Term
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Definition
ADDICTION
primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations
characterized by behaviors including one or more of the following (5Cs):
chronicity
impaired control over drug use
compulsive use
continued use despite harm
craving
DEPENDENCE (physical)
state of adaptation manifested by a class of drugs
specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, administration of an antagonist |
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Term
| characteristics of alcohol dependence |
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Definition
I'M A TOWN DRUNK
INABILITY (to cut down)
MORE DRUG USED (than intended)
A LOT OF TIME (spent obtaining, using, and recovering from using the drug)
TOLERANCE
OLD ACTIVITIES, FRIENDS, FAMILY MEMBERS (given up in favor of the drug)
WITHDRAWAL
NEGATIVE CONSEQUENCES (have no effect on the pattern of drug use)
3 of 7 = dependence |
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Term
| classifications of drugs of abuse according to the Controlled Substances Act |
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Definition
Controlled Substances Act:
I
high potential for abuse
no currently accepted medical use
lack of accepted safety for use
II
high potential for abuse
has a currently accepted medical use (with severe restriction)
abuse lead to severe psychological or physical dependence
III
less potential for abuse
has a currently accepted medical use
abuse may lead to moderate or low physical dependence or high psychological dependence
IV
low potential for abuse
has a currently accepted medical use
abuse may lead to limited physical dependence or psychological dependence
V
low potential for abuse
has a currently accepted medical use
abuse may lead to limited physical dependence or psychological dependence |
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Term
| classifications of drugs of abuse by physiological actions |
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Definition
3 categories:
1) stimulants
increase thinking, feeling, and behavior
2) depressants
decrease thinking, feeling, and behavior
3) confuse-ants
distort or confuse thinking, feeling, and behavior |
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Term
| who is most likely to use illicit drugs? |
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Definition
more common in males
highest for American Indians/Alaska natives, blacks
the mean age at first use of illicit drugs is 17.6 years
the highest rate was among persons aged 18-20 followed by 21-25 years, then decline with increasing age
LOWEST IN ASIANS
majority of pain relievers were obtained from a friend/relative |
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Term
| what is the most commonly used illicit substance? |
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Definition
[image]
marijuana (76.6% of current drug users)
followed by:
psychotherapeutics (prescription drugs - pain relievers, tranquilizers, stimulants, sedative)
cocaine and crack
hallucinogens: LSD, PCP, mushrooms, ecstasy (MDMA)
inhalants: nitrous oxide, cleaning fluids, gasoline, spray paint, glue
heroin |
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Term
| highest rates of nonmedical use of psychotherapeutic drugs |
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Definition
[image]
#1 = PAIN RELIEVERS
tranquilizers
stimulants
sedatives |
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Term
| difference between current alcohol use, binge use, and heavy use |
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Definition
current use:
at least one drink in the past 30 days
binge use:
drinking 5 or more drinks on the same occasion (at the same time or within a couple of hours of each other) on at least 1 days in the past 30 days
heavy use:
drinking 5 or more drinks on the same occasion (at the same time or within a couple of hours of each other) on 5 or more days in the past 30 days |
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Term
| rates of binge and heavy alcohol use is highest among groups of people? |
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Definition
age group that has the biggest bingers and heavy users:
peaks at 21-25 then declines
gender:
males more likely than females (equal for teens)
ethnicity:
highest for whites, blacks, then Hispanics
lowest for Asians for both use and binge |
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Term
| top drug that people become dependent on |
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Definition
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Term
| impact of substance abuse |
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Definition
addiction leads to ~120,000 deaths in the U.S. each year
economic:
drug abuse is one of the most costly health problems in the US
both the use of resources to address health and crime consequences
loss of potential productivity from disability, death, and withdrawal from the workforce
crime:
most crime involves alcohol, illegal drugs
family/social:
withdrawn, relationships deteriortate, change in friends, divorce
personal:
emotional, spiritually, financially, medically, mentally
every dollar invested in substance abuse treatment yields $7 in benefits (reduced cost of crime and inreased employment earning)
benefits of treatment outweigh costs for both outpatient and residential treatment settings |
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Term
| rates of ED visits involving illicit drugs |
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Definition
[image]
ALCOHOL OR COCAINE ARE THE #1 REASONS FOR ED VISITS DUE TO INTOXICATION |
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Term
| stages of alcohol dependents |
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Definition
binge/intoxication:
reward pathway
