Download Combating substance abuse: A review of therapeutic management

COMBATING SUBSTANCE ABUSE:
A review of therapeutic management
Presented by: Adenike Atanda, Pharm.D.
OBJECTIVES
• Utilize the Virginia prescription monitoring program (PMP)
to recognize prescription medication misuse
• Explain the physiological effects of commonly abused
substances
• Differentiate between CNS depressing and CNS
stimulating substances
• Identify signs and symptoms of overdose and withdrawal
syndromes of commonly abused substances and
symptoms of neonatal abstinence syndrome
• Given a patient case, select an appropriate treatment
plan for the management of a substance abuse disorder
and neonatal abstinence syndrome
Epidemiology of substance abuse
• The use of illicit drugs has increased from 8.3% in
2002 to 9.4% in 2013 (24.6 million people)
• In 2009, there were approximately 4.6 million
emergency department visits related to drug
abuse. 21.2% of those visits involving illicit drugs use
and 14.3% involving alcohol abuse with other
medications
Substance Abuse and Mental Health Services Administration. Substance Use and Mental Health Estimates from the 2013 National Survey on Drug
Use and Health-Overview of Findings. The NSDUH Report. Sept 2014.
National Institute on Drug Abuse. Drug-Related Hospital Emergency Room Visits. Drug Facts. May 2011.
Epidemiology of substance abuse
in Virginia
• A survey conducted by the CDC in Virginia in 2013 showed
that, for at least one day in the 30 day survey period;
 11% of high school students had smoked a cigarette
 27% of high school students had at least one drink of
alcohol
 32% of high school students had used marijuana
 6% of high school students had used some form cocaine
• Increase in the number of methamphetamine lab seizures in
Virginia by 958% from 2008 to 2011 (19 vs 201 incidents)
U.S. Department of Health and Human Services: Office of Adolescent Health. Virginia Adolescent Substance Abuse Facts. Nov 2014.
The Office of National Drug Control Policy-The White House. Virginia Drug Control Update. Jan 2013.
Epidemiology of substance abuse
in Virginia
2012 Annual Report of the Office of the Chief Medical Examiner
Substance abuse in Virginia
The state has implemented the following strategies to
help combat the problem of substance abuse:
 A prescription monitoring program started in 2003
 Drug take back programs
 The Virginia Board of Pharmacy now requires all
pharmacists to obtain at least 1 hour of continuing
education (CE) on opioid use or abuse, in the year
2015
The Office of National Drug Control Policy-The White House. Virginia Drug Control Update. Jan 2013.
VIRGINIA PRESCRIPTION MONITORING
PROGRAM
Website
http://www.pmp.dhp.virginia.gov/pmpwebcenter
Virginia prescription monitoring program
• Controlled substances in schedule II to IV
• Data transmitted to the department within 7 days of
dispensing
• All data is confidential and may only be released:
 To the patient (over the age of 18) if requested
 To a prescriber or dispenser who has a direct patient care
relationship
 If the information is relevant to an investigation by a health
regulatory board, investigational grand jury or federal law
enforcement agency authorized to conduct drug diversion
investigation
Department of Health Professions- Virginia Board of Pharmacy. The pharmacy act and the
drug control act with related statues. 2013
Virginia prescription monitoring program
Required data:
• Patient’s name, address and date of birth
• Medication name, quantity dispensed, total number of refills and
date of the prescription
• Prescriber and dispenser’s DEA number
• Method of payment
Reporting exemptions:
• Samples
• Administering covered substances
• Dispensing of covered substances in a licensed narcotic
maintenance treatment program
• Dispensing of covered substances in a hospital, nursing facility or
hospice
• Dispensing by a veterinarian to animals
Department of Health Professions- Virginia Board of Pharmacy. The pharmacy act and the drug
control act with related statues. 2013
POP QUIZ
Which of the following is not a strategy implemented in the state of
Virginia to combat substance abuse?
