Alcohol Withdrawal Relief

Alcohol withdrawal – mild withdrawal starts 6-24 hours after last drink ss include anxiety, diaphoresis, palpitations, and insomnia. Seizures start 12-24 hours. One or multiple, generalized, or tonic clonic. Alcohol hallucinosis 12-24 hours predominantly visual can be auditory and tactile. DT are hallucinations, confusion disorientation aggressive behavior and autonomic hypersensitivity. DISULFARAM (ANTABUSE) used for high functioning alcoholics who want to abstain from alcohol will result in flu like symptoms if alcohol is consumed. CHLORDIAZEPOXIDE- long-acting benzo good for out patient withdrawal management. LORAZEPAM- inpatient withdrawal symptoms. ANTABUSE/ DISULFARAM- used for alcohol withdrawal, used for high functioning alcoholics that want to abstain from use. With make PT sick if used with alcohol. ADMINISTRATION-PO Administer once daily. May be administered at bedtime to reduce daytime drowsiness. EDUCATION- Inform patient of purpose of disulfiram and the consequences of drinking alcohol during therapy. May cause drowsiness. Caution patient to avoid driving and other activities requiring alertness until response to medication is known. Caution patient not to take alcohol or any medication containing alcohol during therapy or for 14 days following therapy; may cause a disulfiram-reaction (blurred vision, chest pain, confusion, dizziness or fainting, fast or pounding heartbeat, flushed or redness of face, increase sweating, nausea, vomiting, throbbing headache, trouble breathing, severe weakness, seizures, unconsciousness, heart attack death). Reaction may persist from 30 min to several hours. Advise patient to check all medications for the presence of alcohol. Advise patient to consult health care professional prior to taking other CNS depressants. Advise patient to notify health care professional of signs of hepatotoxicity (yellow eyes or skin, darkening or urine, light-gray colored stools, severe stomach pain. DO NOT ADMINISTER WITHIN 12 HOURS of use of alcohol. If reaction occurs administer oxygen, monitor ECG k+ levels and provide supportive care. Do not take with benzos, caffeine, tricyclics, isoniazid. Side effects- drowsiness, headache, HEPATOTOXICITY. WORKS BY- inhibits enzyme aldehyde dehydrogenase - results in toxic accumulation of acetaldehyde (one of the initial breakdown products of alcohol). ARTANE- CLASS- beta blocker MOA- anti cholinergic. discontinued in the US. Generic usedtrihexyphenidyl- Artane is used to treat the stiffness, tremors, spasms, and poor muscle control of Parkinson's disease. Also used for muscular conditions caused from other drugs Thorazine, prolixin, trilafon, haldol, navane. SIDE EFFECTS- dryness of the mouth; large pupils or blurred vision; drowsiness or dizziness; difficulty urinating or constipation; nervousness or anxiety; memory problems upset stomach; or decreased sweating Tachycardia Anticholinergic toxicity Psychosis Delirium. How to use- Increase by 2 mg/day at 3 to 5 day intervals to usual therapeutic dose of 6-10 mg/day divided three times per day with meals (15 mg/day). MONITORGoniscope evaluation and close monitoring of intraocular pressures Vital signs Check for signs and symptoms of parkinsonian movement, Assess for urinary retention Get weight daily ATARAX- CLASS-Anti anxiety, antihistamine, sedative, antiemetic USES- preoperative anxiety. prevents post op n/v. potentiates opioid analgesics. Sedation, and pruitis. SIDE EFFECTS- Dizziness. Drowsiness. Seizures. Hypotension. Dry mouth. INTERVENTIONSAssess BP and mental status. If Im give z track. Do not use longer than 4 months. BENADRYL- Antihistamine, Anticholinergic. INDICTIONS- Supplemental therapy to Epinephrine in anaphylaxis and other uncomplicated allergic reactions requiring prompt treatment. Motion sickness, and hay fever. Needed relief of Dystonic reactions resulting from Phenothiazine overdoses. EPS symptoms uticaria, sedation, EFFECTS- Palpitations, hypotension, tachycardia, confusion, insomnia, headache, vertigo, restlessness, tremor, seizures, blurred vision, nausea and vomiting, and anaphylactic shock, QT prolongation- do not give to hypotensive LOC pts. MONITOR- mental alertness, creatinine levels IV no higher than 25 mg/ min. Buspar- actions- Binds to serotonin and dopamine receptors in the brain. Increases norepinephrine metabolism in the brain. ADME- rapidly absorbed. Metabolized by liver excreted in feces. CONTRAINDICATION- Hypersensitivity; Severe hepatic or renal impairment; Concurrent use of MAO inhibitors; Ingestion of large amounts of