University:
West Coast University
Course:
PHAR 835 | IPC Neurology/Psychiatry
Academic year:

2024
Views:

465

Pages:

61
Author:

Asal A.

Substance Use Disorder/Opioid Use Disorder (OUD) Parna Haghparast, PharmD, BCPS Friday 0906 Associate Professor Some slides have been adopted from1Dr. Carol Phar 835 Yuan, PharmD, BCPP Backgroundsedative DiodeBenton centralifessionly MNIistemphong • Opioids are a class of medications (synthetic, semi-synthetic, natural) that binds to opioid receptors and relieves pain • Natural opioids (e.g., morphine, codeine derived from the opium poppy plant) fake•aSynthetic opioids (e.g., fentanyl, methadone, heroine) • Semi-synthetic opioids (e.g., oxycodone, hydrocodone) • Medically, “narcotics” primarily refer to opioids and substances with pain-relieving and sedative effects e.g. BZDs. • Concerns with opioid use • Risk of overdose • Risk of Dependence • Side effects • Opioid prescribing increased in late 1990, early 2000s opioid-related deaths , non-medical use of Rx opioids • Oxycontin ® promoted as less addictive than traditional opioids • Opioid prescribing promoted by professional organizations (ex. American Pain society) • Joint commission linked healthcare quality and patient satisfaction with pain control 7 • According to provisional data, the CDC estimates more than 108,000 drug overdose deaths occurred in the 12-month period ending April 2022.1 • Opioids accounted for almost 75% of all drug overdoses deaths in 2020 Figure 1: Centers for Disease Control and Prevention. Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2022. 8 OUD continues to plague individuals… • In order to address the public health issue • • • • • Clinical guidelines and safety measures on prescribing opioids Rx drug monitoring programs Education on proper storage and disposal of opioids Take-home naloxone programs New legislative efforts • The amount of opioids prescribed in the United States peaked in 2010 and then decreased each year through 2015. Despite reductions, the amount of opioids prescribed remains approximately three times as high as in 1999 • Due to illicit manufactured fentanyl (IMF), fentanyl analogs, and heroin use 9 Substance Use Disorder • “ Treatable mental disorder that affects a person’s brain and behavior, leading to their INABILITY to control their use of substances despite harmful consequences.” 10 Definitions Addiction/dependence Physical Dependence Tolerance • Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Addiction leads to drug seeking behavior • Physiological adaptation that occurs when medications acting on the CNS are ingested with rebound when the medication is abruptly discontinued (e.g. rebound effect, withdrawals, tolerance) but does not necessarily mean pt is addicted • Need for increased amounts of substances use to achieve desired effect. • Diminished effect with continued use of same amount of substances AT Intoxication poised Being • Development of a substance-specific syndrome after recent use and presence of substances in the body • Intoxication can lead to acute withdrawal from substances 11 TYPES OF SUBSTANCE USE Beneficial Use Problematic Use • Positive health, spiritual or social impact • e.g. medical pharmaceuticals; coffee/tea to increase alertness; moderate consumption of red wine • Use that begins to have negative consequences for individual, friends/family or society • e.g. impaired driving; binge consumption; harmful routes of administration Casual/Non-problematic Use casual or other use that has Big• Recreational, negligible health or social effects (limited 835to certain substances use) Chronic Dependence • Use that has become habitual and compulsive despite negative health and social effects 12 REASONS DESCRIBED FOR SUBSTANCES USE To Feel Good – Feeling of pleasure, “high” or “intoxication” To Feel Better – Relieve stress, forget problems, or feel numb To Do Better – Improve performance or thinking Curiosity and Peer Pressure – leading to experimenting 13 THE DSM-5 ESTABLISHES NINE TYPES OF SUBSTANCE-RELATED DISORDERS: 1. 2. 3. 4. 5. 6. 7. 8. 9. Alcohol Caffeine (requires further research) Cannabis (e.g., marijuana) Hallucinogens (e.g., phencyclidine, MDMA) Inhalants Opioid (e.g., heroin) Sedatives, Hypnotics, or Anxiolytics (e.g., benzodiazepines) Stimulants (e.g., cocaine, methamphetamine) Tobacco Others (non-substances): Internet gaming (requires further research) and Gambling Disorder. 