a) Prescription monitoring program
b) Drug take back programs
c) Tracking device on prescription bottles
d) Opioid abuse CE requirement for pharmacists
Which of the following is true regarding the Virginia prescription
monitoring program?
a) All dispensed CII to CV drugs should be reported
b) Required data include patient’s name, address and
method of payment
c) Data from the program can be released to a patient’s
employer
d) CII drugs dispensed in a licensed narcotic treatment
program must be reported
MANAGEMENT OF SUBSTANCE ABUSE
DISORDERS
• Pathophysiology
• Special considerations
• Clinical presentation
• Assessment tools
• Management
Commonly abused substances
• Alcohol
• Cocaine
• Heroin
• Marijuana
• Methamphetamines
• Nicotine
Substance abuse disorder
DSM-V criteria
Presence of at least 2 of the following within a 12 month period:
Substance often taken in larger amounts
or over a longer period than intended
Persistent desire or unsuccessful efforts to
control use of the substance
Significant time spent in activities to
obtain, use or recover from the substance
Craving or strong desire or urge to use the
substance
Recurrent use resulting in failure to fulfill
major obligations
Continued use despite social and
interpersonal problems
Continued use despite knowledge of
problem that can be worsened by the
substance
Tolerance: Need for increased amounts
to achieve effect or diminished effect
with use of the same amount
Important activities reduced or
abandoned because of use
Withdrawal: Symptoms of withdrawal or
the substance is taken to avoid symptoms
Recurrent use in hazardous situations
Diagnostic and statistical manual of mental disorders, 5th ed., text revision. Washington, DC:
American Psychiatric Association, 2013.
Classification of abused substances
CNS depressants
• Alcohol
• Heroin and prescription opioids
CNS stimulants
• Methamphetamines
• Cocaine
CNS DEPRESSANTS
ALCOHOL USE DISORDER
• Contributes to 79,000 deaths
annually in the US
• $223.5 billion in societal cost
annually in the US
• 9% of Americans meet
criteria for alcohol use disorder
Nicknames: Booze, moonshine, liquid courage etc.
Friedmann PD. Alcohol Use in Adults. N Engl J Med 2013;368:365-73.
Pathophysiology
Glutamate - Excitatory
• Inhibited at low doses
• Increased effect with
chronic intake
GABA - Inhibitory
• Stimulated with acute
intoxication
• Decreased effect with
chronic intake
Dopamine - Reward
• Release stimulated
Mu (Opiate) - Reward
• Increased release of
endogenous opioids
Anton RF. Naltrexone for the management of Alcohol Dependence. N Engl J Med 2008;359:715-21.
Clinical presentation
Acute intoxication
Withdrawal
• Slurred speech
• Cognitive impairment
• Unsteady gait and
incoordination
• Stupor or coma
• Metabolic acidosis
•
•
•
•
•
Long term effects
• Steatosis (fatty liver)
• Alcoholic hepatitis and cirrhosis
• Pancreatitis
• Cardiomyopathy
Nausea and vomiting
Anxiety and insomnia
Sweating
Hand tremors
Delirium tremens
 Autonomic hyperactivity
 Altered mentation;
hallucinations, disorientation,
decreased attention or
fluctuating cognition
 Psychomotor agitation
 Generalized tonic-clonic
seizures and severe tremors
Schuckit MA. Recognition and Management of Withdrawal Delirium. N Engl J Med 2014;371:2109-13.
Diagnostic and statistical manual of mental disorders, 5th ed., text revision. Washington, DC: American Psychiatric
Association, 2013.
Clinical presentation
Labs
Abnormal markers of hepatic function, nutrition and elevated
blood alcohol levels
↑ AST
↑ ALT
↑ Alk Phos
↑ INR
↑ PT
↑ MCV
↑ GGT
↑ CDT
↓ Albumin
↓ Mg
↓K
↓ Glu
Thompson W, Lande GR, kalapatapu RK. Alcoholism workup. Medscape. 2014
Assessment tools
CAGE Questionnaire
1. Have you ever felt you should cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady
your nerves or to get rid of a hangover (eye-opener)?
