QPR / PGx
What is a behavioral clue that someone may have thoughts or intent to attempt suicide?
Which assessment tool is used to objectively measure alcohol withdrawal symptoms?
Clinical Institute Withdrawal Assessment for Alcohol (CIWA)
-Revised (CIWA-Ar)
Which setting is methadone legally dispensed through for the treatment of OUD?
Opioid treatment programs (OTPs)
A patient is interested in reducing their binge drinking. Which MAUD is least appropriate for them?
Disulfiram (Antabuse)
--
Better options: Naltrexone, topiramate, gabapentin
Which medication for OUD has a black box warning for risk of QT prolongation?
Methadone (Dolophine)
Which populations are at high risk for suicide?
A patient begins to have seizures on POD2. CT head rules out other causes. Nurses noted tremors the day prior. What substance is he most likely withdrawing from?
ALCOHOL
Initial symptoms begin within 24 hours - Tremor, anxiety, nausea, vomiting, irritability
Seizures may occur within 48 hours
Delirium tremens (DTs) typically occur 4-5 days after cessation - Autonomic instability, confusion, disorientation, and hallucinations
Describe two positive characteristics of buprenorphine/naloxone which set it apart from other MOUD treatment options?
SL formulations combined with naloxone to deter adulteration and misuse/diversion
a “ceiling effect” which reduces (but does not eliminate) the risk of abuse. Additionally, there is a lower risk of respiratory depression and overdoses on buprenorphine alone are uncommon
Patients may fill and pick up their prescription at a local pharmacy, usually for a week or so at a time initially, rather than presenting every day for their dose.
Can transition to different LAI options
Mild-moderate withdrawal
Which medication for AUD is best for a patient with severe hepatoxicity?
Acamprosate (Campral)
Which benzodiazepine is usually first line for alcohol withdrawal due to its long half-life?
Diazepam (Valium) --> active metabolites (temazepam, nordiazepam, oxazepam)
What is your goal of "persuasion" when preventing suicide?
For the person to agree to get help.
The onset and severity of opioid withdrawal symptoms generally depends on:
Type of opioid used (long-acting versus short-acting)
Short-acting (heroin, hydrocodone, oxycodone)
•Severe symptoms
•Onset: ~ 12 hours following missed dose
•Duration: ~4-7 days
Long-acting opioid (methadone)
•Milder symptoms
•Duration: 2 weeks or more
Please provide two (2) important counseling points for a patient who is newly starting on Naltrexone IM injection:
Indicated for OUD* and alcohol use disorder
MUST abstain from opioids for 7-10 days prior to administration to avoid precipitated withdrawal
Injectable suspension must ONLY be administered as a deep intramuscular gluteal injection
380mg every 28 days, alternating sides with each injection
S/sx of liver dysfunction or changes: Caution in hepatic insufficiency; not recommended in acute hepatitis or hepatic failure
Potential adverse effects: injection site reaction including nodule, swelling, pain, tenderness, itching, bruising, abscess, tissue necrosis
Opioid pain medications will be ineffective if needed in emergency or other acute situation
•Carry identification to alert medical personnel of use
•Will need to develop treatment plan for scheduled procedures which may require opioids
Increased sensitivity to opioids after treatment is discontinued, at the end of a dosing interval, or after a missed dose à elevated overdose risk
AK is a 52 year old male presenting to his PCP after a recent hospitalization for treatment of alcohol withdrawal. While admitted, he was diagnosed with Wernicke-Korsakoff syndrome and family confirm significant cognitive decline over the last few years. His sister recently moved in with him due to safety concerns and falls.
PMH:HTN, GERD, and chronic pain. Renal and hepatic function are WNL.
Current medications: atenolol 50mg daily, omeprazole 20mg BID, thiamine 100mg daily and hydrocodone/APAP 5mg/325mg BID PRN for pain.
The patient is interested in pursuing medication for AUD. What is the most appropriate pharmacologic treatment for this individual and why?
Which medications for alcohol use disorder (MAUD) require dose adjustment in renal impairment?
Topiramate (Topamax)
Gabapentin (Neurontin)
Acamprosate (Campral)
What is the effect of a CYP enzyme poor metabolizer (PM) phenotype on an active drug?
Reduced drug metabolism
Higher plasma concentration
Potential for increased adverse effects
What is the mechanism of action of lofexidine (Lucemyra)?
•α2- receptor agonist
•FDA-approved for opioid withdrawal symptoms
•NOT a treatment for opioid use disorder
•Usual dose: 0.54 mg (3 tablets) four times daily for 5-7 days
•“Lucemyra treatment may be continued for up to 14 days with dosing guided by symptoms.”
•Discontinue with gradual dose reduction over 2-4 days to avoid lofexidine discontinuation symptoms
•Adverse effects - Hypotension/bradycardia/orthostasis, Sedation, QTc prolongation, Dose adjustment needed for hepatic and renal impairment
Suboxone - subcutaneous
•Patients should be established on 8mg – 24 mg BUP daily
•300mg x 2, then transition to 100 or 300 mg every 28 days (must have at least 26 days between injections)
Brixadi - weekly or monthly SQ, dose depends on current oral dose and can be < 6mg
Both have a REMS program, so only administered by a healthcare professional
JC is a 38 y/o who was admitted to your hospital overnight for alcohol withdrawal. He has a past medical history of AUD, HTN, and hypothyroidism. At the time of admission, his BAC was 233 and he had a UDS + cocaine. His renal and hepatic function are both within normal limits.
You speak with him at the bedside to review home medications and notice he has not filled his HTN and thyroid medications in over 6 months and that he has several missed appointments documented in his chart. He says he tries to take medication daily but struggles with remembering doses. He estimates forgetting to take his maintenance medications about 2-3 times per week.
A few days later, you receive a call from his medical team saying JC is interested in starting medication assisted therapy for alcohol use disorder. What is the most appropriate pharmacologic treatment for this patient and why?
Naltrexone - can start with oral naltrexone to assess tolerability and transition to once-monthly IM Vivitrol injection due to history of poor adherence.
A 26 year old presents to the ED with a BAC of 265 and becomes acutely agitated requiring medication management. What do you recommend?
IM SGA --> ziprasidone or olanzapine
IM FGA --> haloperidol
Avoid benzo during acute intoxication with CNS depressant
What are two possible benefits of pharmacogenomic testing?
One-time testing
Less trial and error with medications.
Fewer adverse drug reactions
Improved adherence
Improved satisfaction/ trust in provider
Which medication has been shown to effectively treat mild-moderate alcohol withdrawal syndrome with lower risk of CNS sedation compared to benzodiazepines?
Gabapentin (Neurontin)
What do you do in the case of a suspected opioid overdose?
What are important counseling points for a patient starting disulfiram?
Irreversible inhibitor of aldehyde dehydrogenase - Duration of effect may last up to 2 weeks while body generates new enzyme
Avoid all forms of alcohol, including topical products
Not appropriate therapy for patients who are unable to understand consequences of alcohol use and consent to treatment
Adverse effects: drowsiness, metallic taste, hepatitis
A patient takes Tegretol for seizures. What impact would this have on a patient taking buprenorphine?
CYP3A4 inducer --> may decrease serum concentrations of buprenorphine
Also interacts with methadone!!