Drugs Affecting the CNS

Added: 2026-05-15

[00:00:01]hello this is Dr Garner and I will be lecturing on several different topics starting off with drugs affecting the central nervous system here are the objectives and I will let you read those for yourself just an overview the central nervous system consists of the brain the spinal cord and the retina it contains the majority of the nervous systems it coordinates the activity of all parts of the body the brain in the spinal cord serve as the main processing center for the entire nervous system and control all the workings of the body there's millions of neurons that provide the capacity as a reason experience feelings and understand the world in general and the neurons provide the capacity to remember numerous pieces of information we'll go over some of the anorexins anticonvulsants antidepressants and so forth so here are some of the interactions and I won't spend a lot of time on these um because nurse practitioners in Louisiana do not prescribe any Medicaid controlled medications for obesity or weight loss so these are short-term generally about 8 to 12 weeks and they are used for weight loss they are chemically and pharmacologically related to amphetamines again nurse practitioners do not prescribe these um recently there was a discussion among the Louisiana lawmakers over whether to let nurse practitioners write prescriptions for patients even with chronic pain and obesity that ended up being this big debate over whether the state is doing enough to address its Health Care disparities a lot went on at this meeting short of the story is that it was not approved um the lawmakers asked for more information as far as how can we do this safely what is our plan and then we have anti-convulsants they're used in the treatment of seizures and they're also used in the treatment of mood disorders so anti-convulsants are first line in the treatment of the tonic clonic and partial complex seizures these drugs are metabolized in the liver some of the medications would be the peganome which is only available in a 250 milligram tablet there's the remix um that's not for Primary Care I just put that in there so you'll have an idea of it and then there's the dilant one that you'll probably see patients on often that comes in a chewable tablet a suspension and extended release tablets so here are some of the adverse drug reactions of course it's not used IV or I am in clinic you have to monitor these patients closely for a livery kidney disease you also need to be monitoring for their levels um and to let them know that they may experience some nausea vomiting gingival hyperplasia is one of the common complaints especially when children have to start an anti-convulsant young um then they have the gingival hyperplasia that may or may not go away usually it does not um also urinary retention and discoloration of the urine and then here are some of the drug interactions so these medications are best initiated by NPS who work with neurologists to make the diagnosis this is generally not something you're going to start in primary care you can refill these medications um you're going to monitor some baseline Labs you're going to want plasma levels and thyroid levels and make sure you do a thorough assessment of what medications they're taking in addition to this medication it's always prudent to do a medication assessment at every single visit again one thing that's important to know is that if a patient is started on an anti-convulsant they need to be seizure free for more than a year before they begin to dry a lot of them do not like that but they do have to be seizure free um also you want to educate them on good oral hygiene because of the gingival hyperplasia Tegretol Tegretol XR is carbamenzapine if your patient is on that you need to make sure they're avoiding great fruit juice due to the drug interactions know that it can depress bone marrow can possibly cause liver damage and impaired thyroid function so put your thinking caps on put your thinking cap on if you're prescribing carbamazepine to a patient and it can cause liver damage or impaired thyroid function what are you going to do what is it your responsibility to do that's how I want you to think when you see medications like this put your thinking cap on so before you even start this you're going to get a CBC a Kim panel a hepatic panel and thyroid levels and then I have some other medications in there as well Lamictal that is a anti-convulsant and it's also used as a mood stabilizer um this is used as an adjunct treatment in adults and children greater than two years old you can use this with Dilantin or valproic acid note that um if they consume alcohol their levels will be increased so you need to educate your patient well it's metabolized in the liver and the kidneys and one thing you always want to tell your patient is to look for a rash they may get a little rash that looks like it's nothing and turn all the way into Stevens Johnson's or tens so educate your patient document your education about that rash again you'll get some baseline labs some of the typical antipsychotics there is the phenothiazine which is thorazine um thorodiazine and some others and then there's the non-phenol diazines like Haldol there's the uh typical antipsychotics aren't