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Digital PharmD

Informatics in Pharmacy

opioid dependance

Substance Abuse Disorders

August 13, 2018 By Dr. G, PharmD

Alcohol Withdrawal –

  • Tremors start around 6 hours, seizures around 12 hours, but can occur 3-5 days later.
  • Mortality can be as high as 35%.
  • 3 Ts – Increase temp, tremor and tachycardia
  • Treatment: correct electrolyte imbalances, benzos, can use propofol or barbiturates in refractory cases, magnesium, alpha 2 agonists, Beta blockers, calcium channel blockers
  • Avoid: tramadol, meperidine, Thorazine, bupropion, TCAs, fluoroquinolones, carbapenems, theophylline, romazicon (huge risk of seizure in chronic user)
  • Use Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar): 0-67, higher is worse. Treat if 8-10.
  • Benzos are main treatment:
    • Lorazepam: 2-4 mg every 6 hours (preferred, no active metabolites, no liver interactions)
    • Diazepam: 10-20 mg every 5 hours (lower in liver failure)
    • Chlordiazepoxide: 50-100 mg every 6 hours (long-acting, decrease dose in liver issues
  • Thiamine: prevent Wernicke-Korsakoff syndrome
  • Magnesium: Check labs to see if needed
  • Electrolyte labs, such as potassium
  • Vitamins: Patients are usually undernourished
  • Fluid therapy: patients are initially overhydrated, then dehydrated, usually give 5% dextrose
  • Hallucinations can be controlled by BZDs or haloperidol
  • Beta-blockers: can control tremor, heart rate and blood pressure
  • Alpha-agonist: clonidine can help with withdrawal
  • Can use disulfiram, naltrexone, acamprosate for chronic therapy.  All are liver toxic.  Naltrexone is better in liver dysfunction.

Opioid Dependence –

  • Maintenance with methadone, naltrexone, buprenorphine.  Opioid withdrawal is not fatal (flu-like symptoms).  Methadone must be tapered to 30 mg daily or less before discontinued.

Tobacco –

  • 10+ cigarettes a day = 21 mg patch, decrease in 2 weeks
  • <10 cigarettes a day = 14 mg patch, decrease in 6 weeks
  • Gum: max = 24 pieces a day, use at least 9 pieces per day.  > 24 cigarettes a day = 4mg gum, all others use 2 mg gum
  • Lozenges – people who smoke within 30 minutes of waking use 4 mg, all others use 2 mg.
  • Bupropion – start at least 7 days before quitting.  Treat at least 8 weeks, up to 6 months.
  • Varenicline: start 7 days prior to quitting, use at least 12 weeks (can use up to 24 weeks).  Black box warning for psychosis.  Can be combined with bupropion or a patch.

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia bcps Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020