14 DSM-5: Substance use disorder Problematic pattern of use that causes significant distress or harm, with at least two of the following over 12 months 1. Larger amounts or longer duration than was intended 2. Unsuccessful efforts to cut down or control use 3. Large amounts of time spent obtaining, using or recovering from alcohol 4. Cravings Is 5. Continued use despite adverse consequences 6. Enjoyable activities given up or reduced 7. Use in physical or hazardous situations 8. Use despite knowledge of condition that is exacerbated by the substance 9. Tolerance 10. Withdrawal symptoms or alcohol or benzodiazepines (BZD) used to avoid withdrawal symptoms 0559 15 DSM-5, 2013 SUBSTANCES OF ABUSE Classification by DEA Category RX (Schedule II-V, non-schedule) Illicit substances (Schedule I-II) OTC Classification by effects • MDMA, LSD, PCP etc. • Dextromethorphan CNS Stimulants (“Uppers”) • Cocaine, Amphetamines, Caffeine, Nicotine CNS Depressants (“Downers”) • Opioids, Sedative-Hypnotics, Alcohol Hallucinogenics (“All-Arounders”) • LSD, PCP, MDMA MDMA: (3,4-methylenedioxymethamphetamine)—stimulant and hallucinogen LSD: (lysergic acid diethylamide) –hallucinogen PCP: Phencyclidine—Dissociative and hallucinogen • Opioids, Stimulants, Benzos, etc. HI 16 PATHOPHYSIOLOGY OF ADDICTION • • Reward system (thru Mesolimbic Reward Pathway) • Dopaminergic reward system, primarily involving the ventral tegmental area (VTA) and the nucleus accumbens (NAc) by releasing DApleasurable sensation • Substances of abuse increase Dopamine release in the Nucleus Accumbens • The compulsive nature of addiction diminishes the executive functions (e.g. decision making) in the pre-frontal cortex—poor decision despite consequences, poor impulse control due to DA and changes to glutamate signalling • Amygdala and hippocampus are involved in the formation of emotional and contextual memories e.g. places you used drugs can activate memory/emotion associated with drug use making harder to resist Major NT involved good • DA release leads to pleasurable effect and euphoria and • Initially DA increased neuronal adaptation by reducing DA receptorstolerance • DA influences glutamate activity • Glutamate, another key neurotransmitter, plays a role in learning, memory, and the regulation of the reward system. Addiction alters glutamate signaling in the prefrontal cortex and the nucleus accumbens, affecting decision-making and increasing drug-seeking behavior. • Glutamate involved in memories associated with drug, contributing to cravings • Other NT involved: serotonin feel exits 19 DOPAMINE-RELEASING BEHAVIORS Food Sex Relationships Other People Gambling Cults Performance Collection/Accumulation Rage/Violence Media/Entertainment so 20 DOPAMINE-RELEASING CHEMICALS 2 0 Alcohol & SedativeHypnotics Opiates/Opioids Cocaine Amphetamines Entactogens (MDMA) Hallucinogens Dissociants (PCP, Ketamine) Cannabinoids Inhalants Nicotine e Caffeine Anabolic-Androgenic Steroids e 21 DOPAMINE AND GLUTAMATE DOPAMINE GLUTAMATE • Drugs of abuse and potential compulsive behaviors increase DA • Drugs of abuse and potential compulsive behaviors effect Glu • Reward salience • Drug seeking • Drug memories “This is important!” “OK, I’ll remember” “I really need this!” “Fine, go and get some” 22 CYCLE OF ADDICTION DRUG USE Relapse worsen Withdrawal Symptoms Physical Dependence Attempts at Abstinence Bdo 24 RISK FACTORS FOR CHEMICAL DEPENDENCE Risk Factors 1. Co-occurring psychiatric disorders 2. Males, younger adults, single individuals, unemployed 3. Personality traits 4. Exposure to substance: earlier the age, the stronger the risk 5. Stressful environmental factors (i.e:, home, work, relationships, etc.) 26 Environmental Influences Sexual/ physical/ emotional abuse Stress Love Nutrition Living condition Family relationships Healthcare Neighborhood safety School quality Peer pressure Internet Television 27 PHARMACISTS ROLE IN SUBSTANCE USE DISORDER Pharmacists should screen for substance abuse and addiction • Pharmacists must acquire a complete drug history for all patients under their care Bonzo long as prescription) Prevent