Neurology/Psychiatry Exam #3 (Pain/Addiction)

Detoxification with methadone is typically only allowed in licensed facilities, but there is an exception for outpatient settings. In these cases, a physician can prescribe up to 72 hours of methadone to treat a patient's opioid withdrawal. Therefore, the statement is true.

The combination of buprenorphine (partial) and naloxone (full) mu antagonist would cause withdrawal in patient that was not in withdrawal. Suboxone is meant to give relief from withdrawal, not cause it

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) is a tool used to assess the severity of alcohol withdrawal symptoms. It is a standardized assessment tool that helps healthcare professionals evaluate and monitor the symptoms experienced by individuals going through alcohol withdrawal. The CIWA-Ar includes a list of 10 common withdrawal symptoms, such as nausea, tremors, and anxiety, and assigns a score to each symptom based on its severity. This tool helps healthcare providers determine the appropriate treatment and level of care needed for individuals experiencing alcohol withdrawal.

Pharmacology side effects of constipation is a result of action on the mu (like your mother said, Trebek! http://i.imgur.com/31vllYu.png) receptor.

Opiate withdrawal is not associated with mortality, seizures, coma, or death

The statement is true because methadone is the standard treatment for opiate withdrawal in pregnant patients. However, further studies have shown that buprenorphine also has potential benefits in this population.

Capsaicin is a compound found in chili peppers that is commonly used in topical creams for pain relief. When applied to the skin, capsaicin can help alleviate pain by reducing the levels of substance P, a chemical that transmits pain signals to the brain. However, it can take some time for the effects of capsaicin to become noticeable. This is because capsaicin needs to build up in the body over time in order to have a significant impact on pain perception. Therefore, it is true that it may take up to 1 month to see a noticeable effect of treatment with capsaicin.

Subutex (buprenorphine) is not preferred over Suboxone for opiate maintenance, except in pregnant patients. This is because Suboxone contains buprenorphine along with naloxone, whereas Subutex only contains buprenorphine. Naloxone is added to Suboxone to deter misuse and reduce the risk of overdose. Therefore, Suboxone is generally the preferred option for opiate maintenance treatment, except in cases where the patient is pregnant, as the use of naloxone during pregnancy may not be recommended.

Tapentadol is classified as a Schedule II medication because it has a higher abuse potential than tramadol. Schedule II drugs have a high potential for abuse, which may lead to severe psychological or physical dependence. Tapentadol is a centrally acting opioid analgesic that works by binding to the mu-opioid receptors in the brain, providing pain relief. However, it also has a higher risk of misuse, addiction, and overdose compared to tramadol, which is classified as a Schedule IV medication. Therefore, the statement is true.

Starting dose = - 75 mg BiD (I try to avoid dosing questions, but should have an idea within 10X the appropriate doses)

take on an empty stomach

Longer acting BZD create smoother withdrawal course
Liver impairment is not an absolute contraindication in all BZD
Chlordiazepoxide and Diazepam are limited to PO use

Treatment of sedatives/hypnotics is based on agent of abuse (also, alcohol has delayed delirium 48-72 hours, sed/hyp may be more immediate)

Pain from nerves to thalamus via the dorsal horn follows the ascending pain pathway, while the descending (from brain to dorsal horn) signals modulate activity to control pain transmission.

IV is preferred, short course = 500 mg IV/IM tid x 3 days; then 500 mg IV/IM daily x 5 days; then oral therapy if symptoms have improved

Chronic back pain may be present without morphologic changes

Methadone can be administered in an inpatient setting only if patient was admitted for something other than opiate addiction/withdrawal

Is not FDA approved for opioid withdrawal

The onset of alcohol withdrawal delirium (including delirium tremens) comes 48 to 72 hours after the last drink (Note- This is a differentiating factor from benzo withdrawal)

Mu = ADE and euphoric effects

The given answer states that all of the statements about gabapentin (Neurontin) are true. This means that all of the following statements are true: common adverse effects of gabapentin are dizziness and somnolence, the onset of action for gabapentin is 2-3 weeks, a trial of gabapentin requires 3-8 weeks, gabapentin requires renal adjustment, and the titration schedule for gabapentin is 300mg at bedtime on day 1, 300mg twice a day on day 2, and 300mg three times a day on day 3.

While pain control may not be supported by evidence, it may be trialed in (appropriate) patients and may be used to treat Depression

Alcohol Withdrawal Delirium is a severe and potentially life-threatening condition that occurs when a person abruptly stops drinking alcohol after a prolonged period of heavy consumption. The symptoms of delirium tremens include confusion, hallucinations, seizures, and severe agitation. Treatment typically involves the use of benzodiazepines (BZD) to manage symptoms and prevent complications. However, in some cases, the addition of phenobarbital, a long-acting sedative, may be necessary to effectively control symptoms and ensure the safety and comfort of the patient. Therefore, the statement that Alcohol Withdrawal Delirium is treated with phenobarbital in addition to BZD is true.

Don’t crush, break, or chew CR formulation
Renal dysfunction = 33-50% reduction in initial dose
Dose can be increased every 1-2 days, max = as tolerated

Methadone is a medication that is used for both the treatment of opiate withdrawal and opiate maintenance treatment. It acts as a full mu receptor agonist and weak NMDA antagonist. It is important to monitor patients taking methadone for QT prolongation via EKG. Dose tapering of methadone depends on the opiate of abuse from which the patient is withdrawing. Therefore, all of the above statements about methadone are true.

Acute toxicity of alcohol does not stem from down regulation of alcohol dehydrogenase. Acute toxicity is primarily caused by the depressant effects of alcohol on the central nervous system, leading to impaired coordination, respiratory depression, and potentially fatal alcohol poisoning. Alcohol dehydrogenase is an enzyme responsible for metabolizing alcohol in the liver, and down regulation of this enzyme can occur with chronic alcohol consumption, leading to increased alcohol tolerance.

In hepatic dysfunction, dose can be reduced/extended

Max dose = 400 mg/day

Taper can be 25-50% reduction of daily dose per week

Dosed as needed based on COWS assessment

No single agent is superior in efficacy. Patient preference and compliance are very important.

Proper administration (or the notes say) q12 hours. Patch can be cut to fit the site

Not recommended for use in patient with CrCl