used as much as the atypicals you'll probably see some of your patients coming through clinic on atypical psychotics these are not drugs that you're going to generally initiate your patients on unless you are in the psych mental health program these patients will come to you on these medications but these will not be medications that you're going to initiate in the clinic some of the side effects of antipsychotics the typicals especially are those extracinal symptoms or EPS they also Elevate the prolactin and can cause the gynecomastia males so you want to make sure you're monitoring for bone marrow depression in these um it's contraindicated if they have any severe liver or cardiac disease or narrow angle glaucoma there is a black box warning for the older population if you're using typical antipsychotic so you need to be very very careful again these are not medications that you will prescribe if you're in the FNP program but you may see some of your patients on these medications and you need to be just as aware of the contraindications in different drug drug interactions as anyone else so again here are some of the reactions the adverse drug reactions for the typical such as sedation weight gain EPS also neuroleptic malignant malignant syndrome which is rare but can happen um these patients require monitoring of their um abnormal involuntary movement scale or an aim scale which has to be done again that will be done in the mental health setting but these are just things you need to watch for if your patient comes in and you're doing an assessment you want to assess their movement this will be assessed in mental health care but also if you notice any abnormal movements lip smacking um toes moving fingers moving involuntary body movements you want to make note of that and you also probably want to make sure that they're seeing their mental health care provider some of the direct reactions of atypical weight gain diabetes um the orthostatic hypotension and if the clozapine I just want you to know can cause a fatal a granulocytosis again you will not be initiating clozapine in the clinics now you may see a patient on lithium a lithium carbonate um the mechanism of action for that is unknown there's a half-life about 15 to 36 hours and they reach steady state in about five to seven days there is a very narrow therapeutic index for this and it's 0.6 to 1.5 if a patient's on lithium they need to have their mono their levels monitored every 10 to 14 days once they first start and then about every two to three months thereafter you may be asked by the mental health provider when you're obtaining Labs if you can get their lithium level but most mental health providers will monitor this on their own because they know that they're responsible if this pay if their patient is on lithium and you want to tell the patient to maintain an adequate some intake if they're taking Lithium lithium is a pregnancy category D there's many many drug interactions that can happen with patient taking Lithium I want to educate your patient to monitor for bruising or delayed clotting and now we'll go into some of the non-classified mood stabilizers like I said earlier Lamictal is one Neurontin and topopath Topamax um with Neurontin or Gabapentin there's a high risk for abuse potential with that medication these stimulants would include um dexameth dexa dexa amphetamine amphetamines um the methylphenidate these are more like your Adderall your rhythms your conservatives and just to talk briefly about them they're contraindicated in heart disease hypertension and pregnancy so put your thinking cap on if they are contraindicated in heart disease hypertension or pregnancy what are you monitoring for they can um in cause insomnia so you want to make sure if your patient's taking it they're taking it first thing in the morning um weight loss due to anorexia palpitations and headache if you are prescribing any of these medications they are scheduled two medications um you need to be monitoring in the prescription drug monitoring um program you have to be a part of that if you have a DEA number you want to know how much of this medication your patient is using definitely how often are they requesting refills this is one that you will not refill early if the dog ate it if their friends stole it if it dropped out of the car they flush them down the toilet no matter what this is schedule 2 medication you will not want to prescribe this medication early the DEA does monitor how often we write scheduled medications so if you gave your patient say you gave them Adderall and a week later they came back and said somebody stole it out of their car maybe they lost it even with a police report I have them wait until the next time that they can get it filled because this is not a life or death medication uh also you can use Strattera which is what I normally start adults at um because it is a non-stimulant medication okay we'll talk a little bit about it so Nia so here's some of the benzodiazepine hypnotic drugs which is Restoril Halcyon domain these are agonists and they enhance the body's own Gaba um gaba-mediated inhibitory process so some of the advantages is that they produce sleep with a various risk of respiratory depression and they are taken orally some of them are very inexpensive overdose