Clinical Institute Withdrawal Assessment of Alcohol Scale,
Revised(CIWA-Ar)
• 0 - 7= Mild
• 8 – 15 = Moderate
• >15 = Severe
Schuckit MA. Recognition and Management of Withdrawal Delirium. N Engl J Med 2014;371:2109-13.
Supportive care
Fluids
Adrenergic agonist and antagonist
• Thiamine, folic acid and multivitamins • Used to reduce autonomic
can be added to fluids, commonly
hypersensitivity (BP, HR and tremors)
know as “banana bag”
• Propranolol or clonidine
• Thiamine is needed to prevent
Wernicke encephalopathy
Anticonvulsants
• Control seizures
Electrolyte supplementation
• Carbamazepine or divalproex
• Replete K, Mg, PO4 as necessary
Benzodiazepines
• Control agitation and seizures
• Chlordiazepoxide, lorazepam or
diazepam given IV or PO
• Lorazepam is short acting and
preferred in hepatic dysfunction/
elderly patients
Antipsychotics
• Control delirium and hallucinations
• Haloperidol preferred
• Can be used as adjunct therapy to
BZD
Manasca A, Chang S, Larriviere J et.al. Alcohol Withdrawal. Southern Medical Journal. 2012; 105(11): 607-612
American Psychiatric Association. Treatment of Patients with substance use disorders. 2006
Maintenance therapy
Disulfiram (Antabuse)
• Interferes with aldehyde dehydrogenase
and causes an increase in acetaldehyde
levels with alcohol consumption leading
to flushing, nausea, palpitations, vertigo
and hypotension.
• Initial dose of 500 mg once daily for 1-2 weeks then 250 mg once
daily (MAX: 500 mg daily)
• Efficacy: Mixed results, but a RCT showed that disulfiram has a higher
rate of abstinence when compared to naltrexone (79.3% vs. 51.7%) in
adolescent patients. More beneficial in combination with CBT.
• Adverse effects: Metallic aftertaste, rash and hepatotoxicity
Kalra G, Sousa A and Shrivastava A. Disulfiram in the management of alcohol dependence: A comprehensive
clinical review. Open Journal of Psychiatry, 2014, 4, 43-52
Maintenance therapy
Acamprosate (Campral)
• Increase the activity of GABA and decrease glutamate
• Reduces alcohol intake and craving
• Dose: 666 mg PO three times daily
• Efficacy: A metaanalysis of 24 trials showed that acamprosate
reduced the risk of returning to any drinking by 86% and increased
the cumulative duration of abstinence by 11% when compared to
placebo.
• Adverse effects: Metallic aftertaste, diarrhea, insomnia rash and
hepatotoxicity
Witkiewitz K, Saville K and Hamreus K. Acamprosate for treatment of alcohol dependence:
mechanisms, efficacy and clinical utility. Ther Clin Risk Manag. 2012; 8: 45–53.
Maintenance therapy
Naltrexone
• Oral (Revia) or extended release IM injection (Vivitrol)
• Opiate receptor (mu) antagonist
• Prevents the euphoria and reward sensation associated with alcohol
consumption (reduction in dopamine levels)
• Dose: 50 mg PO daily or 380 mg IM once every 4 weeks
• Efficacy: COMBINE study showed that naltrexone 100 mg PO daily for 16
weeks was more effective than placebo at increasing the percentage of
abstinence days (80.6% vs. 75.1%) and reducing the risk of heavy drinking
days (66.2% vs. 73.1%)
• Adverse effects: Opioid withdrawal, nausea, vomiting, dysphoria, fatigue,
ALT elevation and hepatotoxicity (especially at higher doses)
Anton RF. Naltrexone for the management of Alcohol Dependence. N Engl J Med 2008;359:715-21.
