3/27/2013 1 Opioid and Alcohol Addiction Eve Segal, PharmD PGY2 Oncology Pharmacy Practice Resident St. Luke’s Mountain States Tumor Institute Objectives • To define addiction • To identify the signs and symptoms of alcoholism • To understand how to manage patients experiencing alcohol withdrawal in an acute care setting • To list the long-term complications of chronic alcohol addiction and misuse • • To identify the signs and symptoms of opioid addiction • To understand how to manage patients experiencing opioid withdrawal in an acute care setting • To list the long-term complications of chronic opioid addiction and misuse Scope of our talk • What and which drugs? • Why now? • Who abuses prescription drugs? • What can we do? What is prescription drug abuse and addiction? What is “abuse behavior?” NIDA, 2002 & DEA 1970 • Any non-prescribed use of a drug. SAMHSA 2002 • Non-medical use of a substance for psychic effect, dependence, or suicide attempt or gesture. IOM 1996 • Any harmful use, irrespective of whether the behavior constitutes a “disorder” in the DSM-IV diagnostic nomenclature. APA 1994 • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one or more behaviorally-based criteria. (Ling, 2005)
Transcript
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Opioid and Alcohol AddictionEve Segal, PharmD
PGY2 Oncology Pharmacy Practice Resident
St. Luke’s Mountain States Tumor Institute
Objectives
• To define addiction
• To identify the signs and symptoms of alcoholism• To understand how to manage patients experiencing alcohol
withdrawal in an acute care setting• To list the long-term complications of chronic alcohol
addiction and misuse
•• To identify the signs and symptoms of opioid addiction• To understand how to manage patients experiencing opioid
withdrawal in an acute care setting• To list the long-term complications of chronic opioid
addiction and misuse
Scope of our talk
• What and which drugs?
• Why now?
• Who abuses prescription drugs?
• What can we do?
What is prescription drug abuse and addiction? What is
“abuse behavior?”
NIDA, 2002 & DEA 1970
• Any non-prescribed use of a drug.
SAMHSA 2002
• Non-medical use of a substance for psychic effect, dependence, or suicide attempt or gesture.
IOM 1996
• Any harmful use, irrespective of whether the behavior constitutes a “disorder” in the DSM-IV diagnostic nomenclature.
APA 1994
• A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one or more behaviorally-based criteria.
(Ling, 2005)
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DSM 4 Criteria for Drug Abuse
• Significant impairment or distress resulting from use
• Failure to fulfill roles at work, home, or school
• Persistent use in physically hazardous situations
• Recurrent legal problems related to use
• Continued use despite interpersonal problems
DSM 4 Criteria for Drug Dependence
• ≥3 of the following occurring in the same 12-month period▫ Desire or unsuccessful efforts to cut down on use▫ Large amount of time spent obtaining drugs, using
drugs or recovering from drug effects▫ Social, occupational, or recreational activities reduced
because of drug use▫ Drug use continued despite knowledge that a physical
or psychological problem is being caused or exacerbated by use
▫ Use of drug in larger amounts or for longer periods of time than originally anticipated
Tolerance
• Need for an increasing amount of drug to achieve desired effect OR
• Diminished effect with continued use of the same amount of drug
Withdrawal
• Withdrawal manifests with cessation of use, reduction of use, or use of an antagonist.
• Drugs or related substances relieve or avoid withdrawal symptoms.
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How does someone become addicted?
Addiction pathways continued
Drugs of Abuse: Not Just Opioids
• Opioids and other pain killers
• Stimulants
• Anti-anxiety medications
• Sedatives/hypnotics
• Antidepressants
• Steroids
• Psychedelics
Epidemiology• Prescription drug abuse is
increasing at an alarming rate.
• 2010: 7.0 million persons in the US were considered users of prescription drugs.
▫ Pain relievers – 5.1 million
▫ Tranquilizers – 2.2 million
▫ Stimulants – 1.1 million
▫ Sedatives – 0.4 million
• 1 in 12 high school seniors report nonmedical use of Vicodin™
• 1 in 20 high school sensiors report abuse of OxyContin™
Drugabuse.gov
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Epidemiology Epidemiology
Commonly Abused Opioids
Hydromorphone Dilaudid
Meperidine Demerol
Hydrocodone Loratab, Vicodin, Norco
Oxycodone OxyContin,Percodan, Percocet, Tylox
Diacetylmorphine Heroin
Oxycodone and Oxycodone CR
• Oxycodone: OxyIR, Roxycodone
▫ Acute pain
▫ Duration of action: 4-6 hours
▫ Available as tablets, capsules, and liquid
• Oxycodone CR: OxyContin
▫ Chronic pain, opioid tolerant patients
▫ Duration of action: 12 hours
▫ Not for “as needed” use
▫ Available in tablets only
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Rates of emergency department (ED) visits for nonmedical use of opioid
• Major withdrawal symptoms peak 48-72 hours after the last dose
• Duration and intensity dependent on quantity and type of opiate used▫ Heroin withdrawal
subsides after a week ▫ Methadone withdrawal
can last weeks
Symptoms of withdrawal
Opiate Overdose Treatment
• Respiratory depression, CNS depression, myosis, signs of drug abuse history
• R/O hypoglycemia, acidemia, fluid and electrolyte abnormalities
• Provide airway, ventilation, and cardiac function support
• Naloxone HCl 0.4-0.8 mg initially, repeat as needed
Treatment of Opiate Dependence
• Multi-modal comprehensive treatment gives best chance of lasting remission.
