hyperactivity, anxiety, and fluctuating levels of psychomotor activity (Boland & Verduin, 2022). Alcohol induced disorders Wernicke encephalopathy (alcoholic encephalopathy) is charac- terized by ataxic gait, vestibular dysfunction, confusion, horizontal nystagmus, lateral orbital palsy, and gaze palsy (Boland & Verduin, 2022). The condition is reversible but may progress to Korsakoff syndrome (Boland & Verduin, 2022). Korsakoff syndrome is a chronic amnestic syndrome that follows Wernicke encephalopa- thy (Boland & Verduin, 2022). The main feature is anterograde amnesia, with possible confabulation (Boland & Verduin, 2022). Thiamine deficiency is the pathophysiologic between these two syndromes (Wernicke-Korsakoff syndrome) (Boland & Verduin, 2022). Thiamine is involved in the conduction of axon potential and synaptic transmission (Boland & Verduin, 2022). Antidipsotropic medications ● Acamprosate is the most effective medication for maintaining abstinence in alcohol use disorder (France, 2022). Acampro- sate is thought to target GABA and N-methyl-D-aspartate glu- tamatergic receptor activity, thereby decreasing cravings and relapse (France, 2022). The individual must be alcohol-free at initiation and is contraindicated in severe renal disease. Side effects include diarrhea and nausea. Dosing is weight based, and titration is not required (Mariani, 2014). ● Disulfiram is a second-line treatment to treat individuals who are dependent on alcohol but are motivated to discontinue use (Stokes & Abdijadid, 2022). Alcohol consumption increas- es serum acetaldehyde causing diaphoresis, palpitations, fa-
cial flushing, nausea, vertigo, hypotension, and tachycardia. These symptoms are known as disulfiram-alcohol reaction and discourage alcohol intake (Stokes & Abdijadid, 2022). Side effects include headache, skin rash, drowsiness, and metallic aftertaste; adverse reactions include hepatitis and peripheral neuropathy. ● Naltrexone is a first-line treatment for alcohol and opioid de - pendence by blocking the µu receptor (Singh & Saadabadi, 2022). Additionally, naltrexone also modifies the hypotha - lamic-pituitary-adrenal axis to suppress alcohol consumption (Singh & Saadabadi, 2022). Absorption is almost complete after administration but has an extensive first pass effect. Nau - sea and abdominal pain are common. Caution is needed in hepatic and renal impairment. Healthcare Considerations: Delirium tremons should be considered a medical emergency and can be fatal if not managed. The best-validated tool to assess the severity of alcohol withdrawal is the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar). The main treatment objectives for alcohol withdrawal are controlling agitation, lowering seizure risk, and reducing morbidity and mortality. Benzodiazepines are the first-line treatment for all alcohol withdrawals. Barbiturates are used for those patients who are refractory to benzodiazepines. Propofol in conjunction with benzodiazepines could be used in patients refractory to barbiturates; however, this would require mechanical ventilation (Hoffman & Weinhouse, 2023).
ANXIOLYTICS OR SEDATIVE-HYPNOTIC RELATED DISORDERS
Sedative hypnotics are among the most commonly prescribed psychoactive drugs by clinicians in primary care (Ehrlich, 2022). These drugs are frequently taken orally to obtain a steady intoxi- cated state. Individuals with sedative-hypnotic or anxiolytic use disorders are frequently treated in the outpatient setting, as the overall stability requires less monitoring. Sedative drugs decrease activity diminishes excitement, and calm the individual (Mihic & Mayfield, 2023). Sedatives are often used to alleviate unwanted side effects of other substances (APA, 2013). Hypnotic drugs produce drowsiness and facilitate the onset and maintenance of sleep that resembles electroencephalography where the individu- al is easily aroused (Mihic & Mayfield, 2023). The usual course of these disorders begins in the teens or 20s, with social patterns, moving into daily use with high tolerance lev- els (APA, 2013). A less frequent pattern begins with prescription use and reports of anxiety, insomnia, or other complaints (APA, 2013). Individuals demonstrating a problematic pattern of sub- stance use that leads to significant impairment as manifested by two or more criteria over a 12-month period meet the criteria for sedative, hypnotic, or anxiolytic use disorder: 1. Sedatives, hypnotics, or anxiolytics often taken in larger amounts or over a longer period than was intended. 2. A persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use. 3. A great deal of time spent in activities necessary to obtain the sedative, hypnotic, or anxiolytic or to use, or recover from the sedative, hypnotic, or anxiolytic. 4. Craving or a strong desire or urge to use the sedative, hypnotic, or anxiolytic. 5. Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedative, hypnotic, or anxiolytic. 7. Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotic, or anxiolytic.
8. Recurrent sedative, hypnotic, and anxiolytic use in situations in which it is physically hazardous (driving, operating machinery). 9. Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic. 10. Tolerance: a. A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of sedative, hypnotic or anxiolytic. 11. Withdrawal: a. Characteristic withdrawal syndrome. b. Sedatives, hypnotics, or anxiolytics are taken to relieve or avoid withdrawal symptoms. (APA, 2013) Benzodiazepines (BZDs) are one of the most widely prescribed drug classes in the United States, known for depressant effects on the central nervous system (Edinoff et al., 2021). BZDs are Federal Drug Administration (FDA) indicated for anxiety disorders, insom- nia, acute status epilepticus, induction of amnesia, spastic disor- ders, and agitation (Edinoff et al., 2021). Non-FDA-approved in- dications include Tourette’s syndrome, delirium, delirium tremens, sleep disorders, and abnormal medication movements (Edinoff et al., 2021). Barbiturates were popular before the introduction of benzodiaz- epines. Pentobarbital and secobarbital have short half-lives and are lethal, producing coma and death. Barbiturates produce pro- found respiratory depression, especially when added to another substance. These drugs are not widely utilized. Individuals with sedative-hypnotic or anxiolytic disorders are frequently treated in the outpatient setting as the overall stability requires less moni- toring.
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