Summary of management
Supportive care
Acute intoxication
Withdrawal
Hydration
Hydration
Decrease external stimulation
Benzodiazepines
Adrenergic agonist and antagonist
Anticonvulsants
Antipsychotics (Haloperidol)
Ethanol
Maintenance therapy
• Naltrexone
• Disulfiram
• Acamprosate
HEROIN AND PRESCRIPTION OPIOID
• Increased prevalence of heroin addiction
admissions in patients aged 20 - 34 years
from 2001 to 2011 (23% vs 45% )
• 4 out of 5 heroin users state that they
started with prescription opioid misuse
• 16,651 people died in the US due
to prescription opioid use in 2010
Nicknames
Heroin: Big H, china white, skag, black tar, smack, dope etc.
Opioids: Oxy, blue, kickers, monkey, miss Emma, dollies, wafers, subs etc.
Dart RD, Surratt HL, Cicero TJ et.al. Trends in Opioid Analgesic Abuse and Mortality in the United States. N Engl J Med 2015;372:241-8.
Pathophysiology
Mu receptor
• Heroin is converted into morphine
in vivo
• Opioids bind to mu receptors and
cause the release of dopamine
• Results in an initial “high” that is
followed by CNS and respiratory
depression
Dopamine - Reward
• Release stimulated
Goldstein, A. Heroin addiction: neurobiology, pharmacology, and policy. J Psychoactive
Drugs 23(2):123–133, 1991.
Clinical presentation
Acute intoxication
•
•
•
•
•
•
CNS depression
Reduced respiratory rate (<12 bpm)
Constricted “pin point” pupils
Constipation
Hypothermia
Coma
Withdrawal
•
•
•
•
•
•
Restlessness and anxiety
Nausea, vomiting and diarrhea
Muscle and bone pain
Cold sweats
Tachycardia
Dilated pupils
Long term effects
• Infections
• Blood borne diseases
• Respiratory infections
National Institute on Drug Abuse. Heroin. National Institute on Drug Abuse. Bethesda, MD: November 2014
Assessment tools
Clinical Opiate Withdrawal Scale (COWS)
• 5-12 = Mild
• 13-24 = Moderate
• 25-36 = Moderately severe
• > 36 = Severe withdrawal
Wesson DR and Ling W. The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive drugs. 2003; 35(2):
253-259
Supportive care
Naloxone
• Short acting opioid antagonist
• Doses are started at 0.04 mg IV,
IM or SQ and titrated up. Usual
doses range from 0.4mg to 2mg
repeated q2 to 3 mins
• Reversal can cause withdrawal
Clonidine
• Alpha 2 agonist
• 0.1 to 0.3 mg every hour until
symptom resolution
• Reduces noradrenergic
hyperactivity
Boyer EW. Management of Opioid Analgesic overdose. N Engl J Med 2012;367:146-55.
