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Substance Use Disorder DSM 5

Clinically significant impairment or distress manifested by at least two of the following in a 12 month period:

Substance taken in large amounts over longer period of time than intended, persistent desire or unsuccessful effort to cut down, great deal of time spent obtaining substance, strong cravings, continued use despite worsening problems, giving up other activities for drug and use continued despite knowing their is a problem


Best option(s) for Nicotine use disorder

Pharmacotherapy shows highest levels of success

Verenicline or combination of NRT patch with faster acting form give optimal results

Consider NRT for smoking reduction


First line Nicotine UD drugs

NRT (patch, gum, lozenge, spray, inhaler)

Bupropion (zyban), Verenicline


Second line Nicotine UD drugs

Nortriptyline, Clonidine

**more ADEs**


NRT common ADEs

All formulations: blurred vision, dizziness, headache, nervousness, pounding in ears

Patch: abnormal/vivid dreams, skin irritation

Nasal spray: irritation, burning, runny nose, watery eyes

Inhaler: airway irritation

Gum/lozenge: mouth sores, sore throat

Serious AEs: Tachycardia (monitor HR, BP), arrhythmia, anaphylaxis


NRT counseling points

Park gum

Do not chew or swallow lozenge

Remove patch before MRI

Patch is disposable (fold ends together and discard in garbage, do not cut)


Why is it bad to cut the nicotine patch? Additional useful information about the patch?

Causes rapid evaporation of nicotine

Remove patch before bedtime if patient experiences night time issues

Patch may be worn 16-24 hours (if left on longer, will cause skin irritation)


Verenicline as Nicotine UD drug

Partial agonist at a4b2 nicotinic receptors

Monitor patient for true abstinence and renal function

Common AEs: NV, flatulence, constipation, dream disorder, headache and insomnia

Rare and Serious AEs: angina, MI, CVA, visual disturbances, hostility, mood changes, suicidal ideation, seizures

Drug-Drug Interactions: bupropion, ethanol

Counseling: take after eating and with full glass of water, limit alcohol


Black Box Warning for Verenicline

CAUTION USE IN PSYCH PATIENTS (may worsen psychiatric symptoms)


Bupropion as Nicotine UD drug

Inhibits neuronal uptake of DA and NE

Monitor abstinence from tobacco, renal function, BP and psychiatric/neuro reactions

Common AEs: tachyarrhythmia, constipation

Serious AEs: cardiac dysrhythmia, seizure, depression, mania, psychotic disorder, suicidal thoughts

Drug-Drug Interactions: MAOIs, metoclopramide, methylene blue, linezolid

Counseling: avoid bedtime dosing due to insomnia, BID doses take 8 hours apart, skip missed dose


Contraindications for Bupropion

abrupt discontinuation of alcohol, benzos, barbs, antiepileptic drugs, MAOI use within 14 days, prior/current diagnosis of bulimia or anorexia, seizure disorder


Nortriptyline for Nicotine UD

TCA (inhibits serotonin and NE reuptake, also blocks H1 and a1)

Metabolized by 2D6

Monitor abstinence from tobacco, ECG (if cardiac diagnosis or hyperthyroidism), behavior changes, suicidal ideation

Common AEs: Constipation

Serious AEs: CV stuff, bone marrow suppression, hepatic failure, suicidal ideation

Drug-drug Interactions: QT prolonging agents, MAOIs, methylene blue, linezolid, metoclopramide


Contraindications with Nortriptyline

Use within 14 days of MAOI, use with linezolid or IV methylene blue, during acute recovery of MI


Clonidine in Nicotine UD

Centrally acting alpha 2 agonist

Dose usually 0.1 mg PO BID (if BP under 90/60, skip next dose; lower initial dose in renal impairment)

Monitor BP, HR

Common AEs: contact dermatitis, erythema, xerostomia, HA, dizziness, sedation

Drug-drug interactions with other antihypertensive drugs

Counseling: do not abruptly discontinue (rebound HTN), may cause somnolence


Nicotine patch dosing guidelines

if less than 10 cigs/day (21 mg patch x6 weeks, 14 x2 weeks, 7 x2 weeks)

