ETOH
The most widespread self-help group for Alcohol Use Disorder is called
Alcoholics Anonymous
codeine and morphine are examples of ____.
Opium – dried sap from the opium poppy (Papaver somniferum)
Opiates – alkaloids found in the opium poppy (e.g., codeine, morphine)
Opioids – compounds with opiate-like actions (e.g., endogenous endorphins, heroin, prescription pain medications
TRUE OR FALSE: there are now more former smokers than current smokers
TRUE!
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.
Gold standard rating scale to assess status of AUD
CAGE: Cut down, Annoyed, Guilty, Eye-opener
or
Alcohol Use Disorders Identification Test (AUDIT)
First-line pharmacotherapy for opioid dependence
methadone
buprenorphine/naloxone
On average, _____ attempts are necessary for a patient to quit successfully
7
What is the most commonly abused illict drug?
Marijuana - it is still illegal at the federal level regardless of state regulations/laws
Cofactor depleted d/t altered GI absorption/poor diet. may lead to Wernicke's encephalopathy and Korsakoff Syndrome
thiamine.
MOA of buprenorphine
partial agonist at the opioid mu receptor and an antagonist of the kappa receptor. T
The five R’s can increase motivation to quit:
relevance, risks, rewards, roadblocks, and repetition.
For pts on opioid therapy, at what point are they most at risk for an OD?
Risks for opioid overdose are greatest during the first 3-7 days after opioid initiation or an increase in dosage, particularly when ER/LA opioids are initiated.
Indirect Biomarkers for AUD
Ratio AST:ALT >2:1 suggests liver damage from alcohol. ALT less sensitive than AST
GGT: Enzyme that increases after weeks to months of heavy alcohol consumption. high sensitivty. potential false positive.
MOA of methadone
full opioid receptor agonist
true or false: Varenicline can be combined w/ nicotine patch and buprenorphine
TRUE. Combining varenicline with nicotine replacement therapy may increase adverse effects, though varenicline has been used in combination with the nicotine patch. Varenicline can be combined with bupropion.
When do DT's start?
3-5 days after last drink
Direct Biomarkers for AUD
**DAILY DOUBLE**
Ethyl glucuronid: urine-based biomarker. Indicator that alcohol ingestion has occurred in the last 3-4 days Commonly used in zero tolerance or abstinence-based program
phosphatidyl ethanol: serum-based biomarker; linear dose-response relationship; more research is warranted
When can methadone be dispensed from a pharmacy?
When prescribed for pain. Inpatient use has different rules/regulations
The maximum number of pieces of nicotine gum is ___ pieces in 24 hours.
24
half life of methadone (chronic use)
With ongoing dosing, the half life of methadone is extended to between 13 and 47 hours with a mean of 24 hours.
First-line pharmacotherapy for AUD
either naltrexone or acamprosate, unless there is a patient-specific reason to begin with disulfiram
American Psychiatric Intervention First-line
Association (APA) (2006, 2018)
Length of recommended abstinence prior to initiation of naltrexone.
What is 7-10 days for short-acting opioids and 10-14 days for long-acting?
The maximum number of pieces of nicotine lozenge is ___ pieces in 24 hours.
20
TRUE OR FALSE: CYP 3A4 inhibitors decrease buprenorphine exposure
FALSE
Contraindications of Naltrexone
-opioid use within the last 7-10 days (potentially longer if using long-acting opioids, i.e., buprenorphine or methadone within the last 14 days)
-acute opioid withdrawal
-failure of a naloxone challenge
-history of hypersensitivity to naltrexone or other product ingredients
-acute hepatitis, severe hepatic impairment (LFTs greater than 3 times the upper limit of normal)
Prescribing consideration for buprenorphine for outpatient setting
X-waiver: Qualifying practitioners need 8 hours of training while qualifying other practitioners need an additional 16 hours.
DEA X# Inpatient has different rules/regulations
Varenicline MOA
A nicotine receptor partial agonist. Varenicline blocks the effects of nicotine from smoking . (nicotine is full agonist)
explain how naloxone works as an abuse deterrent in buprenorphine/naloxone.
naloxone is more rapidly inactivated after oral/ sublingual absorption than parenteral administration
Dosing of Acamprosate
666mg TID
Prescribing consideration for methadone
Can be used to treat OUD only via accredited opioid treatment programs (OTP).
42 in VA w/ 1 in Roanaoke.
BBW for Varenicline
neuropsychiatric symptoms, including depression, suicidal ideation, suicide, psychosis, mood disturbance, and hostility
buprenorphine's MOA allows patients enough effect to “feel normal” but minimizes functional impairment, which is something referred to as the__________.
the ceiling effect
Duration of time for ALDH concentrations to return to baseline after disulfiram discontinuation.
~14 days
Treatment with buprenorphine involves what three phases
induction, stabilization and maintenance phase
Bupropion SR should be initiated ____.
7 days before quit date. Treatment should last for at least 8 weeks but can be continued for up to 6 months to increase chances of quitting
Clinical drinking outcomes with acamprosate?
decreased in heavy drinking days, decreased cravings
Antiepileptics recommended as 2nd line tx
Topiramate has been associated with decreases in heavy drinking days and drinking days overall
Gabapentin has been shown to reduce heavy drinking days and increase abstinence rates
If IV drug use is identified, this should be offered to vets.
pre-exposure prophylaxis (PrEP
Tenofovir disoproxil fumarate-emtricitabine
For patients who smoke more than 10 cigarettes/day, patch schedule
21 mg/day for 2 weeks, then 14 mg/day for 2 weeks, then 7 mg/day for 2 weeks
MOA of lofexidine
Lofexidine is a central alpha-2 adrenergic agonist that reduces the release of norepinephrine and decreases sympathetic tone