MPharm4 SL52117 > SUHRT > Flashcards

SUHRT Flashcards

(51 cards)

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1
Q

4 risks of alcohol dependence

A

Cognitive impairment
Poor nutrition
HArmful to stomach, liver, blood
Increased levels of violence

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2
Q

What is used for pharmacological EtOH detox?

A

Chlordiazepoxide, or oxazepam if liver concerns

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3
Q

What is used for pharmacological benzo detox?

A

Diazepam and weaned, oxazepam if liver concerns

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4
Q

What is used for alcohol relapse prevention?

A

Disulfram - blocks metabolism of EtOH, accumulation of acetaldehyde in blood, can be dangerous, no longer used

Acamprosate - may stimulate GABAergic inhibitory neurotransmissino and antagonise excitatory amino-acids to reduce craving

Naltrexone - specifc, high affinity, long acting competitive antagonist at opioid receptors

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5
Q

Concerns with stimulant dependence

A
  • may be other drugs involved
  • strong psychological dependence
  • binge use not always daily
  • Risks to CV system, MH and admin risks
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6
Q

Concerns with cannabis dependence

A
  • use disorder in susceptible individuals (eg psychosis, depression, psychiatric problems)
  • may be underlying self medication ie for ADHD
  • risks from tobacco smoke too
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7
Q

Concerns with prescription med dependence

A
  • may be augented by poor prescribing practice
  • obtained legally or illegally
  • could be self medication
  • may be associated with poly drug use
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8
Q

Pharmacy team support with non opioid detox

A
  • discuss individual goals and praise positively
  • encourage engagement with psychosocial support
  • signpost to services
  • know what is available in community (foodbanks advice services etc)
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9
Q

What is physical drug dependence?

A
  • physiology rebalancing of neurotransmitters in the brain in prescence of constant drug exposure
  • when effects wear off, imbalance occurs (noradrenaline strom)
  • vomiting, chills, rigors, hallucinations, stomach cramps, bone pain
  • lasts 4-5 days, back to normal after 7 days
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10
Q

What is psychological drug dependence?

A
  • reward systems in the brain activated by opioids
  • severe dysphoria and anxiety on stopping
  • receptor plasticity plays important role
  • absence of drug leads to intense craving
  • desire to use drug can override ability to fulfil basic needs
  • cues, stress and exposure can trigger relapse
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11
Q

What is the purpose of OST?

A
  • provide stability to engage in psychosocial support and stability to make changes in behaviour and social circumstances
  • replaces illicit short half life drug with prescribed long half life drug
  • reduces overdoses and deaths
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12
Q

How does methadone work?

A

opiate agonist with main activity at mu receptor, antagonist at NMDA receptors

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13
Q

How does buprenorphine work?

A

opiate receptor partial agonist mainly at mu receptor at adequate dose, kappa antagonist

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14
Q

What are the aims of OST for society?

A
  • reduce drug related crime so imorove community safety and reduce fear
  • save money spent within criminal justice system on drug related crime
  • save NHS money on health costs
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15
Q

What is the starting process for methadone?

A

20-30 mg on day 1, increase 5-10mg daily to max increase of start dose + 30mg. Increase once or twice weekly i=until stable dose, best outcomes at 60-120mg OD
- half life is 24-36hrs

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16
Q

What is the starting process for buprenorphine?

A

Day 1: drug free for 6 hours to start, take 4mg when feeling withdrawal, then 4mg in 6-8 hours
Day 2: 12-16mg
Max dose 32mg (SL) or 18mg (OL)

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17
Q

How to switch from methadone to buprenorphine?

A

Allow 24 hrs since last dose
Only when daily dose is 30mg or less

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18
Q

QT interval prolongation in methadone

A
  • methadone at 100mg+ OD has increased risk of prolonged QT
  • ECG recommended
  • if abnoraml, consider replacing with long acting morphine (off license)
  • avoid any other QT implicated drugs
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19
Q

CYP3A4 in methadone

A

Key interactions
- some HIV meds can reduce levels
- macrolides that inhibit CYP3A4 increase buprenorphine levels, clarithromycin increases methadone levels
- st johns wort reduces plasma conc of methadone

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20
Q

OST in pregnancy

A
  • key objective is stabilisation
  • detox only in second trimester
  • volume of distribution increases
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21
Q

Preventing overdose

Study These Flashcards
A
  • withhold from intoxicated patients
  • 3-day rule
  • take home naloxone scheme
  • support re-engagement with treatment
22
Q

Management of pain in OST

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A
  • people with history of opioid dependence may be more sensitive to pain
  • clinicans fear causing dependence
  • in acute situations, high dose opioids can control pain with careful monitoring and short duration
  • buprenorphine can block affects
23
Q

What are the three dopamine pathways?