substance abuse via counseling (i.e:, Ativan Prevent drug abuse by identifying forged prescriptions Build a list of local resources to refer patients to • A person who expresses desire for help today may have been unwilling to accept a referral yesterday and by tomorrow the urgency may have passed 29 six TALKING TO PATIENTS ABOUT PRESCRIPTION DRUG ABUSE • Combat the misconception • Educate on dangers of misusing prescription drugs • Educate about strength and danger of prescription drugs to discourage abuse and prevent overdose • Know the commonly abused medications • When you fill prescriptions for these drugs, take extra time to talk with those patients. Inform them about safe storage, the dangers of sharing and the importance of adhering to the dosage instructions • Discourage sharing drugs • Half of prescription drug abusers obtained their drugs for free by taking them from a friend or relative • Promote drug security • Prescription drugs are a common target of theft in pharmacies and homes • Inform patients about drug take-back programs 30 43 Cash Prescriptions High Quantities / High Doses SIGNS OF DIVERSION 1351 Distance Traveled Patterns in Prescriptions Combination of Drugs Scope of Prescribing Doctor Refill Too Soon 31 Inability to take medications according to an agreed upon schedule Takes multiple doses together SUSPECT PATIENT BEHAVIORS Frequently runs out of medication early despite dose agreement Frequently reports lost or stolen prescriptions Solicits multiple prescribers Okay Uses multiple pharmacies to fill prescriptions 32 4 5 POSSIBLE CHARACTERISTICS OF A PRESCRIPTION DRUG ABUSER • May show unusual knowledge of controlled substances or give medical history with textbook symptoms a • Will often request a specific controlled drug and is reluctant to try something different • Claims allergy to other drugs such as NSAIDs, local anesthetics or codeine • States a prescription has been lost or stolen and needs replacing • Patient claiming to be visiting from another town • Evasive answers, strange stories 53 33 PROTECT YOURSELF • Don’t let your pharmacy become an easy target • If you inadvertently dispense fraudulent Rxs, more are likely to show up • If a pattern is discovered, contact: • State board of pharmacy • Local DEA Diversion Field Office • Local police • IF YOU DETECT A DRUG ABUSER: • Inform the physician(s) who have issued RX to the individual or in the case of suspected forgeries, the physician(s) whose name(s) appears on the RX • Verify the status of prescriber’s licensure against the licensing Board • Inform other pharmacies • If the patient resorts to verbal abuse or acts of violence, contact law enforcement authorities if you are threatened in any way 34 STAGES OF CHANGE & APPROPRIATE INTERVENTION Stage of Change Characteristic Intervention Approach Suggested Language Precontemplation Not thinking about change Discuss risks of drug abuse and benefits of quitting. Link specific negative consequences to drug use. Strongly advise quitting. “What would it take for you to consider seeking help?” Contemplation Thinking about change in next 6 months but not within 30 days Discuss immediate benefits of quitting to self and loved ones. Emphasize health, economic and interpersonal payoffs “What would it take for you to seek help now?” Preparation Ready to change in next 30 days Discuss strategies and options. Pick a change date. Refer to specialist if necessary “Which option do you think will work best for you?” Action Has initiated and Support decision. Encourage change. maintained new behavior Discuss pitfalls and common sources for up to 6 months of failures. “What do you think will be your biggest challenge? How might you deal with it?” 35 PHARMACISTS ADDICTION WITHIN THE PROFESSION 36 PHARMACISTS AND ADDICTION • No healthcare professional is immune to the problem of substance abuse • A recent study indicated that 46% of pharmacists and 62% of pharmacy students studied had used controlled substances at some time without a prescription. • Pharmacists at higher risk due to increased access and other job-related factors • Stressful and unpleasant workplace issues • Substance use among pharmacists • Represents a significant threat to public safety • Errors in compounding/dispensing medication