Chapter 7 Antidepressants, Antipsychotics, Antianxiety Agents, and Alcoholism.
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Transcript of Chapter 7 Antidepressants, Antipsychotics, Antianxiety Agents, and Alcoholism.
![Page 1: Chapter 7 Antidepressants, Antipsychotics, Antianxiety Agents, and Alcoholism.](https://reader038.fdocuments.in/reader038/viewer/2022102707/56649ddd5503460f94ad51c3/html5/thumbnails/1.jpg)
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Chapter 7Antidepressants, Antipsychotics,
Antianxiety Agents, and Alcoholism
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Chapter 7 Topics
• Antidepressants
• Antipsychotics
• Antianxiety Agents– Panic Disorders– Sleep Disorders
• Alcoholism
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Learning Objectives
• Differentiate the antidepressant, antipsychotic, and antianxiety agents.
• Be prepared to discuss the antidepressant classes, their uses, and their side effects.
• Know why and how lithium and other drugs are used in treating bipolar disorders.
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Learning Objectives
• Be familiar with antipsychotics and the drugs that prevent their side effects.
• Define anxiety, learn its symptoms, and know the drugs used in its treatment.
• Recognize the course and treatment of panic disorders, insomnia and alcoholism.
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Antidepressants
• Used to treat depression• Depression, common feelings
– Pessimism– Worry– Intense sadness– Loss of concentration– Slowing of mental processes – Problems with eating and sleeping
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Antidepressants Common Symptoms of Depression
– Loss of interest in usual activities
– Low self-esteem
– Self-pity
– Significant weight loss or gain
– Insomnia or hypersomnia
– Extreme restlessness
– Loss of energy
– Feelings of worthlessness
– Diminished ability to think
– Feelings of guilt
– Recurrent thoughts of death
– Suicide attempts
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Antidepressants
Depression
• Women are affected more often than men
• When men are affected, it is usually later in life
• Levels of neurotransmitters in the brain may be a causative factor
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Mood Disorders
• Mania
• Bipolar Disorder
• Unipolar Disorder
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Mood Disorders
• ManiaMood of extreme excitement, excessive elation, hyperactivity, agitation, and increased psychomotor activity
• Bipolar Disorder
• Unipolar Disorder
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Mood Disorders
• Mania
• Bipolar DisorderMood swings alternate between major depression and mania
• Unipolar Disorder
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Mood Disorders
• Mania
• Bipolar Disorder
• Unipolar DisorderMajor depression with no previous occurrence of mania
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Discussion
Describe the differences that may be seen in patients with unipolar and bipolar disorders.
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Discussion
Describe the differences that may be seen in patients with unipolar and bipolar disorders.
Answer
Unipolar – Depression Symptoms Bipolar – Depression and Mania Symptoms
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Treatment for Depression
Electroconvulsive Therapy• Introduction of brief, but convulsive
electrical stimulation through the brain
• Can induce seizures
• Effective for major and delusional depression
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Antidepressants
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Cyclic Antidepressants
• Monoamine Oxidase Inhibitors (MAOIs)
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Antidepressants
Selective Serotonin Reuptake Inhibitors (SSRIs)
– Block the reuptake of serotonin, with little effect on norepinephrine
– Fewer side effects than older meds
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Treatments
Cyclic Antidepressants – Two Types
• Tricyclic antidepressants (TCAs)• Tetracyclic antidepressants
– Prevent reuptake of norepinephrine and/or serotonin
– Agents in this class differ in adverse effects, cost, and response
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Treatments
Monoamine Oxidase Inhibitors (MAOIs)Allows for buildup of norepinephrine at the synapse
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SSRIs for Depression
• citalopram (Celexa)
• escitalopram (Lexapro)
• fluoxetine (Prozac,)
• paroxetine (Paxil)
• sertraline (Zoloft)
• venlafaxine (Effexor)
Drug List
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Dispensing Issues
Look-Alike Drugs
– Prozac and Proscar (urinary drug)
– Zoloft and Zocor (high cholesterol)
– Celexa and Cerebyx (seizures) and Celebrex (arthritis)
Warning!
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SSRIDispensing Issues
• Do not discontinue abruptly
• Alcohol consumption should be avoided while taking these medications
Warning!