potential is very low so and they have multiple uses so you can use this for insomnia and you can use it as an ambiolytic most of them have a rapid onset of about 15 to 30 minutes and they're good of course for inducing sleep there is lorazepam and clozapam um they have a rapid onset and a long delayed duration of action so those are good if you need to induce sleep and make the patient stay asleep if the patient's having trouble falling asleep and staying asleep the Temazepam or restaurant um and the proton those have a delayed onset an intermediate duration of action now some of the disadvantages could be the risk of dependence um if they're used you really shouldn't use sleep aids for greater than two to three weeks these patients should be practicing sleep hygiene which you'll learn about in your didactic courses but you always want to start with sleep hygiene before medications but these medications are available to be used some sleep aids can cause the Amnesia of amnesic effects they have had patients take sleep aids that wake up during the night and have no clue what they're doing is um they're almost kind of like that date rape drug or because the patient can get the sleep medication I've had patients tell me they woke up with food cooked in their kitchen and they have no recollection of it but they were the only person home and that had not happened before they left so these medications you do want to be very careful when you're prescribing some of the other hypnotic drugs like Lunesta Ambien rosarum uh Lunesta Ensenada Ambien is one of the culprits that is known for having that Amnesia effect where patients can tell you they took it and they have no earthly idea how they did what they did during the night so the the Nesta Sonata and Ambien have a rapid onset of action about 15 to 30 minutes and the duration is about eight hours so these should be good at inducing sleep and helping the patient to stay asleep now the Lunesta is the only sedative hypnotic that's approved by the FDA for chronic use and that's up to six months granted you will see some of these patients on this medication much longer much much longer than the two to three weeks but know that that's off label FDA only approves Lunesta for long-term chronic use the rosarum is orally that's not a controlled substance and that induces sleep within about 30 minutes so of course prep your patient educate them tell them to be ready for bed when they take their sleep medications um an overdose of these medications can cause severe um central nervous system depression and hypotension they are not recommended for children they are a category C and their controlled substances okay so we'll move on to the treatment of Parkinson's so what is Parkinson's it's a spontaneous degeneration of the dopamine producing cells in the midbrain and dopamine is an inhibitory neurotransmitter and at this location of the brain it's responsible for firing off certain nerve cells that are involved with skeletal muscle contraction Parkinson's patients have a deficiency of dopamine which leads to impaired relaxation um muscle rigidity is the typical complaint or manifestation of Parkinson's disease here's some of the dopamine agonists like um some you've probably heard of a cinnamon mirapex harleydale and requip the dopamine acne drugs they replace the natural deficiency of the inhibitory neurotransmitter dopamine it attempts to re-establish the balance between the contraction and the relaxation of and relaxation of the brain on skeletal muscle so they're they're well absorbed orally and they're metabolized in the liver uh let's see levodopa is metabolized in the GI tract these medications usually have a rapid onset of action about 10 to 15 minutes in the duration of action is about 12 to 24 hours so levodopa Carbidopa or cinnamon that's metabolized into dopamine there's a sustain released it's vid dosing it's initial monotherapy and it treats that muscle rigidity levodopa again is metabolized in the GI tract that has a rapid onset it is no longer available as a monotherapy in the United States um it may cause some orthostatic hypotension smiled but if you think about the older adult population orthostatic hypotension can be dangerous some other dopamine agonists or bromocriptine and amanadine brahmacryptin um patients May complain about nausea derogeneous and headache there may be some possible hypotension which again is dangerous in our adult population it's not useful as a monotherapy and it's only effective when it's used as an adjunct to levodopa Carbidopa so you need to have cinnamon in the barometry together amenity that can be used as an initial monotherapy it can also improve mood and sense of well-being and it's inexpensive it has very minimal adverse effects because it's not metabolized in the liver it's not metabolized I'm sorry it's not metabolized so that's why it causes minimal effects pergolide you may have heard of this one it's the one daily dosing and that is also taken with levodopa and just a little bit more about the amenities is that it's useful for Parkinson's and it's also useful as an antiviral agent for influenza the patients will take that twice a day okay pergoli is not useful as a monotherapy and it's only effective when given as an adjunct it's very expensive so you probably won't