grapefruit juice. Use Cautiously in: Patients receiving other antianxiety agents (other agents should be slowly withdrawn to prevent withdrawal or rebound phenomenon); Patients receiving other psychotropics SIDE EFFECTS- dizziness, drowsiness, excitement, fatigue, headache, cp, blurred vision, rashes, nausea. Incoordination, myalgia, paresthesia. INTERACTIONS- MAO inhibitors. May cause hypertension. Avoid phenytoin/phenobarbital. Alcohol. Avoid grapefruit. ASSESSMENT- Assess degree and manifestations of anxiety before and periodically during therapy.Buspirone does not appear to cause physical or psychological dependence or tolerance. However, patients with a history of substance use disorder should be assessed for tolerance or impaired control. Restrict amount of drug available to these patients. Decrease in subjective feelings of anxiety. Some improvement may be seen in 7–10 days. Optimal results take 3–4 wk of therapy. Buspirone is usually used for short-term therapy (3–4 wk). If prescribed for long-term therapy, efficacy should be periodically assessed. COGENTIN- Classification of Benztropine USE Anti-Parkinson; Drug induced extrapyramidal symptoms- Diminished excess cholinergic effect associated with dopamine deficiency. Suppress tremor/rigidity. SIDE EFFECTS sedation, drowsiness, dizziness, insomia, hallucinations, confusion, palpitations, tachycardia, flushing, blurred vision, nausea, vomiting, paralytic ileus, dysuria MONITOR- Monitor I&O ratio and pattern, monitor muscle weakness or inability to move, monitor HR Lamictal ( Lamotrigine) USES- partial seizures with epilepsy, bipolar disorder ActionsStabilizes neuronal membranes by inhibiting sodium transport. CONTRAINDICATED: Hypersensitivity; Acute manic or mixed episodes. SIDE EFFECTS- Aseptic meningitis, suicide thoughts, ataxia, dizziness, headache, photosensitivity, stevens-johnson syndrome, rather (higher in children). Hepatic failure, nausea vomiting Hemophadocytic, lymphohistocytocis, Concurrent use with carbamazepine may ↑ levels of an active metabolite of carbamazepine. INTERACTIONS: Concurrent use with drugs that induce glucuronidation, including phenobarbital, phenytoin, primidone, carbamazepine, estrogen-containing oral contraceptives, rifampin, lopinavir/ritonavir, or atazanavir/ritonavir may ↓ levels; lamotrigine dose adjustments may be necessary when starting and stopping oral contraceptive or atazanavir/ritonavir therapy. Concurrent use with drugs that inhibit glucuronidation, including valproic acid , may ↑ levels and ↑ incidence of rash; may also ↓ valproic acid levels (↓ lamotrigine dose by at least 50%) Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression. ASSESSMENT-Assess patient for skin rash frequently during therapy. Discontinue lamotrigine at first sign of rash; may be life-threatening. Stevens-Johnson syndrome or toxic epidermal necrolysis may develop. Rash usually occurs during the initial 2–8 wk of therapy and is more frequent in patients taking multiple antiepileptic agents, especially valproic acid, and much more frequent in patients <16 yr.Monitor for signs and symptoms of multiorgan hypersensitivity reactions–DRESS (rash, fever, lymphadenopathy). May be associated with other organ involvement (hepatitis, hepatic failure, blood dyscrasias, acute multiorgan failure). If cause cannot be determined, discontinue lamotrigine immediately. Bipolar disorders: Assess mood, ideation, and behaviors frequently. Initiate suicide precautions if indicated. DO NOT STOP ABRUPTLY. Risk for impaired skin integrity and injury. Lithium- treatment for bipolar disorder, acute mania and prevention of recurrent manic and depressive episodes. Pharmacokinetics- Monovalent cation that is well absorbed. Complete in 6-8 hours, peak levels in 30min-2 hours Distributed in total body water, some sequestration in bone. No protein binding Not metabolized Excreted in urine (90%) Plasma ½ life 20 hours Narrow Therapeutic Window (monitor blood levels) Enhances some actions of serotonin ↓ norepinephrine and dopamine turnover May block the development of dopamine receptor sensitivity May augment the synthesis of acetylcholine, perhaps by increasing choline uptake into nerve terminals INTERACTIONS- clearance decreased by thiazides and some NSAIDs MOA- Mechanism of action uncertain, suppresses inositol signaling and inhibits glycogen synthase kinase-3 (GSK-3), a multifunctional protein kinase SIDE EFFECTS- vomiting, nausea, diarrhea, Motor movement disorders: Tremor (propranolol and atenolol reduce this effect) Mental confusion (toxic