Withdrawal
challenges after stopping ETOH consumption
prevention of relapse
management of persistent emotional & physiologic disturbances
adverse rxn to ingestion of ETOH r/t ETOH sensing meds
tx of psychiatric sx that return when user stops "self medicating"
Opioid Agents (3) which are opioid agonist that DIRECTLY reduce ETOH consumption
Naltrexone FDA approved 1985 for opioid dependence, 1994 for RTOH dependence
Vivitrol - IM sustained released injection approved in 2005
Nalmefene- approved in US for IV formulation for reversal of opioid effects during surgery
Naltrexone
Long acting opioid antagonist
complete blockade of opioids receptor when taken at least 3 x's week
total weekly dosage 350 mg
treatment retention20-30% over 6 months-low
What is the gold standard for OUD for pregnant women?
Methadone
d/t combination therapy naloxone although inactive may still effect the fetus
Can use mono-oproducts
Drugs that induce (decrease blood levels) Methadone
rifampin
phenytoin
ethyl ETOH
Barbiturate's
Carbamazepine
St. John's wart
ETOH sensitizing Agents
alters body's response to ETOH=Antabuse & carbamise)
if ETOH ingested after enzyme acetaldehyde blood levels rise causing disulfiram ethanol reaction (EDR)
EDR varies in intensity depending on dose and volume of ETOH ingested.
12 week study yielded?
success rate 40% adding naltrexone which is a lot lower than treating opiate user.
Buprenorphine preparations
Subutex and Suboxone
schedule 3
SL for tx of opioid dependence
typical dosage 4-24mg per day
2mg Bup.0.5 naloxone
4mg Bup/2 mg Naloxone
8mg Bup/2 mg naloxone
12mg Bup/3 mg Naloxone
Principles for prescribing methadone
older than 18
at least 1 year of physiological dependence
(documented withdrawal and tolerance)
meet criteria for opioid dependence
Drugs that inhibitot (INCREASE blood levels) Methadone
fluconazole
cimetidine
Erythromycin
fluvoxamine
fluoxetine
ketoconazole
Nefazadone
Ritonavir
Clomipramine
Haloperidol
paroxetine
alprazolam
Disulfiram MOA and dosing
absorbed immediately after administration
metabolized rapidly to DDC (active metabolite)
Disulfiram & DDC stops ALDH by binding to it irreversible
inhibits beta hydroxylase= INcreased DA and exacerbation of psychiatric sx i.e. schizophrenia
250-500 mg per day (med not widely used)
can't use mouthwash or some moisturizers, and hand sanitizers
What is the result when treat ETOHics with SSRI?
ondansetron also used
give SSRI -depression resolves= ETOH use resolves. d/t ppl self medicate with ETOH
Fluoxetine 60 mg little effect
citalopram 20 mg little effect
Buprenorphine monotherapy for opioid addiction
comes in SL tabs, SQ injection, patch, and implants)
burprenx Injection( not for MAT)
Subutex SL tab
Probuphine Subdermal Implant
Butrans patch
Sublocade injections- long acting SQ
Methadone dosing to achieve adequate steady-state dosing (5 half lives)
induction dosing
establish maintenance dosage
avoid drugs that increase methadone prescribing or induce withdrawal
evaluate need for detox or continued maintenance
***** if continuing to use INCREASED methadone to decrease cravings
The treatment must be utilized with
MOTHER study( article)
Maternal Opioid Treatment Human Experimental Research
Psychotherapy to address psychosocial needs of pt
meds work on behaviors but NOT CAUSE of behaviors
Buprenorphine babies required less morphine than methadone babies suggesting Bup was better
s/s of Disulphiram Ethanol Reaction ( EDR)Syndrome
warmness/flushing of the skin
increased HR, palpitations
decreased b/p
n/v
SOB
sweating, dizziness, bl. vison
confusion,
last about 30 minutes and are self limited.
Acamprosate: MOA:
effects both GABA and glutamate. glutamate antagonist= decreases anxiety- dosed TID pts noncompliant
pt will drink less
maybe more helpful in combination with disulfiram
Opioid Combination therapy
Suboxone STANDARD for OUD
Comes in SL tabs films
Suboxone sl tab and film
Zubsolv SL fim
Bunavail Bucaal film
Prevent Relapse
Educate pt and family
Encourage involvement in NA or Nar-Anon
monitor for s/s of opioid intoxication or drug seeking behavior
adjust dose according to need
Sublocade injection (insert)
monotherapy
treatment for MODERATE to SEVERE OUD who have initiated treatment with a product containing buprenorphine
100mg and 300 mg in a prefilled syringe 19"g 5/8 inch needle
dosage adjustment a minimum of 7 days
measures to enhance compliance
provide incentive-contingency management
contract with pt
provide reminders and information
behavioral training
warn about side effects using otc preparations with ETOH
Naltrexone regimen initiated after acute withdrawal from opioids
5-7 days opioid free (short acting
7-10 days opioid free (long acting)
25 mg 1st day d/t GI side effects (take at HS)
50 mg dly or 350 mg weekly divided into 3 doses
serious side effect liver toxify
Methadone MOA
blocks euphoria from full agonist opiates (heroin)
psychosocial stabilization
reduces criminal activity
No serious side effects- constipation, sweating, drowsiness, decreased sexual interest/performance
methadone clinics---- need high doses d/t purity of drug
Evaluate and treat medical conditions
Infectious Disease-reduce risk of contacting and transmitting disease.
educate family and involve them in efforts
Pain management-
consider non narcotic agents 1st
evaluate cross tolerance in narcotic analgesia
avoid narcotics that cause withdrawal
Vivitrol injection (Insert)
naltrexone extended release IM injectable
380 mg q 4 weeks in the gluteal muscle alternating each injection
treatment for ETOH dependence able to abstain from drinking in outpt setting
also used for prevention of relapse for OUD
contraindications
acute hepatitis or liver failure
receiving opioids analgesics
pt with current physiologically OUD
acute OUD withdrawal
failed naloxone challenge or sensitive to naloxone