Methadone
• Long acting opioid agonist
• Onset 30 mins to 1 hour
• Dose
Induction: 20 to 30 mg PO daily
Maintenance: Titrate up by 5 to10 mg
as needed until patient’s symptoms
are controlled (range 80 to 120
mg/day)
Withdrawal: Titrate down by 10 to 20%
every 10 to 14 days
• Adverse effects: Similar to
buprenorphine and includes
cardiovascular effects (QT
prolongation and arrhythmias)
Johnson RE, Chutuape MA, Strain EC. A comparison of levomethadyl acetate, buprenorphine
and methadone for opioid dependence. N Engl J Med 2000;343:1290-7
Buprenorphine
• Partial opioid agonist
• Available as monotherapy
(subutex) or in combination with
naloxone (suboxone)
• Dose
Induction: (depends on type of
opioid and time since last dose)
Day 1: 8 mg SL
Day 2: 16 mg SL
≥ Day 3: 16 mg SL and titrate to
response
• Naloxone provides deterrent for
abuse
Maintenance: 12 - 16 mg/day;
suboxone preferred
• Onset within 15 minutes
• Adverse effects: Sedation,
dizziness, hypotension, nausea and
respiratory depression
Naltrexone
• Opioid antagonist
• Blocks pleasurable effects of
opioids
• Dose
Induction:
25 mg PO initially and then 50 mg
daily
• Must be opioid free for a minimum Maintenance:
of a week before treatment initiation Oral
• 50 mg daily
• Pretreatment with clonidine can
• 50 mg on weekdays and 100mg
be used to alleviate withdrawal
on Saturday
symptoms
• 100 mg every other day
• 150 mg every 3 days
• Adverse effects: Abdominal pain,
diarrhea, nausea, vomiting, anxiety
IM
• 380 mg once a month
American Psychiatric Association. Treatment of Patients with substance use disorders. 2006
Comparison of treatment
Volkow ND, Frieden TR, Hyde PS et al. Medication-Assisted Therapies — Tackling the Opioid-Overdose Epidemic N
Engl J Med 2014; 370:2063-2066
Summary of management
Supportive therapy
Acute overdose
Withdrawal
Ventilation
Buprenorphine
Naloxone
Methadone
Clonidine
Maintenance therapy
• Buprenorphine
• Methadone
• Naltrexone
PATIENT CASE
CC “My husband is confused shaky,
agitated and sweating a lot”
CJ is a 48 year old man who presents
to the ED with tremors, vomiting and
altered mental status. His wife states
that his symptoms started this
morning and she thinks it’s because
he tried to quit drinking “cold turkey”.
He had been drinking about 9 bottles
of beer per day since he lost his job
last year and has not had a drink
since yesterday morning. She also
reports that he had a seizure on the
way to the hospital .
Pertinent labs
Na
137 mEq/L
AST
300 IU/L
K
3.0 mEq/L
ALT
275 IU/L
Cl
90 mEq/l
BUN
15 mg/dL GGT
T. Billi 1.8 mg/dL
200 U/L
SCr
1.1 mg/dL Alb
2.4 g/dL
Glu
80 mg/dL INR
1.20
Mg 1.5 mg/dL PT
Vitals
Phos 3.0 mg/dL ETOH
17 sec
negative
BP: 170/90 mmHg
P: 106 bpm RR: 25 bpm
T: 38.4 0C Wt: 55 kg
Ht: 5’9 ft
CIWA score: 11
PATIENT CASE
What is CJ’s diagnosis?
What information supports your diagnosis?
PATIENT CASE
All of the following are laboratory abnormalities in this patient except?
a) Elevated AST/ALT
b) Elevated K
c) Reduced Albumin
d) Reduced Mg
All of the following would be appropriate for the management of the
patient except?
a) IV lorazepam - control agitation
b) Supplement K and Mg
c) ½ NS, D5W infusion with thiamine 100 mg and folic acid 1 mg
d) Insulin glargine 10 units qhs
CNS STIMULANTS
METHAMPHETAMINES
• Can be smoked, snorted, injected or
orally ingested
• Accounted for 103,000 ED visits in 2011
(4th common illicit drug in ED cases)
• In 2012, over 12 million people reported
that they had used methamphetamine
and the average age of new users was
19.7 years old
Nicknames: Meth, crank, ice, tweak, glass, speed etc.
National Institute on Drug Abuse. Methamphetamine. 2013
Manufacturing
• Manufactured from common
household ingredients:
Pseudoephedrine, acetone,
fertilizer etc.
Methamphetamine act in 2005:
• Limits the sale of ephedrine
products to a max of 3.6 g/day
and 9 g/30 days
• Pharmacies are required to keep
a log of every pseudoephedrine
product sold
Pathophysiology
• Increased release in catecholamines
(dopamine, norepinephrine and
serotonin)
• Increased production of tyrosine
hydroxylase, enzyme responsible for
dopamine synthesis
• Redistribution of catecholamines to
the cytosol
• Blocked activity of monoamine
transporters
• Inhibition of monoamine oxidase
activity
Barr AM, Panenka WJ, MacEwan GW et al. The need for speed: an update on
methamphetamine addiction. J Psychiatry Neurosci. 2006 Sep;31(5):301-13.