doses), polydipsia, polyuria, sick sinus bradycardia- tachycardia Early signs and symptoms of lithium toxicity: (lithium level 1.5-2 mEq/L) GI: V/D/N, abdominal pain, dryness of mouth Neurologic symptoms: Ataxia, tremor, dizziness, slurred speech, nystagmus, lethargy or excitement, muscle weakness. Moderate to severe intoxication: (lithium level 2-2.5 mEq/L) GI: A/N/V - persistent Neurologic symptoms: Blurred vision, clonic limb movements, convulsions, delirium, EEG changes, stupor, coma, cardiac failure Severe lithium intoxication (lithium level > 2.5 mEq/L) Generalized convulsions, oliguria, renal failure and death! General Pearls about Lithium Toxicity: Risk factors for toxicity includes exceeding the recommended dosage, renal impairment, low-sodium diet, drug interactions, and dehydration. Elderly are more vulnerable. The higher the lithium level (concentration) the worse the s/s of toxicity will be. Lithium Toxicity = Medical emergency. Greater than 80 of patients taking lithium experience side effects. Neuro: Lack of spontaneity, memory difficulties, tremor, ataxia, irritability. seizures,mild parkinsonism, dysarthria Endocrine: Goiter, hypothyroidism, exophthalmos, hyperthyroidism CV: Benign T-wave changes (flattening or inversion) resemble s/s of hypokalemia on EKG. Renal: Concentrating defect, polyuria, polydipsia, DI, reduced GFR, nephrotic syndrome Thryoid effects: Hypothryoidism especially in women. Check TSH every 6-12 months. Patient who develop rapid cycling > risk of developing. Treatment = Levothyroxine (Synthroid) Treatment may involve fluid replacement, lowest effective dose of lithium and thiazide or potassium sparing diuretic. If diuretic is used, cut lithium dose in half, and start diuretic in 5 days. Derm: Acne, hair loss, psoriasis, rash, and alopecia. GI: Appetite loss, N/V/D, weight gain, fluid retention (divide doses, take with food or switch to different preparation to reduce GI effects). Lithium citrate less likely to cause diarrhea. ****Excessive Na+ intake = lower lithium concentrations. Low NA+ intake = Can lead to potentially toxic concentrations of lithium. MECLIZINE- Dramamine ANTIVERT- motion sickness, vertigo. Onset is 1 hour. Antiemetic. Anticholinergic side effects. Memantine (Namenda) for OCD Due to increasing evidence of glutamate’s involvement in the pathophysiology of obsessivecompulsive disorder (OCD), some investigators have hypothesized that a drug modulating glutamate release, such as memantine, may be effective. Two recent open-label case series suggest that the addition of memantine to standard medication therapy can benefit both children and adults with OCD. Preliminary studies also showed adjunctive memantine improved a number of different attention-deficit/hyperactivity disorder (ADHD) measures. Namenda is approved for the treatment of Alzheimer’s disease. Methadone - oral tablet is used to treat pain. It’s also used for detoxification or maintenance treatment of an opioid drug addiction- side effects- constipation, nausea, sleepiness, vomiting, headache, dizziness, stomach pain. -Administer in smallest effective dose-Observe for development of dependance.-Monitor respiratory status and vital signs, intake and output.-Encourage fluids and high-bulk foods. Naltrexone (Revia)/ NALOXONE (NARCAN) – blocks opioid receptors. for Behavioral Addiction- Naloxone used as antidote to overdose, while Revia is used to help recovering addicts from relapsing. Oral naltrexone is approved for the treatment of alcohol and opioid dependence OFF LABEL USES There is preliminary evidence that naltrexone might be beneficial in the treatment of impulse control disorders such as kleptomania, compulsive gambling, or trichotillomania (compulsive hair pulling). Other off-label uses include preventing self-injurious behavior and treatment of fibromyalgia. Naloxone SE mental depression, apathy, n/v, irritability and tachycardia Naltrexone: N/V, anorexia, headache Naltrexone SE Hepatoxicity Suboxone- buprenorphine/naloxone- synthetic opioid. Blocks effects of withdrawal from Opioids Has maximum effect at relatively low doses Has a ceiling effect, 24 mg? Does not make you high or euphoric Can be done as an outpatient Physician must be certified Only thirty patients allowed per physician in first two years, then 100 patients Part of a comprehensive program with Counseling and drug testing mandated by Federal Gov. EFFECTS- withdrawal symptoms, hypoesthesia, constipation, slows breathing, headache, numbness, backpain, insomnia. It can be abused. Do not take with benzos SUBUTEX is just Bupenorphine.