see it often several side effects from that um and it may cause a cardiac valve fibrosis as well so you probably won't be seeing pergoli too often next we have the monoamine oxidase b or the malb inhibitor drugs um you see them there which is the depronyl um as a light um these increase the availability of dopamine they're taken orally metabolized in the liver and excreted in the urine so these drugs selectively and irreversibly bind to and block the actions of the maob so is that in that maob is the enzyme that metabolizes dopamine and because dopamine is not metabolized more of it remains available for interaction with its receptors some of the disadvantages is not effective as a monotherapy it's very extensive may cause some nervousness anxiety and nausea and then we move on to the com T Inhibitors which is tasmar and content um they inhibit inhibit the enzyme catacolo methyl transferase or com T so that raises the dopamine level their oral administered orally or I am and they're metabolized in the liver and excreted in the urine some of the advantages of these drugs when they're used in combination with the levodopa they reduce the off time during that on off period and so the period of return of symptoms when the effect of levodopa wears off that's reduced with these medications some of the disadvantages of course is that it's not useful as a monotherapy and it can cause um liver failure the Tasman can cause liver failure so if youth is limited to those patients who have exhausted all other treatment options so com T is not your go-to even if no benefit has happened within three weeks then you should withdraw this treatment because this can cause like diarrhea or the static hypotension in hallucinations again come to drugs are not your go-to these are not the ones that you're going to pick up first so some of the takeaways put your thinking cap on I want you to know the advantages and disadvantages of the Parkinson medications which medications are monotherapy which which are good monotherapy medications used know about um Dilantin Tegretol and mictal no um your which or your typical antipsychotics and the atypical antipsychotics know the side effects of those mechanism of action understand lithium um what you're going to be monitoring for for lithium are there any drug levels what about the toxicity understand a little about the stimulants in the high hypnotic drugs as well okay now we will review some of the mental health conditions that affect the central nervous system so we'll talk a little bit about depression and anxiety and Primary Care we'll go over a little bit about the pharmacodynamics medications that are available some of the goals of treatment and of course the drug selection so major depression is one of the top reasons for disability in the United States it affects about 350 million people across their lifespans whereas anxiety about 18 of adults are affected Behavior as Primary Care Providers you will often be the first treat of patients depression and anxiety you are instrumental in screening early identification assessment treatment and referral I say referral because you have to know when to refer your patient you can start off treating with some of the common go-to depressive medications but if your patient is not improving um you see their condition is deteriorating refer them to mental health um also if they have a major just major depressive disorder that is severe that is probably not somebody that you want to treat because they need dual therapy um they need more than just medication they probably need counseling they may need more than one medication they may need adjuncts and these are outside of your realm so know when to refer so neurotransmitters have specific neuroreceptors um there's the serotonin or 5-ht there's norepinephrine dopamine there's the gamma amiobutyric acid and there's acetylcholine so the neurobiology and mental health is important because it gives us an understanding of why certain medications work on certain receptors and that helps us to treat anxiety and depression so some of the pharmacodynamics they have the different types of medications that you'll see and will go over the majority of these in this brief lecture we'll start off with the non-selective nor epinephrine serotonin reuptake inhibitors these were formerly called tricyclic antidepressants or the tcas they inhibit the reuptake of norepinephrine and 5-ht they also while blocking the serotonogric alpha adrenergic histamine and miscarinic receptors these are not first line because of the side effects and you have to be very very careful when you prescribe this medication because a patient can overdose with just a one week supply of this medication so you want to make sure you're assessing your patient for suicidal ideations if they have any history of suicide or if they're in a high-risk population so these are also used the tcas to be used as a sleep aid in a low dose um at bedtime also can be used amitriptyline is also used for chronic pain syndrome and that's because it has an ability to see a long duration linked to healing and quality of life next we have the serotonin reuptake Inhibitors or the ssris these are your initial drug of choice for many patients and they block the transport mechanism for Unbound 5ht they do interact with