▫ Opiate replacement or pharmacologic support of withdrawal symptoms
▫ Cognitive behavior treatment: counseling, 12-step work
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Group Question
Which of the following is NOT a symptom of opiate withdrawal?
A. Sweating
B. Anxiety
C. Tachycardia
D. Urge to sleep
E. None of the above
Effects of Common Opiates at Mu
Receptor
Heroin, morphine, methadone
Full agonist
Buprenorphine,tramadol
Partial agonist
Naltrexone, Nalmefene, Naloxone
Antagonist
Agonist “opens door”
Morphine likeeffect
Partial agonist “opens door with safety chain”
Weak morphine-like effects with strong receptor affinity
Antagonists “dummy key”
No effect in absence of an opiate or opiatedependence
Alcohol Abuse Current perspectives about alcohol
abuse
• “Alcohol is the number one drug of choice among our nation’s youth. Yet the seriousness of this issue does not register with the general public or policymakers.”
Enoch Gordis, MD Director, National Institute on Alcohol Abuse and Alcoholism
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Epidemiology
• 7.4% of adult population in the US are alcoholic
• 185 billion dollars
▫ Cost of alcohol abuse in the US
• 100,000 annual deaths related to alcohol
• 1.2 billion dollars spent on wine, beer, and liquor advertisements in the US
Fetal Alcohol Syndrome (FAS)
• Most common preventable cause of adverse CNS development
• 4,000 – 12,000 infants in the US per year• Characteristics:
▫ Growth retardation▫ Facial malformations▫ Small head▫ Greatly reduced intelligence
• Milder form of FAS ▫ 7,000 – 36,000 infants per year in the US ▫ Characteristics:
� Growth deficiency� Learning dysfunction� Nervous systems disabilities
Effects of Prenatal Alcohol Acute Effects of Alcohol
• CNS depressant
• Depression of inhibitory control
• Vasodilation, warm, flushed, reddish skin
• Emotional outbursts
• Decreased memory and concentration
• Poor judgment
• Decreases reflexes
• Decreased sexual response
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Long term adverse effects of alcohol
• Alcoholism, death, cancer (oral cavity, esophagus, liver), fetal effects
• Alcoholism
▫ Cirrhosis of the liver, appetite loss, poor judgment
• Indirect effects
▫ Lost of productivity, impaired performance, motor impairment, cost to society
Minor withdrawal symptoms
• Insomnia
• Tremulousness
• Mild anxiety
• Gastrointestinal upset
• Headache
• Diaphoresis
• Palpitations
• Anorexia
Minor Withdrawal Symptoms Timeline
• Present within 6 hours of last drink
▫ Even if BAL is still elevated
• Resolves in 24-48 hours
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Withdrawal Seizures
• Generalized tonic-clonicconvulsions
• Occur within 48 hours of last drink▫ May occur as soon as 2
hours from last drink
• 3% of chronic alcoholics have withdrawal-associated seizures ▫ 3% of this group may
develop status epilepticus
Alcoholic Hallucinosis
• Not synonymous with delirium tremens
• Develop within 12-24 hours of abstinence
• Resolves within 24-48 hours
• Usually visual, may be tactile or auditory
Delirium Tremens
• Occurs in 5% of alcoholics
• Signs and symptoms:▫ Hallucinations,
disorientation, tachycardia, hypertension, low grade fever. Agitation, and diaphoresis
• Develops 48-96 hours after last drink, lasts 1-5 days
• Total score is sum of each item score (max score is 67)
▫ <10: very mild withdrawal
▫ 10-15: mild withdrawal
▫ 16-20: modest withdrawal
▫ >20: severe withdrawal
Group Question
What is the preferred benzodiazepine for alcohol withdrawal?
A. Lorazepam
B. Diazepam
C. Temazepam
D. All of the above
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Refractory DT
• Possibly due to low GABA levels or conformational changes to GABA
▫ Not clearly defined may be present if > 50 mg of diazepam or 10 mg of lorazepam is required to control symptoms in 1st hour of treatment
• Barbiturates may be an effective alternative
Group Question
Per the CIWA protocol, scheduled dosing is the preferred method of benzodiazepine administration:
a. True
b. False
Prophylaxis
• For those with a hx of seizures, DT, or prolonged heavy alcohol consumption
▫ In minimally symptomatic and asymptomatic
▫ Chlordiazepoxide 50 to 100 mg every 6 hours for day one , 25 to 50 mg every six hours for an additional 2 days
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