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What is the definition of drug (substance) abuse?
drug use inconsistent with medical or social norms
What is the definition of drug (substance) misuse?
indiscriminate or recreational use of a chemical substance or its use for purposes other than those for which it is intended
What is the definition for addiction?
a complex disease of the central nervous system characterized by a compulsive, uncontrolled craving for a dependence on a substance to such a degree that cessation causes sever emotional, mental and/or physiologic reaction
What is the definition of dependence?
reliance on a substance that has reached the level that its absence will cause impairment in function
what is the definition of tolerance?
decreased effect of a substance that results from repeated exposure.
Note: it is possible to develop cross tolerance to other substances in the same category
What is the definition of detoxification?
involves treating an intoxicated client to diminish or remove drugs or their effects from the body
what is the definition of withdrawal syndrome?
constellation of physiologic and psychological responses that occur when there is abrupt cessation or reduced intake of a substance on which an individual is dependent or when the effect is counteracted by a specific antagonist
what is the definition of abstinence?
sustained avoidance of substance use.
what is abstinence syndrome?
when a client abruptly withdraws form a drug on which he is physically dependent, can be distressing and my lead to coma or death
Nicotine - pharmacokinetics
- rapidly absorbed through the lungs (smoking), slowly through bucal/nasal mucosa (chewing/sniffing).
- crosses membrane easily and distributed throughout body easily.
- Toxic - breastfeeding
- plasma protein binding <5%
- liver metabolizes nicotine (first pass)
- eliminated through urine
- t1/2 = 1-2 hours
Nicotine - Pharmacodynamics
- low doses, activates nicotinic receptors (smoking)
- activates receptors in autonomic ganglia and adrenal medulla
- CNS - activates on mesolimbic reward system of brain, release dopamine
- mimics the effects of cocaine (or other highly addictive substances)
Nicotine - SEs/ADE
- cardiovascular stimulation - increased myocardial oxygen consumption
- Brain - general CNS stimulation
- phsyical effects - increased RR, tremor
- physiologic effects - increased arousal, alertness
- GI - increases GI secretions and smooth-muscle tone
- effects seen when withdrawal is relieved by further nicotine - depressant effect, relief of anxiety/relaxation
- abstinence syndrome - irritability, nervousness, restlessness, insomnia, and difficulty concentrating
- causes very strong psychological dependence
- symptoms present a few hours after withdrawal, peaks at 24-48 hours but can be seen weeks to months after withdrawal.
Nicotine - Bupropion (Zyban)
- atypical antidepressent
- unrelated to nicotine
- inhibits uptake of DA and NE
- Decreases nicotine craving
- AKA: Zyban/Wellbutrin
Nicotine - Varenicline (Chantix)
- nicotinic receptor partial agonist
- alternative to NRT and Bupropion
- reduces cravings
- decreases pleasurable effects (tobacco and Cigarettes)
- approved course - 12 weeks
- ADE - nausea, headache, vomiting, flatulence, insomnia, abnormal dreams, and change in taste
Nicotine - Nortriptyline (aventyl, pamelor) and Clonidine (Catapres)
- second-line drugs to reduce nicotine withdrawal symptoms (promote cessation)
- NOT APPROVED - FDA
- action is not understood
- Nortriptyline - tricyclic antidepressant
- Clonidine - alpha2-agonist (treat hypertension)
Nicotine - treatments
- NRT (nicotine replacement therapy)
- Burpropion (Zyban)
- Varenicline (Chantix)
- Nortriptyline (Aventyl, Pamelor) and Clonidine (Catapres)
Nicotine - NRT
- Nicotine Gum (Nicorette)
- Nicotine patch (Nicotrol)
- Nasal Spray
- reduces nicotine previously obtained from cigarettes
- provides nicotine with slow delivery and eliminate the carcinogens and gases associate with smoke
Nicotine - Patient education
- Zyban - dry mouth - chew gum, hard candy, water, ice chips
- avoid caffeine and other CNS stimulants
- Nicotine gum - no longer than 6 months, chew slowly over 30 minutes, avoid eating drinking 15 minutes prior and while chewing gum
- Nicotine patch - place patch on area of clean, dry skin each day, remove patch prior to MRI scan
Cocaine - Pharmcokinetics
- Absorption rate: depends on route (free based,snorted, smoked, or injected)
- Smoking and IV have fastest absorption.
- Peaks and blood levels within 5 - 30 minutes.
- Longest effects occur following internasal use
- t1/2: 50, 80, and 60 minutes (oral transnasal and IV)
- Tolerance appears with long term use. Crosses the placenta during pregnancy.