many many other drugs and one of the big things is that they can a patient can get serotonin syndrome which is potentially life-threatening and that's if they have too much serotonin if you're giving them um they have an excess from the serotonin Agonist activity when they first start taking it they might feel a little bit fuzzy you might get a little bit nausea this is usually transient um Paxil paroxetine has a very long Half-Life which when if you have a patient that you prescribe Paxil II um maybe they have a mild depression and you want to get them started on some paroxetine you need to let them know not to abruptly stop taking that medication you will have to taper them off of that medication slowly to avoid any withdrawal symptoms that they may get we have the selective norepinephrine reuptake Inhibitors or the snris and they increase both serotonin and norepinephrine by inhibiting their reuptake in the cells of the brain now addition of norepinephrine makes these drugs lethal in an overdose so these are your venlafaxines your your Duloxetine and your Desmond La vaccines um Duloxetine or Cymbalta is also used for neuropathic pain and venlafaxine or Effexor Effexor XR has been used for reduction of the vasal motor changes in menopause so these are some other reasons you can prescribe these medications the norepinephrine dopamine reuptake Inhibitors these are used for smoking cessation they block those receptor sites in the reward center of the brain with these medications your patient could have an increased risk for seizure so you want to assess before prescribing do you have any history of any seizure disorder and these may make anxiety and agitation worse these are your medications like bupropion which is Wellbutrin Wellbutrin XL they're really really good drugs however they're not good for everybody also one selling point for males is that in females as well is that there's a lower risk of sexual dysfunction reported in this drug actually this is also used as an adjunct if a patient is having some of those effects with another medication the norepinephrine and serotonin-specific agonists so what do they do they block the five ht2 and 5 ht3 receptors they block histamine so they cause drowsiness and weight gain and that's the rimrod so who would this be good for you're thinking Okay who wants to be drowsy and gain weight okay put your thinking cap on put your thinking cap on the elderly population they usually have trouble sleeping they usually can't their their weight becomes very they low and they're thin and they want to gain weight so this would be a good patient to prescribe Mirtazapine too if you prescribe Mirtazapine to a younger person and they gain 30 pounds they're gonna hate you they're gonna be so mad they're not going to want to have taken this medicine why'd you give me this so know your side effects and know your audience know who you're prescribing to know your patient um like I said it's good for the elderly population it's very good for sleep you may see it as a sleep aid it may help your patient to sleep but they're also probably going to gain some weight and be very upset about that so the monoamine oxidase Inhibitors or the maolis they block monoamine oxidase by binding to the enzyme and permanently inactivating it so these are rarely prescribed rarely prescribed but they are should only be prescribed in the mental health care setting um they have to have very very specific restrictions with these drugs um because if not followed they can have lethal side effects things like hard aged cheese cannot be eaten things retirement in it so it's very hard to monitor that patient's dietary habits when they're away from you so it's safer just not to prescribe these unless it's you have no other choice and again as a primary care you will not be prescribing these medications so we'll talk a little bit about benzodiazepines they enhance the Gaba Gaba when you think of Gaba um think of a slowing down of responses it slows down the reactivity of the of the brain so I think of Gaba kind of like that teacher on Charlie Brown which is slow Gaba slows reactivity now benzos have a very high abuse potential so we only want to give those when necessary there's short there's three different kinds they're short acting intermediate acting and long acting and then we also have the non-benzo Gaba agonis Buspar boosterum which is very effective in treating anxiety should only be used short-term because the abuse is so high and for the goal of treatment you want to tell your your patient you want to reduce their symptoms you really want them to be able to manage their symptoms without medication using things such as coping skills um and in depression we want to achieve remission um but know that they also may need some counseling coping skills whatever so that's why I said referral is really really good um that's what we're here for as a mental health providers to take care of those patients so why are you going to select your drugs what's the rationale drug selection first you need to have the correct diagnosis you need to be able to understand that the relationship between anxiety and depression which a lot of times they go hand in hand you know the population how to treat your older adults versus children versus adolescents and also be on the