Clinical presentation
Acute intoxication
•
•
•
•
•
•
•
•
•
•
•
Increased wakefulness
Decrease appetite
Dry mouth
Dilated pupils
Tachycardia
Hypertension
Hyperventilation
Hyperthermia
Convulsion
Aggressive behavior
Hallucinations and delusions
(insects creeping under skin)
Withdrawal
• Intense cravings
• Depression
• Fatigue
Long term effects
• Anorexia
• Changes in brain structure and
function
• Memory loss
• Severe dental problems
National Institute on Drug Abuse. Methamphetamine. 2013
Acute intoxication management
Agitation
Benzodiazepines
• IV lorazepam or diazepam
• Can be used for seizure control
Hyperthermia and
Hyperventilation
Neuromuscular blockade
agents
• Temporary paralysis to control
Antipsychotics:
hyperthermia
• IV or IM haloperidol
• Used as adjunct therapy to BZD •Avoid succinylcholine due to
increased risk of rhabdomyolysis
• Ensure patient has adequate
Hypertension
ventilation support and analgesia
Nitroprusside
• Caution with beta blocker
therapy due to unopposed
alpha vasoconstriction
Cooling blankets
American Psychiatric Association. Treatment of Patients with substance use disorders. 2006
Buxton JA and Dove NA. The burden and management of crystal meth use. CMAJ 2008;
178(12): 1537 - 1539
COCAINE
• Can be inhaled, smoked
or injected
• In 2012, 1.6 million Americans
used some form of cocaine
• Accounted for 4.6 million
ED visits in 2009
• Nicknames: Crack, coke, blow, snow, snow white, rock,
blanca etc.
National Institute on Drug Abuse. DrugFacts: Cocaine. 2013
Manufacturing
• Made from coca plant
Two forms:
• Water soluble HCl salt (powder)
• Water insoluble base (solid)
• Cocaine powder is mixed with
ammonia or baking soda and
water and heated to remove
the HCL to produce the crystal
rock “crack”
National Institute on Drug Abuse. DrugFacts: Cocaine. 2013
Pathophysiology
• Increased catecholamines
(norepinephrine, serotonin
and dopamine) and
glutamate activity
• Blockade of monoamine
oxidase
• Norepinephrine stimulates
alpha receptors
• Sodium channel blockade
O’Connor PG. Drug Use and Dependence: Cocaine. Merck Manual. 2013
Clinical presentation
Acute intoxication
•
•
•
•
•
•
•
•
•
•
•
•
Increased wakefulness
Decrease appetite
Abdominal pain
Dilated pupils
Constricted blood vessels
Chest pain
Tachycardia
Hypertension
Hyperthermia
Aggressive behavior
Myocardial infarction
Strokes
National Institute on Drug Abuse. Cocaine. 2013
Withdrawal
• Intense cravings
• Depression
• Fatigue
Long term effects
•
•
•
•
Bowel gangrene
Paranoia
Anorexia
Infections and blood borne
diseases like HIV
Management
Acute intoxication
Maintenance
• Same as amphetamine therapy
Disulfiram
• 250 mg daily
• Mixed efficacy data
• Nitroglycerin for cocaine
induced chest pain
Modafinil
• 200 – 400 mg daily
• Abuse potential
Tiagabine
• 12 – 24 mg daily
Topiramate
• 200 – 300 mg daily
American Psychiatric Association. Treatment of Patients with substance use disorders. 2006
Summary of management
Supportive therapy
Acute overdose
Benzodiazepines
Antipsychotics
Nitroprusside
Neuromuscular blockade agents
Cooling blankets
Cocaine maintenance therapy
• Disulfiram
• Modafinil
• Tiagabine
• Topiramate
POP QUIZ
Appropriate therapy for the management of methamphetamine
overdose includes?
a)
b)
c)
d)
Benzodiazepines
Naloxone
Acamprosate
Warming blanket
The sale of ephedrine products has been limited to?
a)
b)
c)
d)
5.6 grams per day
7 grams per 30 days
There is no limit on the sale of ephedrine products
9 grams per 30 days
SUBSTANCE ABUSE AND PREGNANCY
Survey conducted by the National Survey
on Drug Use and Health in 2008 – 2009:
• 15.8% of pregnant women aged 15 to 17
years old reported illicit drug use
• 7% of pregnant women aged 18 to 25
years old reported illicit drug use.