Study These Flashcards
A

nigro-striatal
- connects the nubstantia nigra to the caudate
- involved in motor control, linked to parkinsons
mesocortical
- connects the ventral tegmental to cortex
- involved in hypodopamine for negative symptoms of schizophrenia
mesolimbic
- connects the ventral tegmental to nucleus accumbens
- encoding reward from dopamine stimulus
- encourages repeat behaviours, like food, sex, friendship

24
Q

Kappa opioid receptor agonists cause

25
Mu opioid receptor agonists
euphoria, almost always analgesic
26
What do cocaine and amphetamines do
increase DA release or inhibit reuptake
27
Vesicles of dopamine released to synaptic cleft to activate post synaptic dopamine receptors
- action potential comes down to ventral tegmental area neurons go to nerve terminal in nucleus accumbens - activates receptors which causes reinforcing/rewarding pathways - dopamine is reuptaken through transporters - cocaine and amphetamines block transporters, more dopamine
28
How does disinhibition occur?
GABA is main inhibitory neurotransmitter in brain, released from GABAergic interneurones Neurones fire action potential, GABA A receptors become hyperpolarised and less likely to fire action potential (more GABA = more inhibition) GABAergic neurones in the VTA, express Mu opioid receptors, if activiated will inhibit the neurone (less GABA = disinhibition)
29
G protein coupled receptors
- all opioid receptors (mu, delta, kappa) are GIGO typr - binds opiatem activates ihibition that allows cycles which decrease cAMP and decreases activation state of PKA and opens certain potassium channels - both inhibitory, causes hyperpolarisation when of the neurone, causing inhibition of neurotransmitter release
30
Ethanol
Acts directly on DA in VTA, decreases after-hyperpolarisation, increases firing rate, GABA A allosteric modulator, NMDA receptor antagonist, calcium channel antagonist (this occurs at higher doses and believed to be mechanism for memory loss) - believed its main action in VTA for euphoria is potassium channel blocking causing hyperpoparlisation and channels open
31
Nicotine
acts on nicotinic acetylcholine receptors on DA neurones in VTA, increasees firing rate
32
Nicotine receptors are
ligand-gated ion channels. Nicotine opens them, mostly permeable to sodium ions form outside to inside the cell, depolarises the cell making the neurone more likely to fire action potentials menaing more dopamine release
33
THC acts on
cannabinoid receptors on GABAergic neurones in process identical to opioids
34
Relative speeds of administration
- Fastest: inhaling - Injecting - Snorting - Slowest: ingesting
35
Most important factor of dopamine release
Speed to peak, no the peak itself
36
The dopamine-reward hypothesis
- natural rewards kuje food + sex increase DA levels in Nacc, addictive drugs drugs mimic natural rewards - reward is the intial drive but doesn't explain addiction
37
Long term affects of drugs of abuse
- physical dependence (withdrawal syndrome) - tolerance (increasing doses for equiv effect) - psychological 'dependence' (craving, compulsion)
38
Withdrawal affects of alcohol treated with
benzos, antiepileptics, antipsychotics
39
Withdrawal affects of opiates treated with
clonidine, benzos, sedation, OST
40
Withdrawal affects of nicotine treated with
NRT
41
Psychological effects of withdrawal
- repeated withdrwal lowers baseline mood - dysregulation of stress hormones - increased production of dynorphin
42
Stress hormones
- CRH-1 receptor antagonists (antalarmin) - glucocortcoid recpetor antagonists (mifepristone) - still in development, don;t want to remove all stress
43
Dynorphin
- endogenous agonist at kappa opioid receptor, D1 expressing neurones in nucleus accumbens will go back to dopaminergic nerurones in a negative feedback loop om GABAergic interbeuron -
44
D2 receptors influence likelyhood of taking drugs
More D2 receptors means less likely to want to take drugs? 'rewarding' environments decrease D2 receptors
45
Drugs affecting dopaminergic system
buproprion - dopamine/noradrenaline reuptake inhibitor, possibly works soley as an antidepressant Bromocriptine - D2 partial agonist Both may work better in those with low D2 levels
46
Dopamine D2 antagonists
Don't work - competitive antagonism - risks of low D2 receptors
47
Addiction as a learned behaviour
- an element of psychosocial dependence is learned - memory formation is thought to occur bc of synaptic plasticity at glutamatergic synapses - inhibits synaptic plasticity, inhibits conditinoed learning - deconditioning?
48
Approaches to improve opoioid analgesics
- ligands with actions restricted to peripheral tissues - restricted to inflamed tissue (with lower pH) - slow access to CNS (poor action in studies) - bivalent/biased ligands (high abuse potential)
49
Buprenorphine/naltrexone combo
Would be a kappa antagonist, mu antagonist, and possibly NOP partial antagonist - would help with imblance in heroin addicts Small doses increase EtOH intake by stimulation of classic opioid receptors, larger doses decrease it, by stimulation of NOP receptors. However - buprenorphine given SL as inactive PO and naltrexone given PO as inactive SL
50
Buvidal
injectable, long-lasting buprenorphine - increases stability socially, biologically, and psychologially - most on 24mg per week, moving to 96mg monthly - cost effective - £6k per QALY
51
Case study checklist
- Hisotry taking - Initial agreed goals - Indication for OST? - Weigh up treatment choices - Safety info to check - Monitoring and safety netting
MPharm4 SL52117
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