin 3 hours ago. How would you initiate buprenorphine for detox?
Wait at least 24-36 hours Must be in withdrawal with moderate symptoms (COWS >12) Administer 2mg buprenorphine Q2H until max 8mg reached (short acting opioids start with 4mg)
200
Varenicline?
α4β2 nicotinic partial agonist (nicotine is full agonist)
200
Dosed 666mg TID?
Acamprosate
200
Which drug(s) reduce alcohol craving?
Naltrexone, acamprosate
200
Effects of naloxone on patients without opioids in their system?
None. It is safe to use even if unsure if patient had an opioid overdose.
300
CHF is a 22 year old woman with a long history of substance abuse. She has been treated with suboxone (buprenoprhine/naloxone) 16mg/4mg for 2 months and has remained clean during that time. She recently found out she was pregnant. What would be the appropriate treatment at this point of the opioid use disorder?
Initiate Subutex (buprenorphine) 16mg daily
300
Acamprosate?
Structurally simialr to GABA increased GABAergic effects and/or inhibit glutamatergic activity via NMDA antagonism
300
Dosed as 380mg monthly?
naltrexone LAI (Vivitrol)
300
Clinical drinking outcomes with acamprosate?
Increased time to drinking Decreased days of drinking
300
How long does it take for naloxone to work and how long does it work for?
2-3 minutes 30-90 minutes may need repeat doses long acting opioids may need high dose for fentanyl/carfentanil carfentanil 10,000 X more potent than morphine, 5,000X more potent than heroin, 100Xmore potent than fentanyl.
400
SUD has a long history of binge drinking. He has had multiple problems with law enforcement and has lost his license secondary to DUI. He reports that he doesn't have huge craving problems, it's just once he starts he has a hard time stopping. What medication would be most appropriate for SUD?
naltrexone (PO or IM) - beneficial for decreasing heavy drinking
400
Disulfiram?
Aldehyde dehydrogenase inhibition ETOH=>acetaldehyde=>broken down by ADH= acetic acid
400
What is delirium tremens?
syndrome of acute autonomic hyperactivity and delirium - this is different than ETOH hallucinosis and W/D seizures
400
Drinking + disulfiram =>
N/V, tachycardia, hypotension +/- death
400
What is needed to prescribe buprenorphine in an outpatient setting according to
DEA X# Inpatient has different rules/regulations
500
RBG has been unable to quit smoking with NRT. She smokes 2 PPDs. She is on bupropion 150mg BID for depression and reports this has not helped her quit smoking. She is otherwise healthy. What would be the most appropriate treatment to offer RBG
Varenicline 0.5mg QD X 3D, 0.5mg BID X4D, 1mg BID up to week 24.
500
Naltrexone?
Competitive antagonism of mu opioid receptor => block DA release induced by ETOH => block opioid effetcs
500
What treatment of substance abuse causes the following adverse effects? insomnia, nervousness, headache, n/v, muscle aches
Naltrexone
500
Impact of naltrexone on drinking outcomes?
Reduced heavy drinking days & relapse rates
500
When can methadone be dispensed from a pharmacy?
When prescribed for pain. Inpatient use has different rules/regulations
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