National institute on drug abuse. Prenatal exposure to drugs of abuse- May 2011.
Neonatal abstinence syndrome
• Withdrawal syndrome in babies
exposed to opioids in utero
• Severity evaluated by the modified
Finnegan Scale
Symptoms
• CNS hyperirritability
• GI dysfunction
• Respiratory distress
• Metabolic disturbances
• Vasomotor disturbances
Complications
• Diarrhea
• Feeding difficulties and weight loss
• Seizures
• Death
Jones HE, Kaltenbach K, Heil SH et.al . Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure.
N Engl J Med 2010;363:2320-31.
Medline Plus. Neonatal abstinence syndrome
Management
Non-opioid therapy*
Opioid therapy
Clonidine
• 0.5 to 1 mcg/kg PO q4 - 6 hrs
• Wean by 0.25 mcg/kg q6hrs
Morphine
• 0.03 mg/kg PO q3 -4hrs, MAX dose
of 0.2 mg/kg/dose
• Wean by 10 – 20% every 48 to 72 hrs
Phenobarbital
• 5 mg/kg/day PO or IV divided
every 12 hours
• Wean by 20% every 48 hours
• DOC for non narcotic related
withdrawal or polydrug abuse
* Adjunct to opioid therapy
Methadone
• 0.05 – 0.2 mg/kg PO or IV q12hrs
• Wean by 10 – 20% every 5-7 days
Buprenorphine
• 5.3 mcg/kg SL q8hrs
• Wean by 10% per day
Siu A and Robinson CA. Neonatal Abstinence Syndrome: Essentials for the Practitioner. J Pediatr Pharmacol Ther. 2014
Jul-Sep; 19(3): 147–155.
POP QUIZ
Which of the following is a CNS
stimulating substance?
a) Alcohol
b) Cocaine
c) Heroin
d) Morphine
Which of the following medications
cannot be used to effectively
manage neonatal abstinence
syndrome?
a) Buprenorphine
b) Clonidine
c) Morphine
d) Naltrexone
ROLE OF THE PHARMACIST
• Identifying patients with problems related to substance
abuse and prescription medication misuse
• Providing pharmaceutical care to these patients
• Participating in multidisciplinary efforts to manage
patients recovering from substance abuse
• Utilizing the prescription monitoring programs to help
deter prescription medication abuse
American Society of Health-System Pharmacists. ASHP Statement on the Pharmacist’s Role in
Substance Abuse Prevention, Education, and Assistance. Medication Therapy and Patient Care:
Specific Practice Areas-Statements. 2013: 305-308
RESOURCES
• National Institute on Drug Abuse
www.drugabuse.gov
• National Institute on Alcohol Abuse and Alcoholism
www.Niaaa.nih.gov
• Substance Abuse and Mental Health Services
Administration
www.samhsa.gov
Questions
[email protected]
REFERENCES
•
Substance Abuse and Mental Health Services Administration. Substance Use and Mental Health Estimates from the
2013 National Survey on Drug Use and Health-Overview of Findings. The NSDUH Report. Sept 2014.
•
National Institute on Drug Abuse. Drug-Related Hospital Emergency Room Visits. Drug Facts. May 2011.
•
U.S. Department of Health and Human Services: Office of Adolescent Health. Virginia Adolescent Substance
Abuse Facts. Nov 2014.