If 10 or more/day (14mg patch x6 weeks, 7mg x2 weeks)


Nicotine gum or lozenge guidelines

if more than 10 (4mg gum/lozenge 1 piece q1-2h for 1-6 weeks, then 1 piece q2-4h for 7-9 , then 1 piece q4-8h for weeks 10-12)

If less than 10 use 2 mg lozenge


Bupropion dosing regimen

Begin 1 week before quit date (start 150mg/day for 3 days, then increase to 150 bid at interval of 8 hours - max dose is 300/day)


Verenicline dosing regiment

Begin 1 week before quit date (0.5mg for 1-3 days, then 0.5 BID for days 4-7, then 1 mg BID for 12 weeks)


Nortriptyline dosing regimen

Begin 1 week before quit date (75-100mg daily for 6-14 weeks)


Acute/mild alcohol withdrawal

Usually occurs within first several hours of cessation

Symptoms: anxiety, irritability, GI distress, increased BP and HR

Generally supportive care, close monitoring, thiamine is sufficient


Severe withdrawal

Can occur up to several days after cessation

Symptoms: decreased attention, disorientation, hallucinations, tremor, tonic-clonic seizures, respiratory alkalosis, fever, alcohol withdrawal, delirium/delirium tremens

Benzos are primary treatment (Lorazepam, chlordiazepoxide, diazepam, oxazepam)

Thiamine should be given (to prevent Wernicke-Korsakoff syndrome)

Adjunct therapy: CBZ for withdrawal seizures, Beta blockers (tremor, HR, BP, sweating), Clonidine (tremor, HR, BP), Antipsychotics (low dose haldol)


Considerations for benzo in alcohol withdrawal

Lorazepam and oxazepam are preferred for patients with severe hepatic disease, elderly, or those with delirium, dementia or another cognitive disorder

These agents are shorter acting than others


Wernicke-Korsakoff Syndrome

Triad of confusion, ataxia and nystagmus

Technically 2 distinct syndromes: Wernicke encephalopathy (acute confusion), Korsakoff Dementia


Alcohol UD maintenance therapy

Consider naltrexone injection if significant concern in adherence (acamprosate maybe?)

Weigh risks and benefits of disulfiram (best administered with witness)

Non-pharm with pharm always better



Stabilizes glutamatergic function (for effective than naltrexone in those with goal of abstinence)

Excreted by kidneys (caution in renal impairment)

Monitor for abstinence, renal function, depression and suicidality

Common AEs: Diarrhea

Counsel: takes 5-8 days for effect, continue taking if "slip", notify doctor if suicidal thoughts or depression, do not crush, do not take missed dose if close to time of next dose


Naltrexone for Alcohol UD Maintenance therapy

Pure opioid antagonist preventing rewarding effects of alcohol (abstain 3-7 days before initiation)

Monitor signs and symptoms of alcohol withdrawal, depression and suicidal thoughts, LFTs

Caution on hepatotoxicity (usually when given more than 100mg a day)

Drug-drug interactions: opioids


Disulfiram for alcohol UD maintenance therapy

Irreversibly binds to ALDH (can occur if taken within 2 weeks of alcohol)

Reaction can last up to 2 weeks (HA, N/V, flushing, warmth, hypotension, tachycardia, anxiety, dyspnea)

96% protein bound

Common AEs: metallic/garlic aftertaste, dermatitis

Rare/serious: hepatotoxicity, peripheral neuropathy, renal failure, cardiac disease

Drug-drug interactions: alcohol, metronidazole, warfarin (and other highly protein bound drugs)

Counsel on reaction, caution on drinking, let counselor know if you slip, watch for side effects


Disulfiram contraindications

Use of metronidazole, recent alcohol ingestion, psychoses, severe myocardial disease or coronary occlusion


Which alcohol maintenance drug can be used in liver disease?



Other options for alcohol UD maintenance therapy

SSRIs, baclofen (helpful in advanced alcohol liver disease), ondansetron (effective in younger patients alone or in combo with naltrexone), Gabapentin, Topiramate