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fluoxetine (Prozac)
• Indicated for major depression and obsessive-compulsive disorder (OCD)
• Anorexia is a possible adverse effect
• Take in the morning to avoid insomnia
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paroxetine (Paxil)
• Indicated for depression, obsessive-compulsive disorder, and panic disorder
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venlafaxine (Effexor)
• Blocks reuptake of serotonin and norepinephrine
• Indicated for depression
• May cause increase in blood pressure and blurred vision
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sertraline (Zoloft)
• Indicated for depression and obsessive-compulsive disorder
• Primary side effect is nausea
• May also cause drowsiness
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citalopram (Celexa)
• Indicated for depression and obsessive-compulsive disorder
• Minimal drug interactions
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escitalopram (Lexapro)
• Similar to Celexa
• More potent with fewer side effects
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Cyclic Antidepressants
Tricyclic• amitriptyline (Elavil)• nortriptyline (Pamelor)
Drug List
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Tricyclic Antidepressants Dispensing Issues
• Improvements are usually seen in 10 to 21 days
• Can be cardiotoxic in high doses
• May cause postural hypotension
Warning!
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Tricyclic AntidepressantsDispensing Issues
Do not discontinue abruptly.
Warning!
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Cyclic Antidepressants Side Effects
• Sedation is common, but tolerance usually occurs
• Have many anticholinergic effects
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Discussion
Why would cyclic antidepressants be prescribed for bed wetting in children?
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Discussion
Why would TCAs be prescribed for bed wetting in children?
Answer They may be prescribed because of their anticholinergic side effects.
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MAOIs
• phenelzine (Nardil)
• selegiline (Eldepryl)
• tranylcypromine (Parnate)
Drug List
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MAOI Dispensing Issues
Be cautious of many interactions with foods such as aged cheeses, concentrated yeast extracts, pickled fish, sauerkraut, broad bean pods, chocolate, and alcohol.
Warning!
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MAOI Dispensing Issues
If changing to another class of antidepressant, patient must have a two-week “wash out” period before starting the new medication.
Warning!
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Other Antidepressants
• bupropion (Wellbutrin, Zyban)
• mirtazapine (Remeron)
• trazodone (Desyrel)
Drug List
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trazodone (Desyrel)
• Prevents reuptake of serotonin and norepinephrine
• Has a better side effect profile than TCAs
• Caution: possible interaction with Ginkgo
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bupropion (Wellbutrin, Zyban)
• Dopamine-uptake inhibitor
• Does not cause sedation, blood pressure changes, or ECG changes
• Do not discontinue abruptly
• Approved in the aid of smoking cessation
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Other Antidepressant Dispensing Issues
• Wellbutrin SR = BID dosing
• Wellbutrin XL = QD dosing
Warning!
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Bipolar Disorders
Signs or Symptoms– Decreased need for sleep– Elevated or irritable mood– Excessive involvement in pleasurable activities
with a big potential for painful consequences– Grandiose ideas– Pressure to keep talking– Racing thoughts
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Discussion
What is the drug of choice for treating bipolar disorders?
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Discussion
What is the drug of choice for treating bipolar disorders?
Answer
Lithium
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Discussion
What is the two-fold objective of drug therapy for bipolar disorder?
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Discussion
What is the two-fold objective of drug therapy for bipolar disorder?
Answer
Treat acute episodes
Prevent subsequent attacks
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Drugs to Treat Bipolar Disorders
• carbamazepine (Tegretol)
• divalproex (Depakote)
• lithium (Lithobid)
• olanzapine-fluoxetine (Symbyax)
• valproic acid (Depakene)
Drug List
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Lithium Side Effects
• Gastrointestinal
• Dermatologic
• Hematologic
• Neuromuscular
• Weight
• Renal
• Teratogenic
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Lithium Dispensing Issues
Lithobid tablets are only effective for 6 months. Be sure to highlight expiration dates on containers.
Warning!
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divalproex (Depakote)
• Beneficial for patients with rapid mood changes
• Take with food or milk, but not carbonated drinks
• Beware of symptoms of thrombocytopenia
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Antipsychotics
• Also called neuroleptics• Schizophrenia is the primary indication
– Retreat from reality– Delusions– Hallucinations– Ambivalence– Withdrawal– Bizarre or regressive behavior
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Antipsychotics
• Helps with thought disorders, hallucinations, and delusions
• Does not help with emotional and social withdrawal, ambivalence, or poor self-care
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Antipsychotics
• aripiprazole (Abilify)
• clozapine (Clozaril)
• fluphenazine (Prolixin)
• haloperidol (Haldol)
• loxapine (Loxitane)
Drug List
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Antipsychotics
• molindone (Moban)
• olanzapine (Zyprexa)
• prochlorperazine (Compazine)
• quetiapine (Seroquel)
Drug List
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Antipsychotics
• risperidone (Risperdal)
• thioridazine
Drug List
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Antipsychotic Side Effects
• Anticholinergic
• Cardiovascular
• Dermatologic
• Endocrine
• Hematologic
• Ophthalmologic
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Antipsychotic Side Effects
• Withdrawal
• Neurologic– Dystonia– Akathisia– Pseudoparkinsonism
• Tardive dyskinesia
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Atypical Antipsychotics
• Have improved efficacy and reduced side effects
• Better tolerated, but associated with metabolic side effects
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risperidone (Risperdal)
• Indicated for management of psychotic disorders and dementia in the elderly
• It is a serotonin-dopamine antagonist
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Dispensing Issues
Clozaril (antipsychotic) and Clinoril (antibiotic) are look-alike/sound-alike drugs.