can cause fatalities 37 RECOGNIZING CHEMICAL IMPAIRMENT IN A COWORKER • Possible Signs and Symptoms • Odor of alcohol on breath or strong odor of mouthwash or mints to mask the alcohol • Hand tremor that occurs when in alcohol withdrawal • Excessive perspiration • Absence from work without notice, frequent absenteeism or late for work • Unexplained disappearance during work for long periods of time • Sleeping or dozing off while on duty or complaints of difficulty sleeping • Frequent bathroom breaks • Volunteering for overtime or being at work when not scheduled to be there II • Deterioration in personal appearance • Confusion, memory loss, and difficulty concentrating • Reports of illness, minor accidents, and emergencies • Heavy drug waste and/or drug shortages • Inappropriate prescriptions for large narcotic doses • Increase in medication order entry errors or sloppy recordkeeping • Work performance that alternates between periods of high and low productivity • Unreliability in keeping appointments and meeting deadlines • Personality changes and mood swings 38 CA PHARMACIST RECOVERY PROGRAM • Purpose • The purpose of the Pharmacists Recovery Program is to identify and evaluate the nature and severity of chemical dependency and/or mental illness, develop a treatment plan contract, monitor participation, and provide encouragement and support. • Who can refer to the program? • The rehabilitation and treatment program accepts referrals on a voluntary basis. Any licensed pharmacist or registered intern in California who is experiencing alcohol or other drug abuse or mental illness can voluntarily seek assistance by contacting a 24-hour toll-free number. All voluntary requests for information and assistance are strictly confidential; this information is not subject to discovery or subpoena • If you have a problem or live or work with a pharmacist who does, call the Pharmacists Recovery Program toll-free at (800) 522-9198 39 RESOURCES FOR INFORMATION AND HELP • Alcoholics Anonymous (www.aa.org) • American Society of Addiction Medicine (www.asam.org) • CASAColumbia: National Center on Addiction and Substance Abuse at Columbia University (www.casacolumbia.org) • Narcotics Anonymous (www.na.org) • National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health (www.niaaa.nih.gov) • Opiate addiction (www.opiates.com/opiate-addiction.html) • USA Pharmacists Recovery Network (www.usaprn.org) • SAMHSA www.findtreatment.samhsa.gov • National Alliance on Mental Illness www.nami.org • Mental Health America www.mentalhealthamerica.net • Drug Free www.drugfree.org 40 Opioid Use Disorder 43 Component of Successful Addiction Treatment 46 Substances Use Treatment Goal sis 47 Opioid Intoxication/overdose Can be potentially fatal, especially individuals using opioids IV, using high doses or using potent opiates, such as Fentanyl. Signs/Symptoms: 1. Respiratory depression, < 10breaths/min 2. Cyanosis: exam lips or fingertips us or coma/unconsciousness, 3. Progression to stupor unresponsiveness/hard to awaken 4. Cold or clammy skin 5. Pinpoint pupils 6. Bradycardia 7. Hypotension 8. Gurgling or snoring sounds 48 Opioid Withdrawal Wing Opioid withdrawal occurs: • Cessation of or reduction of heavy and/or prolonged opioid use • Administration of an opioid antagonist after a period of opioid use • Use Clinical Opiate Withdrawal Scale (COWS) to assess opioid withdrawal. 1. 2. 3. 4. 5. 6. 7. 8. 9. pika Signs/Symptoms: Dysphoric mood Nausea or vomiting Muscle aches Lacrimation or rhinorrhea Pupillary dilation, piloerection, or sweating Diarrhea goosebumps Yawning Fever Insomnia 49 COWS • Clinical Opiate Withdrawal Scale (COWS) to assess opioid withdrawal • Mild= 5-12 • Moderate=13-24 • Moderate-Severe=25-36 • Severe= >36 51 Supportive Care for Opioid Withdrawal Diarrhea Loperamide 4 mg initially followed by 2mg po q6hr prn Muscle spasms Methocarbamol 750 mg q 4hrs Muscle ache Ibuprofen 400-800 mg q8hrs Nausea/vomiting Promethazine 25-50 mg Q4-6hrs or Ondansetron4 mg q6hrs Fever Acetaminophen 500 mg q4hrs Insomnia Trazodone 50-150 mg QHS, diphenhydramine, or melatonin Dysphoric mood/depression antidepressant Lacrimation/rhinorrhea antihistamine Anxiety Hydroxyzine (Vistaril ®) 25-50 mg q4 hrs prn or Gabapentin 300 mg TID prn • Others: Clonidine (helps with N/V, diarrhea, cramps, sweating) • • • • • • • • • 52 Pharmacologic Treatment Options Buprenorphine a (Partial opioid agonist) alongactits with yogurt Methadone (Full agonist) bolophireimethedose Naltrexone (Opioid antagonist) Clonidine (Alpha-2 adrenergic agonist ) FDA approved for opioid withdrawal & dependence FDA approved for opioid withdrawal & dependence FDA approved for opioid dependence Off-label for opioid withdrawal Indicated for: • Opioid withdrawal • Long-term relapse prevention Indicated for: • Opioid withdrawal • Long-term relapse prevention Indicated: • Opioid dependence • Alcohol dependence Used to reduce noradrenergic hyperactivity Buprenorphine should be started: 1. When signs of opioid withdrawal occur (moderate-sever sx) 2. No sooner than 12 hours after the last opioid use Initial dose: 20mg to 30mg, additional 5-10mg may be administered as needed, 40mg TDD on the first day. CI: significant respiratory depression 20ms Dose: 50 mg daily Vivitrol (IM injection Q4 weeks): 380 mg Dose: 0.1mg tid and adjust dose based on withdrawal symptoms Max Comes in various formulations: Dispensed in licensed opioid Available in long acting IM 1. Film, Patch, Solution for treatment program injection injection, & Sublingual Relieve of: Nausea, vomiting, diarrhea, cramps 53 and sweating Pharmacological Treatment for OUD • Buprenorphine +/- naloxone (Suboxone ®, Zubsolv ®, Subutex ® (buprenorphine only)) • • • • • Initial phase, maintenance phase Counselling: (Mandatory)-For oral products, swish mouth with water large sip of water and swallow to prevent dental damage. Additionally, pts should avoid brushing teeth for 1 hour Maintenance dose: 4mg/1mg to 24mg/6mg Caution in liver dysfunction Additional ADR for SL: oral hypoesthesia (decreased sensitivity to sensory stimuli), glossodynia (burning/painful sensation of tongue), or mucosal erythema (redness/inflammation of mucous membrane) • Methadone (Mathadose ®) • • • • • Starting dose= 20-30 mg/daily, MAX dose= 120 mg/day Counselling: do not drink alcohol while taking methadone Risk of serotonin syndrome QTc prolongation Prescribed by healthcare providers knowledgeable due to fatal respiratory depression • Naltrexone • • • have bestir i akesure EKG they Atanasiodonesharapine m CI: Hepatotoxicity NOTE: must be opioid-free (including tramadol) for at least 7-14 days to avoid precipitation of opioid withdrawal symptoms Opioid pain management should not be used for surgeries/accidents etc. 54 Buprenorphine MOA 56 Buprenorphine MOA 57 Buprenorphine vs. Methadone vs Naltrexone Naltrexone Can be prescribed by office-based physicians Opioid antagonist Risk of overdoseUpdtae Reduce cravings Very low Complicates pain management Alterations in LFTs 58 Buprenorphine/Naloxone (Suboxone) Formulations: Film, Sublingual Various combination of dosage: 2/0.5mg, 4/1mg, 8/2mg, 12/3mg and others 59 Opioid Reversal Agents: Naloxone vs. Nalmefene v o4mg antagonist opioid of version 61 M Ft Naloxone ● Naloxone serves as the emergency solution for treating opioid overdoses ● In March 2023, the FDA approved Narcan ® (4 mg)to be used as an OTC nasal spray for overdose treatment without a prescription ● On July 28th 2023, the FDA approved of a 2nd naloxone nasal formula, RiVive ® (3 mg), for OTC emergency use as well ● Narcan ® Dosing: 4 mg intranasally or 0.040.4 mg IV which can be repeated after 2-3 minutes as needed. Max dose is 10mg. ○ ○ short ad Nalmefene NaronUmgotc noisy Rivive argot 1 spray (4 mg) intranasally into 1 nostril. Use a new naloxone nasal spray for subsequent doses and administer into alternating nostrils. 0.04 to 0.4 mg IV, repeat dosing or dose increase to 2 mg if the initial response is inadequate 62 Naloxone MOA ● ● ● Competitive inhibitor of mu-opioid, kappa-opioid, and sigma-opioid receptor (ie opioid antagonist) to block the effects of the opioid drugs More specifically, naloxone has a high affinity for μ-opioid receptors that causes the rapid removal of any drugs bound to the receptors by displacing them Time of onset: 2-5 min 63 Nalmefene MOA ● A 6 methylene analog of Naltrexone. ● MOA: acts as a competitive opioid receptor antagonist. ● Onset: 2-5 min ● Dose: - (Nasal Spray): 2.7 mg (1 nasal spray) as a single dose in 1 nostril. Use a new nasal spray for subsequent doses and administer in alternating nostrils May repeat every 2-5 min prn in alternate nostril for continued respiratory depression - (IV): IV: initial dose 0.5mg; followed by second dose of 1mg administered 25 minutes later (if needed). If no response after total dose of 1.5mg, additional doses are unlikely to provide additional effect. 