lookout for those high-risk populations you want to assess for comorbidity such as like drug and alcohol abuse any chronic illness any learning disabilities or any other psychiatric illness like bipolar um do you know well you haven't gotten there yet but you'll under have to understand bipolar and OCD you need to know all of that when you're selecting medications to use before you even select a medication there are some non-pharmacologics therapies out there that you can try first exercise cognitive behavioral therapy um some short term uh psychodynamic psychotherapy there's several different um non-pharmacologic therapies you can go to before a medication know about your black box warnings especially with benzos and the the drug dependency you need to know the Black Box warnings for ssris you know they're going to cause sexual dysfunction so your population may not want to take this be open and honest with them about the side effects of the medication so they can talk to you if they have them versus them just stop taking the medication know that suicidal ideation is increased in the Adolescent and young adult population and it's also increased with anyone with depression and anxiety when you're prescribing these medications have a safety plan in place if you're prescribing these and always always always discuss Black Box warning with your patients know the risk of damage to the fetus um in in pregnant moms know if your patient is pregnant do the benefits outweigh the risks of these medications is there a potential for poor neonatal outcomes if mothers are pregnant and they're untreated during pregnancy educate your patients and parents of your patients to monitor for suicidal ideation or behavior and referral you want to know when to refer um if there's a failed trial of initial medications refer to Mental Health suspected bipolar disorder refer to Mental Health if they have a significant suicide history or current suicidal ideations that patient needs to be referred if there is um suspicion of drug use or alcohol use or personality disorders that could be contributing you want to refer these Patients Out okay so some of the key takeaways ssris when to use them what safety and transmission what neurotransmitters are they working on the snris when to use these safety and transmission maois know a little bit about those what's important to know about maois what's important to know about your tricyclic antidepressants know your side effects of the medications the different classes and know your special populations moving on to alcohol and drug addiction and smoking cessation so there are about 136 million Americans the ages of 12 and older that currently use alcohol that's about 65.3 million people reported alcohol binges including about 16.3 reported heavy alcohol use there's an upward Trend in the number of older adult admissions in substance abuse treatment centers since 2012 in the U.S pspf which is the United States primitive Services Task Force recommends screening all patients 18 of years and 18 years of age and older and we'll screen them with the audit C that the alcohol use disorders identification test you can also use the SAS Q which is the single alcohol screening system and those are just quick screening this quick screening tools which we will talk about um cage very quick have you ever wanted to cut down on the amount of alcohol that you drink do you become annoyed when people ask you about how much you drink or tell you about how much you drink do you feel guilty about the amount you drink have you ever needed an eye opener for a hangover so those are quick questions you can ask in cage there's the tweak that's tolerance worry eye opener Amnesia cut down on drinking and that screens for alcohol use in pregnant women there's also the crabs car relax alone forget friends in trouble and that's used for adolescence so alcohol withdrawal is when alcohol is discontinued the central nervous system excitation and autonomic overactive overactivity occurs and some of the medications that we use for withdrawal benzodiazepine that's first line and that's going to be uh short-term use but it is used for withdrawal symptoms is the long-acting versus the shorter it's only used for acute withdrawal um and some anti-convulsants may also be used like carbamencicate so how are you going to be monitoring the alcohol withdrawal well first you can do the seawall that's the clinical Institute withdrawal assessment for alcohol you can do a seawall on them um they're probably going to need inpatient treatment if they have a history of seizures if they're going through severe withdrawal that nausea and vomiting where they can't take anything oral these people are not going to be managed in clinic these are going to be going through the emergency room managed in the hospital um preferably in the ICU um pregnant women you're not going to manage them in clinic you're not going to manage pregnant women you're gonna you're gonna send those back to their gynecologists who are going to probably send those to mental health who are going to send them to the hospital if that initial C loss score is greater than 15 they need to be hospitalized now Outpatient Therapy can be used if the withdrawal symptoms are mild so medication is started if they have a Cy score of 8 to 10.