drug reinforcement
withdrawal/negative effects:
stress modulation
CRF is released by hypothalamus in response to stress
high CRF causes a down regulation in dopamine D2 receptors eventually leading to anhedonia
dynorphin
preoccupation/anticipation:
craving
glutamate - drugs effect glutamate resulting in long-lasting neuroplastic changes in the brain and preservation of drug memories |
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Term
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Definition
[image]
pleasurable feelings provide positive reinforcement so that the behavior is repeated
natural rewards (food, water, sex, nurturing) as well as artificial rewards (drugs)
in addiction, the drug hijacks the survival hierarchy and is so close to actual survival that it is indistinguishable from actual survival
the reward pathway involves several parts of the brain:
ventral tegmental area (VTA)
nucleus accumbens
prefrontal cortex
when activated by a rewarding stimulus, information travels from the VTA to the nucleus accumbens and then up to the prefrontal cortex
the VTA is connected to both the nucleus accumbens and the prefrontal cortex via this pathway and it sends information to these structures via its neurons
the neurons in the VTA contain dopamine which is released in the nucleus accumbens and in the prefrontal cortex
all known addictive substances (but not necessarily all drugs of abuse) cause a rapid INCREASE IN DOPAMINE LEVELS IN THE NUCLEUS ACCUMBENS by direct or indirect mechanism |
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Term
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Definition
(+)
drug euphoria
positive reinforcement
activated reward pathways
neuroadaptations
withdrawal and tolerance
protracted hedonic dysregulation
(-)
drug craving
negative reinforcement
dysregulated reward pathways
drug and/or use-related cues, limbic activation
loss of control
denial/poor decision making
hypofrontality/low D2
reduced gray matter density
drug administration
drug seeking behavior
failed impulse suppression |
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Term
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Definition
abstinence
lower risk:
more moderate amounts, no consequences (CV benefits for some)
moderate drinking is up to 2 drinks/day for men and up to 1 drink/day for women
risky:
amounts risk adverse consequences, but have not occurred YET
more common than dependence
problem:
consequences have occurred due to drinking
abuse:
harmful
recurrent consequences w/o meeting criteria for dependence
alcohol use disorder (AUD)
alcoholism/dependence
alcohol use disorder (AUD) |
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Term
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Definition
a level of alcohol consumption that is directly harmful, or is correlated with a greater risk of health problems
men:
>14 drinks/week
4 or more drinks per occasion
women and adults > 65 yo:
> 7 drinks/week
3 or more drinks per occasion
amount that increase risk of adverse consequences |
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Term
| DSM-IV criteria for intoxication |
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Definition
development of substance specific syndrome after recent ingestion
alcohol intoxication:
recent ingestion of alcohol
clinically significant maladaptive behavioral or psychological changes (inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that develop during or shortly after alcohol ingestion
one (or more) of the following signs, developing during, or shortly after alcohol use:
slurred speech
in coordination
unsteady gait
nystagmus
impairment in attention or memory
stupor or coma
symptoms are not due to a general medical condition and are not better accounted for by another mental disorder |
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Term
| supportive care for intoxication |
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Definition
maintain vital functions
physical restraints is necessary
AVOID drug therapy
obtain toxicology screen, liver function, CBC
talk-down therapy to minimize sensory input for hallucinogens |
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Term
| DSM-IV criteria for alcohol withdrawal |
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Definition
development of substance specific syndrome after cessation or reduction in intake that was used regularly to induce a state of intoxication
alcohol withdrawal:
2 or more of the following, developing in hours to days, causing distress or impairment, not due to another condition:
autonomic hyperactivity (sweating, tachycardia)
increased hand tremor
insomnia
nausea or vomiting
transient tactile, visual, or auditory hallucination or illusions
psychomotor agitation
anxiety
granmal seizures |
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Term
| ALCOHOL WITHDRAWAL SYMPTOMS |
|
Definition
STAGE I: 6-12 hours after cessation of alcohol use
minor withdrawal symptoms
insomnia, tremulousness, mild anxiety, GI upset, headache, diaphoresis, palpitations, anorexia
STAGE II: 12-24 hours after cessation of alcohol use
alcoholic hallucinations: visual, auditory, or tactile hallucinations
STAGE III: 24-48 hours after cessation of alcohol use:
withdrawal seizures: generalized tonic-clonic seizures
STAGE IV: 48-72 hours after cessation of alcohol use
alcohol withdrawal delirium (delirium tremens)
hallucinations (predominately visual)
disorientation
tachycardia
hypertension
low grade fever
agitation
diaphoresis
risk factors for seizures: recurrent detoxification and prior seizure
risk factors for DTs: prior DTs, early symptoms of withdrawal, hepatic dysfunction |
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Term
| diagnosis of alcohol withdrawal delirium (AWD), commonly known as delirium tremens of DTs |
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Definition
A.
disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention
B.
a change in cognition (such as memory deficit, disorientation, or language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia
C.
the disturbance develops in a short period (usually hours to days) and tends to fluctuate during the day
D.
there is evidence from the history, physical exam, or lab findings that the symptoms in criteria A and B developed during, or shortly after, a withdrawal syndrome
must meet all 4 criteria
DT is the most serious manifestation of alcohol withdrawal syndrome |
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Term
| pros and cons of using alcohol to treat alcohol withdrawal |
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Definition
PROS
perfect cross-tolerant drug
alcoholic's drug of choice
CONS
narrow therapeutic window
many toxicities (hepatitis, gastritis, pancreatitis, marrow suppression)
need to monitor and adjust levels
reinforces acceptability and continued use
more DTs/seizures compared with chlordiazepoxide
no difference compared with BNZ + haloperidol or clonidine |
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Term
| fixed schedule BZD treatment of alcohol withdrawal |
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Definition
q6h for 4-8 doses + PRN
chlordiazepoxide
diazepam
lorazepam
underdosing is common with this approach
long acting BZDs are most effective for preventing seizures and DTs
chlordiazepoxide = less abuse potential for outpatients (long acting, longer onset of action), low cost
AVOID in liver dysfunction!!
lorazepam: no metabolites, BETTER FOR LIVER DYSFUNCTION BUT LESS EFFECTIVE
TAPER over 3-7 days, slower if recurrent |
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Term
| SYMPTOMS TRIGGERED BZD treatment of alcohol withdrawal (PREFERRED!) |
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Definition
q1h when Clinical Institute Withdrawal Assessment (CIWA) > 8 (objective scale)
chlordiazepoxide
diazepam
lorazepam
provides less total medication
requires shorter duration of treatment
symptom triggered regimens potentially avoid over sedation
long acting BZDs are most effective for preventing seizures and DTs
chlordiazepoxide = less abuse potential for outpatients (long acting, longer onset of action), low cost
AVOID in liver dysfunction!!
lorazepam: no metabolites, BETTER FOR LIVER DYSFUNCTION BUT LESS EFFECTIVE
TAPER over 3-7 days, slower if recurrent |
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Term
| use of BZDs for alcohol withdrawal - outcomes |
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Definition
seizure:
BZD cause a relative risk reduction of 93% compared to placebo
delirium reduced more than placebo
sedative hypnotic drugs reduce mortality, reduce the duration of symptoms, and are associated with fewer complications compared with neuroleptic agents in controlled trials |
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Term
| treatment approaches for AWD (DTs) |
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Definition
treatment goal: rapid and adequate control of agitation
medication regimen:
diazepam IV
if the initial dose is not effective, repeat the dose in 5-10 minutes
if the second dose is not satisfactory, increase for the 3rd and 4th doses every 5-10 minutes
if not effective, increase the dose for the 5th and subsequent doses until sedation is achieved
use every hour prn to maintain light somnolence
lorazepman IV q5-15 minutes or lorazepam IM every 30-60 minutes until calm, then every hour as needed to maintain light somnolence
diazepam has rapid onset, long duration (for quick agitation control and less breakthrough)
lorazepam has shorter duration (concern about prolonged sedation then this is the preferred agent - elderly, substantial liver disease or other serious concomitant medical illness) |
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Term
| fluid, electrolyte, and nutrition for electrolyte withdrawal |
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Definition
inadequate nutrition and fluid volume is common
Wernincke-Korsakoff Syndrome (aka Wernicke's encephalopathy):
thiamine deficiency is common
thiamine IV/po daily for 5 days empirically
administer prior to IV fluid containing glucose; since thiamine is the cofactor necessary for glucose metabolism and may precipitate acute thiamine deficiency
triad of ACUTE MENTAL CONFUSION, ATAXIA, AND OCULOMOTOR DYSFUNCTION (paralysis/weakness of one or more of the muscles that control eye movement) followed by memory loss and confusion
potassium, magnesium, vitamin K |
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Term
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Definition
outpatient:
last drink > 26 hours, symptoms unlikely to develop
no other risk factors
consider inpatient:
past seizure, drug use, anxiety disorder, multiple detoxifications, alcohol > 150 (risks more severe symptoms)
inpatient:
older age (>60yo), concurrent acute illness, seizure, moderate to severe symptoms (risks DTs)
ICU level:
DTs |
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Term
| differences between inpatient and outpatient treatment settings |
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Definition
inpatient:
frequent evaluation
medication management and monitoring
alcoholics anonymous
counseling
greater abstinence at 1 month, similar abstinence at 6 months
COSTS way more for inpatient
more people complete inpatient
outpatient:
daily evaluation
review of medications
counseling
similar abstinence at 6 months |
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Term
| maintenance and relapse prevention for alcoholics |
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Definition
anticipate difficult situations (triggers)
emphasize prior successes and use relapse as a learning experience, cope with craving
help patient develop a plan to manage early relapses
facilitate involvement in treatment (12-step groups, counseling, pharmacotherapy, comorbid psychiatric disorders) |