64 Nalmefene vs. Naloxone Naloxone Nalmefene Longer duration of action: plasma ½ life ~11 hours. Higher affinity for opioid receptors: possibility for more opioid withdrawal symptoms. Opvee is Rx only. Both act as opioid receptor antagonists. Both are available as nasal sprays: Opvee 2.7mg & Narcan 4mg Shorter duration of action: plasma ½ life ~60-90 minutes. Lower affinity for opioid receptors. Available OTC. Available as IV/IM/IN Avaialable as IV/nasal spray 65 The Use Of Naloxone 66 Rescue Opioid Intoxication 67 CNS Stimulants: Cocaine and Methamphetamine 69 National Overdose Deaths Number of Deaths from Cocaine 8,000 Total Female Male 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Source: National Center for Health Statistics, CDC Wonder 70 Cocaine Mechanism of Action • High risk of addiction • Inhibits the presynaptic reuptake of dopamine, serotonin and norepinephrine • Increased monoamines in the synaptic cleft  increased binding at the postsynaptic receptors 71 Cocaine Pharmacokinetics • Routes of use • Smoking, intranasal, IV injection • Cocaine exists in several forms, with the two most common being • 1. cocaine hydrochloride (the powder form)- higherpick takes • Dissolved in water and injection IV (water soluble) onset • Insufflation doshtastaslorg more Fast • 2. Crack cocaine (the freebase form)—smoked— • Not water soluble • When heated, crack cocaine vaporizes and is inhaled, delivering the drug rapidly to the lungs, from where it quickly enters the bloodstream. f 72 Cocaine: Absorption • Rapidly absorbed from virtually all sites of application Route of exposure Onset of action Peak action Duration of action Intravenous <1 min Smoking <1 min Nasal insufflation 1-5 min 3-5 min 3-5 min 20-30 min 30-60 min 30-60 min 60-120 min PO 60-90 min Unknown 30-60 min 73 Effects of Chronic Cocaine Use Additional Concerns: - Death from trauma - Developmental abnormalities in infants born to cocaine users - Ulceration of mucous membrane of the nose 74 Methamphetamine Hydrochloride • MOA: Excessive release and reuptake inhibition of dopamine, norepinephrine, and serotonin. This results in heightened stimulation of neurotransmitter systems, producing intense euphoria, increased energy, and other stimulant effects • Methamphetamine hydrochloride in crystalline form (commonly known as "crystal meth") or as a powder • "crystal meth" is often smoked using a glass pipe, also known as a "meth pipe." • Powdered methamphetamine (or crushed crystal meth) can be snorted • powder or crystalline form, can be dissolved in water or another solvent for injection. 75 The “Faces of meth”, The Cause Behind… The use of Methamphetamine causes • Psychosis: paranoia, hallucinations • Aggressive or violent behavior • Mood disturbances • Severe dental problems • Weight loss • Skin sores • Deficits in thinking and motor skills • Increased distractibility • Memory loss 77 overdose 78 Stimulant Supportive Care Supportive Care • Safe, calm environment • May require symptom specific treatment for hypertension, tachycardia, seizures, and persecutory delusions • Benzodiazepines & Antipsychotics for acutely agitated patients • Withdrawal syndromes are self-limited and require supportive care No “rescue” or “antidote” pharmacotherapy 81 Management of Stimulant Dependence • • • • • • Focus on abstinence Psychosocial and behavioral interventions: • CBT, Behavioral therapies, 12-step-oriented individual drug counseling, Self-help groups Treat co-occurring mental health disorders For more severe dependence or not responding to psychosocial treatment, consider adding pharmacological treatment. Anta Medications have limited effectiveness, but topiramate, disulfiram, and modafinil currently show promise for cocaine dependence. provilgic No proven treatments for amphetamine dependence 82

Substance Use Disorder/Opioid Use Disorder (OUD)

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