•
The Office of National Drug Control Policy-The White House. Virginia Drug Control Update. Jan 2013.
•
Department of Health Professions- Virginia Board of Pharmacy. The pharmacy act and the drug control act with
related statues. 2013
•
Diagnostic and statistical manual of mental disorders, 5th ed., text revision. Washington, DC: American Psychiatric
Association, 2013.
•
Friedmann PD. Alcohol Use in Adults. N Engl J Med 2013;368:365-73.
•
Anton RF. Naltrexone for the management of Alcohol Dependence. N Engl J Med 2008;359:715-21.
•
Schuckit MA. Recognition and Management of Withdrawal Delirium. N Engl J Med 2014;371:2109-13.
•
Thompson W, Lande GR, kalapatapu RK. Alcoholism workup. Medscape. 2014
REFERENCES
•
Manasca A, Chang S, Larriviere J et.al. Alcohol Withdrawal. Southern Medical Journal. 2012; 105(11): 607-612
•
American Psychiatric Association. Treatment of Patients with substance use disorders. 2006
•
Kalra G, Sousa A and Shrivastava A. Disulfiram in the management of alcohol dependence: A comprehensive
clinical review. Open Journal of Psychiatry, 2014, 4, 43-52
•
Witkiewitz K, Saville K and Hamreus K. Acamprosate for treatment of alcohol dependence: mechanisms, efficacy
and clinical utility. Ther Clin Risk Manag. 2012; 8: 45–53.
•
Anton RF. Naltrexone for the management of Alcohol Dependence. N Engl J Med 2008;359:715-21.
•
Dart RD, Surratt HL, Cicero TJ et.al. Trends in Opioid Analgesic Abuse and Mortality in the United States. N Engl J
Med 2015;372:241-8.
•
Goldstein, A. Heroin addiction: neurobiology, pharmacology, and policy. J Psychoactive Drugs 23(2):123–133,
1991.
•
National Institute on Drug Abuse. Heroin. National Institute on Drug Abuse. Bethesda, MD: November 2014
•
Wesson DR and Ling W. The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive drugs. 2003; 35(2):
253-259
•
Boyer EW. Management of Opioid Analgesic overdose. N Engl J Med 2012;367:146-55.
•
Johnson RE, Chutuape MA, Strain EC. A comparison of levomethadyl acetate, buprenorphine and methadone for
opioid dependence. N Engl J Med 2000;343:1290-7
REFERENCES
•
Volkow ND, Frieden TR, Hyde PS et al. Medication-Assisted Therapies — Tackling the Opioid-Overdose Epidemic N
Engl J Med 2014; 370:2063-2066
•
National Institute on Drug Abuse. Methamphetamine. 2013
•
Barr AM, Panenka WJ, MacEwan GW et al. The need for speed: an update on methamphetamine addiction. J
Psychiatry Neurosci. 2006 Sep;31(5):301-13.
•
Buxton JA and Dove NA. The burden and management of crystal meth use. CMAJ 2008; 178(12): 1537 - 1539
•
National Institute on Drug Abuse. DrugFacts: Cocaine. 2013
•
O’Connor PG. Drug Use and Dependence: Cocaine. Merck Manual. 2013
•
National institute on drug abuse. Prenatal exposure to drugs of abuse- May 2011.
•
Jones HE, Kaltenbach K, Heil SH et.al . Neonatal Abstinence Syndrome after Methadone or Buprenorphine
Exposure. N Engl J Med 2010;363:2320-31.
•
Medline Plus. Neonatal abstinence syndrome
•
Siu A and Robinson CA. Neonatal Abstinence Syndrome: Essentials for the Practitioner. J Pediatr Pharmacol Ther.
2014 Jul-Sep; 19(3): 147–155.
•
American Society of Health-System Pharmacists. ASHP Statement on the Pharmacist’s Role in Substance Abuse
Prevention, Education, and Assistance. Medication Therapy and Patient Care: Specific Practice Areas-Statements.
2013: 305-308