Cocain - Pharmcodynamics
- Increase activation of DA in the reward system.
- Magnifies pleasure and leads to rapid dependence.
- Increase NE at postsynaptic receptor sites, producing intense vasoconstriction and cardiovascular stimulation.
- Produces a euphoria, energy and altertness
- Adrenaline like actions, impairment to concentration and memory, irritability and mood swings, paranoia, and depression
- Stimulate psychosis progresses from paranoid delusions to visual hallucinations and tactical hallucinacations
- Skin excoriations from scratching, common needle marks, elevated blood pressure, heart rate, and temperature. "Findings that differentiate from schizophrenia".
- Acute cocaine toxicity manifest as cardiac palpitations, tachycardia, increased RR, and fever.
- Overdose: Grand mall seizures, hypertension, dysrhythmias, and myocardial ischemia, restlessness, paranoia, agitated delirium, and confusion, as well as bizarre erotic and violent behaviors well as death may occur
- Withdrawl symptoms: dysphoria, fatigue, depression, and a need to sleep in the first 19 hours to 14 days.
- Craving remains for an infinite period
Cocaine - Treatments
- No antidote
- Cognitive behavior therapies
- No approved drugs currently
- Disulfiram (Antibuse) has helped reduce drug use from 2.5 days a week to 0.2 days a week.
- Modafinil (Provigil) CNS stimulate used to narcolepsy
- topiramate (Topamax) and the antiemetic ondansetron (Zofran) are understudy. Research is being done for a vaccine.
Amphetamines - Pharmcokinetics
Prescribed for oral use. Peak effects 60 to 90 minutes. Lasting 2 to 4 hours. More rapid effects by smoking, snorting, or IV injection. Longer t1/2 than cocaine and is more intense.
Cocaine - Pharmcodynamics
Stimulates release of DA and NE in brain and SNS. Produces euphoria and sense of self confidence.
Amphetamine - SE/ADE
- Initial use - Increased alertness, improved performance, relief of fatigue, anorexia, cardiovascular stimulation, increased HR and BP. Irritability, anxiety, paranoia, hostile, and violent behaviors, tooth decay, and dermatological deterioration.
- Toxic reactions: amphetamine psychosis, paranoia, seizures, death as a result of dysrhythmias, MI, hypothermia, cerebral hemorrhage.
- Withdrawl symptoms: similar to cocaine, mild physical dependence, IV use will cause onset within two hours, oral use results in 8 to 10 hours.
Amphetamine - Treatment
- Emergency treatment is the same as that with cocaine.
- Elevated BP, tachycardia, controlled with vasodillators, and adrenergic beta blockers
- Drug elimination is enhanced by administration of Ammonium Chloride and no specific drug therapy to remain abstinence.
Caffeine - Pharmacokinetics
caffeine is readily absorbed from the GI tract and reaches peak plasma levels in about 1 hour.
Caffeine - Pharmacodynamics
- Methylxanthine that simulates the CNS - Medulla respiratory center
- diuretic and myocardial stimulant
- relaxes smooth muscle and promotes peripheral vasodilation and cerebral vasoconstriction
Caffeine - SE/ADE
- oral doses (200 mg): elevate mood, produce insomnia, increase irritability, cause anxiety and offset fatigue
- Intake of 500mg : nervousness, insomnia, gastric hyperacidity, muscle twitching, confusion, chest pain, tachycardia and cardiac dysrhythmias
- Toxic doses: panic
- physical and psychological dependence seen with use of >500mg/day
- withdrawal symptoms: headache, irritability, drowsiness and fatigue within 21-24 hours
Caffeine - Treatment
- Managed symptomatically
- Assisting client to reduce gradually or stop intake of caffeine.
- Substituting decaffeinated beverages
Alcohol - Pharmacokinetics
- absorbed from stomach and small intestine (slower in the presence of water or food - especially proteins and fats)
- fast absorption occurs when mixed with carbonated liquids
- distributed to all body tissues and fluids
- crosses the placenta
- metabolized in liver at a constant rate
- moderate drinking metabolic rate = 7g/hour
- heave use increase metabolic rate
- women have higher blood alcohol levels than men after the same amount of alcohol intake due to lower rates of stomach metabolism
Alcohol - pharmacodynamics
- CNS depressant
- brain reward system resulting in the release of DA and promoting the addictive process
- potentiation and cross-tolerance with other CNS depressants also may occur
- concentration of alcohol in body determined by assessing the BAC
- interacts with OTC and prescribed medications
- Cross-tolerance develops to general anesthetics, barbiturates, and other general CNS depressants but NOT TO OPIOIDS