[00:45:07]and if you're again short-term use of benzodiazepines diazepine diazepam is 10 milligrams every six hours before doses then five milligrams every six hours for eight doses that's it um you have Lorazepam at two milligrams every six hours for four doses followed by a milligram every six hours for eight Doses and these are the two you'll probably use a little bit more than the chlorodiazepoxide so okay we need to give them something for absence okay so you've told them hey you're going to stop drinking they want to stop drinking but they need some help there is the camp roll which is 666 milligrams three times a day think about your patient in compliance are they going to take something three times a day if not you may want to use the antifuse they'll take that 500 milligrams once a day for a week or two and then they can go on to 250 milligrams daily and something you do want to tell your patient if they're going to take antabuse is do not drink do not drink when you're taking that medicine you will feel violently ill violently ill also they need to be sober for at least 24 hours before they start that medication it could be 12 to 24 hours before they start okay so for antabuse they must be alcohol free for 12 hours prior to initiating this medication there is a black box warning never administer this medication if they have alcohol intoxication and you want to make sure you educate your patient before you give them this medication because then we'll move on to opioid addiction um and of course there's more information in your notes that you'll need to know but this is just we're going to touch briefly on a few of these things um of course you know the youth is increasing the opioid death is just astronomical right now the mortality is increasing um the CDC does have some guidelines for prescribing opioids many many moons ago we as nurse practitioners could write um for Darvocet uh darves that in 100 Vicodin patients coming in with acute pain we'd write it they could get like 90 uh for a month for their acute pain um so were we contributing to the opioid crisis possibly um you know the drug rubs are coming in they were telling us all about them all these were safe to use well now we've learned we've learned um from that and the CDC does have guidelines you will not prescribe more than a seven day script of any kind of opioid and pretty much unless they have a limb falling off be careful on who you prescribed your opioids too and if they have a limb falling off they should be in the emergency room guidelines we want to start off with non-uh pharmacologic options first like rice so before you even get to an opioid use your other measures first use rice um use an infant use a tricyclic antidepressant but remember assess your patient make sure it's safe um you can use snris remember Cymbalta is good for pain even anticonvulsants can help and if you're giving them if you're giving a muscle relaxer uh just use that for a few weeks make sure that's not some long-term medication that they stay on know if your patient's going through any withdrawal um like that dysphoria they may have sweating nausea vomiting um they may have the watery eyes uh yawning fever high fever or insomnia if they're withdrawing from opioids so there are some opioid withdrawal skills um there is the cows which is a clinical opiate withdrawal scale you'll need to know that um there's the South which is the subject opioid withdrawal scale and there's also the Cena which is the clinical Institute of narcotic assessment so there's medication medication assisted treatment um and there's different medications that we use for that the buprenorphine and the methadone um and these are provided by opioid treatment programs you can also they did have a x waiver or nurse practitioners to do medication assistant treatment and now they've gone away as of uh June that has gone away but if you do plan to do any medication it's just a treatment make sure you are educated so you can still take the courses for free it's about 24 hours that you can get take those courses before you do any mat um the uh now track zone or extended release injectable which is Vivitrol you won't be doing that in just regular Clinic you can use uh clonidine which is very effective for some of the symptoms that they may have um in the lock Zone which you need to be familiar with is used for opioid overdose um that can be given IV IM sub Q or internationally families are learning how to use naloxone to save their family members um if it's if it's a naloxone spray nasal spray that's one spray into one nostril um adults and Pediatrics have the same dose and you repeat that every two to three minutes until EMS arrives educate your family members or your patients if they have if they have substance use disorder a family member knows somebody make sure they know and understand how to use naloxone to save their family member's life we'll go a little bit on how do you stop a benzodiazepine in discontinuation of a benzodiazepine is very very important so they don't have withdrawal symptoms from long-term use of benzodiazepines so use long acting benzos when withdrawing a patient from a benzo a diazepine addiction so for discontinuation uh of 10 milligrams of Diazepam is equivalent over 10 weeks is that's not what's generally tolerated um an 8 to 12 week benzo taper should be successful um give them an SSRI or an snri at a low dose before starting that taper if they have anxiety or depression and nine times out of ten they probably have anxiety or depression or both so we'll talk a little bit about smoking cessation um which is nicotine is rapidly absorbed each puff maintains nicotine blood levels they you get a development of Tolerance um patients may have withdrawal symptoms when it's discontinued nicotine acts on receptors in the brain in the central nervous system so there's different treatments nicotine replacement therapy there is gradual controlled reduction of nicotine to avoid the symptoms um zyban which is bupropion they should be tobacco-free in about 7 to 12 weeks Chantix they should be tobacco-free in about 12.