Warning!
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olanzapine (Zyprexa)
• Used for schizophrenia
• Blocks dopamine and serotonin receptors
• Causes fewer movement disorders and is more effective
• Alcohol must be avoided
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Dispensing Issues
Zyprexa (antipsychotic) and Zyrtec (antihistamine) are look-alike/sound-alike drugs.
Warning!
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quetiapine (Seroquel)
• Related to Clozaril
• Lower incidence of hematologic toxicities
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Minimizes Side Effects of Antipsychotics
• benztropine (Cogentin)
• diphenhydramine (Benadryl)
• meclizine (Antivert)
Drug List
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Antianxiety Agents
Anxiety
State of uneasiness characterized by apprehension and worry about possible events
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Antianxiety Agents
Two Types of Anxiety
• ExogenousResponse to external stresses
• EndogenousNot related to external stresses, result of abnormality in cellular function in the CNS
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Discussion
What is the most common self-prescribed treatment for anxiety?
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Discussion
What is the most commonly self-prescribed treatment for anxiety?
Answer
Alcohol
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Antianxiety Agents
• Benzodiazepines
• Other Controlled Medications
• Some Non-Controlled Medications
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Antianxiety Agents
• amoxapine
• buspirone (BuSpar)
• hydroxyzine (Vistaril), antihistamine
• paroxetine (Paxil), SSRI
Drug List
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Antianxiety Agents
• propranolol (Inderal), beta blocker
• venlafaxine (Effexor)
Drug List
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Antianxiety Agents
Benzodiazepines, C-IV• alprazolam (Xanax)• chlordiazepoxide (Librium) • clorazepate (Tranxene)• diazepam (Valium)• lorazepam (Ativan)• oxazepam (Serax)
Drug List
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Antianxiety Agnets
Benzodiazpines
• May cause physical dependence, C-IV
• Should not be stopped abruptly
• Side Effects– Muscle relaxation– Paradoxical excitement– Sedation
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Dispensing Issues
Xanax (antianxiety) and Zantac (H2 Antagonist for the stomach) are look-alike/sound-alike drugs.
Warning!
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propranolol (Inderal)
• Beta blocker used to treat physical symptoms of anxiety
• Not officially indicated for this use
• Lowers heart rate which decreases nervousness due to stage fright or test anxiety
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buspirone (Buspar)
• Selectively antagonizes serotonin receptors
• Take with food
• Report changes in the senses
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Dispensing Issues
Buspirone (antidepressant/antianxiety) and bupropion (antidepressant) are look-alike/sound-alike drugs.
Warning!
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Panic Disorders
Panic• Intense, overwhelming, and uncontrollable
anxiety
• Neither a controllable voluntary emotion nor a condition that can be avoided by ignoring it or wishing it away
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Panic Disorders
• Can occur anywhere at anytime
• Criteria for Diagnosis– Three attacks in a three-week period– At least four qualifying symptoms
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Panic Disorders
Pathophysiology
• Result from a neurochemical defect
• The brain stem is a pathway for sensory information
• If there is a defect in the brain stem, stimuli can be excessively amplified and cause an overreaction
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Panic Disorders
Treatment• Combination of antipanic medication and
behavioral therapy• Psychotherapy is preferred treatment when
symptoms cause significant discomfort or impairment
• Antianxiety medications are indicated for short-term treatment
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Discussion
What fraction of Americans 18 and older have a sleep disorder?
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Discussion
What fraction of Americans 18 and older have a sleep disorder?
