💊Pharmacology for Nurses Unit 15 – Substance Use Disorder Treatment Medications

Key Concepts and Terminology

• Substance use disorder (SUD) characterized by compulsive drug seeking and use despite negative consequences
• Addiction a chronic, relapsing disorder of the brain that involves complex interactions of neurotransmitter systems
• Tolerance occurs when higher doses of a substance are required to achieve the desired effect
• Withdrawal syndrome a set of symptoms that occur when a person abruptly stops or reduces substance use
• Craving an intense desire or urge to use a substance, often triggered by cues associated with previous drug use
• Relapse a return to substance use after a period of abstinence, common in the recovery process
• Harm reduction strategies aim to minimize negative consequences of substance use without necessarily requiring abstinence (needle exchange programs)
• Medication-assisted treatment (MAT) combines pharmacotherapy with behavioral interventions to treat SUDs

Neurobiology of Addiction

• Addictive substances alter brain chemistry by affecting neurotransmitter systems, primarily dopamine, which is involved in reward and motivation
• Repeated substance use leads to neuroadaptations in the brain's reward circuitry, resulting in increased salience of drug-related cues and decreased sensitivity to natural rewards
• The mesolimbic dopamine pathway, connecting the ventral tegmental area to the nucleus accumbens, plays a crucial role in the reinforcing effects of drugs
• Chronic substance use can cause structural and functional changes in the prefrontal cortex, impairing decision-making, impulse control, and emotional regulation
• Genetic factors influence an individual's vulnerability to addiction by modulating the function of neurotransmitter systems and receptors
• Epigenetic modifications, such as changes in gene expression without altering DNA sequence, can occur in response to chronic substance use and contribute to the development and maintenance of addiction
• Stress and adverse life experiences can increase the risk of developing SUDs by altering stress response systems (hypothalamic-pituitary-adrenal axis) and promoting maladaptive coping strategies

Common Substance Use Disorders

• Alcohol use disorder characterized by excessive alcohol consumption, impaired control over drinking, and continued use despite adverse consequences
• Opioid use disorder involves the misuse of prescription opioids (oxycodone, hydrocodone) or illicit opioids (heroin), leading to tolerance, withdrawal, and significant impairment in functioning
• Stimulant use disorders include addiction to cocaine, methamphetamine, and prescription stimulants (amphetamines), resulting in increased energy, euphoria, and potential for cardiovascular and psychiatric complications
• Cannabis use disorder characterized by problematic patterns of marijuana use, including craving, tolerance, and withdrawal symptoms
• Nicotine use disorder primarily involves addiction to tobacco products, with nicotine being the primary psychoactive component responsible for dependence
• Benzodiazepine use disorder involves the misuse of prescription sedatives (alprazolam, diazepam), often in combination with other substances, leading to tolerance, withdrawal, and increased risk of overdose
• Polysubstance use disorder occurs when an individual uses multiple substances, either simultaneously or sequentially, increasing the complexity of treatment and the risk of adverse health outcomes

Pharmacological Approaches to Treatment

• Agonist medications activate the same receptors as the addictive substance, reducing withdrawal symptoms and cravings while preventing the euphoric effects of the drug
• Antagonist medications block the effects of the addictive substance by binding to the same receptors without producing the rewarding effects, helping to prevent relapse
• Partial agonists have mixed agonist-antagonist properties, activating receptors to a lesser degree than full agonists, providing some relief from withdrawal while minimizing the risk of abuse
• Aversive medications produce unpleasant effects when combined with the addictive substance, discouraging its use (disulfiram for alcohol use disorder)
• Medications targeting co-occurring psychiatric disorders (antidepressants, antipsychotics) can help manage symptoms that may contribute to substance use or hinder recovery
• Combination pharmacotherapy involves using multiple medications with different mechanisms of action to address various aspects of addiction and improve treatment outcomes
• Medication-assisted treatment should be tailored to the individual's specific needs, considering factors such as the type and severity of SUD, co-occurring disorders, and patient preferences