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Term
| patient selection for pharmacotherapy for alcoholism |
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Definition
all people with alcohol dependence who are:
currently drinking
experiencing craving or at risk for return to drinking or heavy drinking
considerations:
specific medication contraindications
willingness to engage in psychosocial support/therapy
relationship/willingness to follow-up with health provider
outpatient or inpatient clinical setting with prescriber, access to monitoring (visits, liver enzymes) |
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Term
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Definition
| blocks opioid receptors, resulting in reduced cravings and reduced reward in response to drinking |
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Term
|
Definition
PO = once daily
injection = q 30 days |
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Term
| contraindications to naltrexone |
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Definition
currently using opioids or is in an acute opioid withdrawal
anticipated need for opioid analgesics
acute hepatitis or liver failure |
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Term
| serious and common ADRs for naltrexone |
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Definition
serious:
will precipitate severe withdrawal if the patient is dependent on opioids, infection at injection site
common:
N/V
decreased appetite
HA
dizziness
fatigue
somnolence
anxiety
drug interactions = opioid medications (blocks actions) |
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Term
| MOA of acamprosate (Campral) |
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Definition
| affects glutamate and GABA neurotransmitter systems but its alcohol related action is unclear |
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Term
| dosing of acamprosate (Campral) |
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Definition
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Term
| contraindications for acamprosate (Campral) |
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Definition
| severe renal impairment (CrCl < 30 mL/min) |
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Term
| serious and common ADRs of acamprosate |
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Definition
serious:
suicidal ideation (rare)
common:
diarrhea, somnolence |
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Term
| MOA of disulfiram (Antabuse) |
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Definition
| inhibits immediate metabolism of alcohol, causing a build up of acetylaldehyde and a reaction of flushing, sweating, nausea, and tachycardia if the patient drinks alcohol |
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Term
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Definition
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Term
| contraindications to disulfiram |
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Definition
concomitant use of alcohol or metronidazole
coronary artery disease
severe myocardial disease |
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Term
| serious and common ADRs of disulfiram |
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Definition
serious:
hepatotoxicity
optic neuritis
peripheral neuropathy
psychotic reactions
common:
metallic after taste |
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Term
| drug interactions with disulfiram |
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Definition
warfarin
isoniazid
metronidazole
phenytoin
any non-Rx drugs containing alcohol |
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Term
| stages of pharmacotherapy for alcoholics |
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Definition
withdrawal
"maintenance" or craving reduction
block drug effects: receptor antagonists or circulating antibodies that prevent drug from interacting with brain sites
diminish drug craving: prevent the desire to use drugs and/or interrupt the rewarding properties of drug use
sustained abstinence |
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Term
|
Definition
acute distress, especially when combined with alcohol
for withdrawal, treat similar to alcohol treatment with a benzodiazepine taper to prevent seizures |
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Term
| what drug is given for BZD overdose? |
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Definition
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Term
|
Definition
naturally occurring opiate narcotic drugs:
morphine, codeine
semi-synthetic:
heroin, oxycodone, hydrocodone
synthetic:
meperidine, methadone, fentanyl |
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Term
|
Definition
begins after 4-6 hours
by 8-12 hours:
autonomic symptoms (rhinorrhea, lacrimation, diarrhea)
anxiousness, irritability
excessive sweating, fever, chills
stomach/muscle cramps
withdrawal lasts 1-3 days (as long as 7-10 days) |
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Term
| supportive care for opioid detoxification |
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Definition
withdrawal is not fatal
clonidine controls automonic symptoms
ibuprofen (muscle pains)
cyclobenazepine (muscle pains)
trazodone (insomnia)
loperamide (PRN diarrhea) |
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Term
| therapies for opiate craving |
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Definition
[image]
1) full agonist: activate mu receptors
ex) methadone
2) partial agonist: properties both antagonists and full agonists, bind/activate but at a lesser degree
ex) buprenorphine
3) antagonist: bind and block receptor, injection for opioid overdose
ex) naloxone |
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Term
| formulations of methadone |
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Definition
oral solution
liquid
tablet
powder
ONLY HIGH DOSES OF METHADONE SHOULD BE USED!