[00:53:51]nicotine replacement therapy that's used in patients who smoke more than 20 cigarettes a day and there's the Nicorette nicotrol Nicoderm Commit lozenges there's also nasal sprays and inhalers that can be used so some precautions and contraindications the gum is a category C in this transdermal patch is a category D these cannot be used after a patient has just had a heart attack or a stroke you want to make sure if they're using the gum that they follow the directions so that nicotine is not released too quickly causing them to have an adverse drug reaction if they are 25 cigarette or a day or more smoker you want to start the gum at about four milligrams every hour and if it's less they'll use two milligrams and they should be weaned off medication after about two to three months of nicotine abstinence the nicotine patch that's transdermal so it's through the skin there's 16 hour and 24 hour patches that is a slow onset of medication and it has a steady state once it reaches its peak and the dose of the patch is determined by how many cigarettes they smoke a day the patient cannot smoke while using that patch so you want to educate that patient about nicotine toxicity again we talked a little bit about the bupropion or xivan that started one to two weeks before the quit date so what I usually tell a patient is hey you're going to be on the zyband look at the calendar pick your quick date let's just use February so they want to quit February 14th you know what I told my significant other I'm going to stop smoking that is what I'm giving them for Valentine's Day so on the first I'm going to start up my quit date is on the 14th so I'm going to start this medication on the first I'll take 150 milligrams for three days and then 150 milligrams twice a day so on the 14th bam throw those cigarettes away so that is how you you instruct your patient on using your property on his eye band so you've had that medicine for two weeks you've picked that click date on that quick date throw your cigarettes away and there's uh no more smoking but you can use the nicotine replacement product if needed usually they don't now that therapy is about seven to twelve weeks most do about 12 weeks you can do it longer if needed again with bupropion you have to assess your patient do you have any seizure disorder any Eating Disorders if they do they cannot take bupropion um bupropion should be avoided in pregnancy and if your patient is taking Wellbutrin for anything else you cannot give them bupropion on top of that Chantix Chantix is very good it's highly selective to the alpha 4 beta 2.

[00:57:23]um and it's moderately selective to the five ht3 receptors that when it started a week before the quit date so you tell them hey okay I am going to quit I am going to quit smoking on Valentine's Day because I promised my partner okay I'm going to quit smoking so on the seventh of February I'm going to start my medication and then I'm still going to click the I'm going to quit my cigarettes on Valentine's Day on the 14th now that's a dose you can get a starter pack you can write it as a prescription for a starter path the pharmacy will give that patient a 0.5 orally for the first three days then 0.5 twice a day for days four through seven and on day eight it increases to one milligram twice a day so you can write for a chantic starter pack for that initial starter pack and then you can do Chantix continuation packs and those are good for about 12 weeks they do have some drug reactions and one of the main things that patients will complain about is these very very very vivid dreams or they may have some suicidal ideation or actual suicidal behavior that is a reason take your patient right off that chance it's stop that nope nope nope can't have um category C so it shouldn't be used in pregnancy and this should be used only in adults 18 and older okay some key takeaways you need to understand nicotine how to treat it the withdrawal symptoms and some contraindications to having nicotine the nicotine patches what about alcohol dependence I didn't go over cocaine in this lecture but I want you to go back and review your notes about cocaine and how it affects the brain understand the screening tools and which screening tools are used for what disorder the treatment of alcohol dependence treatment of abstinence the adverse drug reactions for all the classes of medications how do you treat smoking cessation how do you stop benzodiazepines and I want you to know a little bit about medication assistant treatment too okay so you have gotten your lectures and you also have your key takeaways which are you have verbal blueprints so that should conclude your lecture for exam two