Specific Medications and Their Mechanisms

• Methadone, a full opioid agonist, reduces opioid withdrawal symptoms and cravings by activating mu-opioid receptors, allowing for a gradual tapering process
• Buprenorphine, a partial opioid agonist, has a ceiling effect on respiratory depression, making it safer than full agonists while still managing withdrawal and cravings
• Naltrexone, an opioid antagonist, blocks the effects of opioids, helping to prevent relapse by reducing the rewarding effects of the drug
• Acamprosate, thought to modulate glutamate and GABA neurotransmission, reduces alcohol cravings and promotes abstinence in individuals with alcohol use disorder
• Naltrexone, in addition to its use in opioid use disorder, can also help reduce alcohol consumption by blocking the rewarding effects of alcohol
• Varenicline, a partial agonist of nicotinic acetylcholine receptors, reduces nicotine cravings and withdrawal symptoms while diminishing the reinforcing effects of smoking
• Bupropion, an antidepressant that inhibits the reuptake of dopamine and norepinephrine, can aid in smoking cessation by reducing nicotine cravings and withdrawal symptoms

Nursing Considerations and Patient Education

• Assess patients for the presence of SUDs using validated screening tools (CAGE, AUDIT) and conduct a thorough substance use history
• Educate patients about the nature of addiction as a chronic, relapsing disorder that requires ongoing management and support
• Provide information on the mechanism of action, benefits, and potential side effects of prescribed medications to promote adherence and self-monitoring
• Emphasize the importance of combining pharmacotherapy with behavioral interventions (cognitive-behavioral therapy, motivational interviewing) for optimal treatment outcomes
• Monitor patients for signs of medication misuse, diversion, or the development of new substance use disorders
• Collaborate with interdisciplinary team members (addiction specialists, mental health professionals) to ensure comprehensive and coordinated care
• Address co-occurring medical and psychiatric conditions that may impact substance use and recovery, providing appropriate referrals and follow-up
• Promote harm reduction strategies and provide resources for social support, housing, and vocational assistance to foster long-term recovery

Side Effects and Drug Interactions

• Methadone can cause sedation, respiratory depression, and QT prolongation, requiring careful dose titration and monitoring, especially when combined with other CNS depressants
• Buprenorphine may precipitate opioid withdrawal if initiated too early, and can cause hepatic dysfunction, necessitating liver function monitoring
• Naltrexone can cause gastrointestinal distress, headache, and dizziness, and its opioid antagonist properties may complicate pain management in emergency situations
• Acamprosate can cause diarrhea, nausea, and abdominal pain, which may be mitigated by taking the medication with food
• Disulfiram, when combined with alcohol, produces an unpleasant reaction (flushing, nausea, vomiting) due to acetaldehyde accumulation, which can be severe and requires immediate medical attention
• Varenicline may increase the risk of psychiatric symptoms (agitation, depression, suicidal ideation), particularly in patients with a history of mental illness, warranting close monitoring
• Bupropion lowers the seizure threshold and should be used with caution in patients with a history of seizures or eating disorders

Treatment Challenges and Emerging Therapies

• Stigma surrounding SUDs can be a barrier to seeking and engaging in treatment, requiring education and advocacy to promote a more compassionate and evidence-based approach
• Access to medication-assisted treatment can be limited by a shortage of trained providers, inadequate insurance coverage, and regulatory restrictions on prescribing practices
• Polysubstance use and co-occurring disorders complicate treatment, necessitating a personalized, multi-modal approach that addresses the unique needs of each patient
• Long-acting injectable formulations of medications (buprenorphine, naltrexone) can improve adherence and treatment outcomes by reducing the burden of daily dosing
• Vaccines targeting specific addictive substances (nicotine, cocaine) are being developed to prevent the drug from reaching the brain and producing rewarding effects
• Transcranial magnetic stimulation (TMS), a non-invasive brain stimulation technique, is being investigated as a potential treatment for SUDs by modulating neural activity in regions associated with addiction
• Psychedelic-assisted psychotherapy, using substances like psilocybin or MDMA in a controlled therapeutic setting, shows promise in treating SUDs by facilitating insight, emotional processing, and behavioral change
• Advances in precision medicine may enable the development of personalized treatment approaches based on an individual's genetic profile, drug metabolism, and other biological factors