[image] |
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Term
| treatment settings for methadone |
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Definition
| opioid treatment program only |
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Term
formulations of buprenorphine (Subutex) and buprenorphine/naloxone (Suboxone)
addition of naloxone (antagonist) deters abuse |
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Definition
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Term
| treatment settings for buprenorphine (Subutex) and buprenorphine/naloxone (Suboxone) |
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Definition
physician's office
opioid treatment program
other health care setting |
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Term
| formulations of naltrexone |
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Definition
oral tablet
injection (Vivitrol) |
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Term
| treatment settings for naltrexone |
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Definition
physician's office
opioid treatment program
any substance abuse treatment program |
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Term
| using patterns of methamphetamine |
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Definition
[image]
often used in binges, repeated doses every 2 hours
binges may last 12-18 hours and as long as 2-3 or even 7 days
fleeting rush or flash of euphoria results in drug hunger or craving
tolerance to the effects result in higher doses necessary to satisfy the craving |
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Term
| signs, symptoms and behaviors of chronic methamphetamine use |
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Definition
signs and symptoms:
paranoia
visual and auditory hallucinations
rages leading to violence
body sores from scratching at "bugs"
anxiety
insomnia
cardiovascular damage
malnutrition
infection
behaviors:
withdrawal from social activities
consumed with use and acquisition of the drug
increased stereotyped, non-interactive behaviors
disintegration into meaningless ritual like activities
long term changes of loss of neuron structure/function (DA, serotonin) seen in Alzheimer's/Parkinson's |
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Term
| methamphetamine withdrawal symptoms |
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Definition
anxiety, fatigue, depression
paranoia, aggression
intense craving
abdominal cramps, gastroenteritis
diaphoresis, dyspnea
lethargy, anergi, dysphoria
treatment is supportive
BZDs for agitation
symptoms wax and wane for months |
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Term
| onset of action of different administration methods of cocaine |
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Definition
[image]
similar to methamphetamine, but is in hours instead of days
the more rapid and immediate onset of action characteristic of the IV and inhalation routes also results in a rapid decrease in plasma levels
the rapid onset of drug action intensifies the rewarding aspects, howevere the rapid decrease in plasma levels results in the craving or drug hunger that reinforces multiple dosing patterns |
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Term
|
Definition
tolerance/sensitization
restlessness, irritability, anxieity, aggressiveness, hypersexuality, and paranoia
acute toxicity and death:
seizures or stroke in the brain
arrhythmias or infarctions in the heart
vasoconstriction may lead to necrosis and tissue death in the sinuses or injection sites
NO BETA BLOCKERS: increases HTN, reduces coronary blood flow, LVF, and cardiac output and tissue perfusion by means of leaving the alpha adrenergic system stimulation unopposed |
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Term
|
Definition
tetrahydrocannabinol
amphetamine-like:
mescaline
MDMA (ecstasy)
serotonin-like:
LSD
psilocybin
dissociative anesthetics:
phencyclidine
ketamine
GHB
nitrites, nitrous oxide
solvents
the most common agents in the confuse-ant category are grouped into several categories based on the nature of their effects and/or their MOA |
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Term
| impairments from marijuana |
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Definition
acute:
short-term memory
attention, judgment, cognitive function
coordination and balance
persistent:
memory
learning skills |
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Term
| withdrawal from marijuana |
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Definition
increased aggressive responses
increased sleep difficulties
increased irritability
increased craving |
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Term
| MOA of rimonabant (Acomplia) |
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Definition
decreases DA release in nucleus accumbens of reward pathway
blocks actions of THC
prevents cue induced cocaine relapse
reduces alcohol consumption
reduces heroin administration
binds to the CB1 receptor but does not induce a response |
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Term
|
Definition
at a minimum, pharmacists should be able to screen for these problems, assess their severity, refer individuals to appropriate levels of care, and provide appropriate counseling for those in recovery
education:
inform about and refer to support groups
recommend appropriate use of mood-altering substances
encourage pharmacy student and technician education
providing education to fellow pharmacists and other health care professionals
prevention:
substance abuse program
policy, training, employee assistance program
peer support system
drug testing
service programs
discourage alcohol and tobacco sale
assistance:
identify patients and coworkers having problems and refer for evaluation and treatmnet
participate in multidisciplinary efforts to support and care for coworders and patients in recovery
REFUSE TO ALLOW ANY STUDENT OR EMPLOYEE TO WORK, PRACTICE, OR BE ON-SITE FOR ROTATIONS WHILE THEIR ABILITY TO SAFELY PERFORM THEIR RESPONSIBILITIES IS IMPAIRED BY DRUGS, INCLUDING ALCOHOL |
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