Answer
1/3
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Sleep Disorders
Insomnia
• Difficulty falling or staying asleep or not feeling refreshed on awakening
• Treated with hypnotics (to induce sleep)
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Sleep Disorders
Causes– Situational
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Sleep Disorders
Causes– Situational– Medical
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Sleep Disorders
Causes– Situational– Medical– Psychiatric
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Sleep Disorders
Causes– Situational– Medical– Psychiatric– Drug induced
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Sleep Disorders
Stages of Sleep
Stage 1 Somewhat aware of surroundings, but relaxed
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Sleep Disorders
Stages of Sleep
Stage 1 Somewhat aware of surroundings, but relaxed
Stage 2Unaware of surroundings, but can easily be awakened
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Sleep Disorders
Stages of SleepStage 1
Somewhat aware of surroundings, but relaxed
Stage 2Unaware of surroundings, but can easily be awakened
Stage 3Deep sleep (REM sleep); dreams occur
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Sleep Disorders
Narcolepsy
• Involves recurring, inappropriate episodes of sleep during the daytime hours
• No known cause
• Occurs four times more in men than women
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Sleep Disorders
Characteristic Symptoms
1. Patient feels sleepy during the daytime and then enters into REM sleep
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Sleep Disorders
Characteristic Symptoms
1. Patient feels sleepy during the daytime and then enters into REM sleep
2. Patient experiences cataplexy with sudden emotions
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Sleep Disorders
Characteristic Symptoms
1. Patient feels sleepy during the daytime and then enters into REM sleep
2. Patient experiences cataplexy with sudden emotions
3. Sleep paralysis
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Sleep Disorders
Characteristic Symptoms1. Patient feels sleepy during the daytime
and then enters into REM sleep2. Patient experiences cataplexy with sudden
emotions3. Sleep paralysis4. Very vivid hallucinations at the onset of
sleep
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Sleep Disorders
Treatment of Narcolepsy
• Nondrug TherapyLifestyle changes
• Drug Therapy– Stimulants – Tricyclic antidepressants– SSRIs
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Sleep Disorders
• Pharmacological TreatmentHypnotics
• Nonpharmacological Treatment– Normalizing sleep schedule– Increases physical exercise– Discontinuing alcohol use as a sedative– Sleep only 7-8 hours/24 hr– Reducing caffeine and nicotine intake
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Sleep Disorders
Treatment
• Hypnotics should be used in conjunction with other medical therapeutics
• Benzodiazepines are the preferred agents
• Hypnotics should not be taken every night, only as needed
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Dispensing Issues
Diazepam, lorazepam, and alprazolam can be misread and misheard.
Warning!
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Sleep Agents
Benzodiazepines, C-IV• alprazolam (Xanax)• chlordiazepoxide (Librium)• clorazepate (Tranxene)• diazepam (Valium)• estazolam (ProSom)• flurazepam (Dalmane)
Drug List
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Sleep Agents
Benzodiazepines, C-IV
• lorazepam (Ativan)
• oxazepam (Serax)
• temazepam (Restoril)
• triazolam (Halcion)
Drug List
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Sleep Agents
Barbiturates• amobarbital (Amytal), C-II• butabarbital (Butisol), C-III• secobarbital (Seconal), C-II
Antihistamines• diphenhydramine (Benadryl)• hydroxyzine (Vistaril)
Drug List
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Sleep Agents
Hypnotic
• chloral hydrate
Others
• zaleplon (Sonata)
• zolpidem (Ambien)
Drug List
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zolpidem (Ambien)
• Targets benzodiazepine receptors with less effects on skeletal muscles and seizure threshold
• Short-term treatment only– Should not be used for more than 10 days – Alert the pharmacist, but realize there are
exceptions
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Alcoholism
• Denial is one of the major roadblocks for a patient to overcome before getting help
• Linked to genetics
• No cure, but can be arrested
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Alcoholism
Effects on Metabolism and Excretion
• Alcohol is an anesthetic and can cause loss of consciousness
• Emetic action prevents death by preventing absorption of lethal concentrations
• Habitual drinkers metabolize ETOH quicker, which increases tolerance
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Alcoholism Side Effects
• Vitamin deficiency
• Gastritis
• Organic brain damage
• Alcoholic psychosis and dementia
• Cirrhosis of the liver (irreversible damage)
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Alcoholism
Symptoms of Dependence on Alcohol• Blackouts or lapses of memory• Concerns of family, friends, and employers
about the substance use• Doing things that cause regret afterwards• Financial or legal problems from substance
use• Loss of pleasure with the substance
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Alcoholism
Symptoms of Dependence on Alcohol• Neglecting responsibilities• Trying to cut down or quit using a
substance, but failing• Using alone; hiding evidence• Using to forget about problems• Willingness to do almost anything to get the
substance
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Alcoholism
Steps Towards Recovery
1. Acknowledge the problem
2. Limit the time spent with substance abusers
3. Seek professional help
4. Seek support from recovering alcoholics
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Alcoholism
Withdrawal Symptoms• Agitation• Circulatory disturbances• Convulsions• Delirium treatments• Digestive disorders• Disorientation• Extreme fear
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Alcoholism
Withdrawal Symptoms• Hallucinations• Mental disturbances• Nausea and vomiting• Restlessness• Sweating• Temporary suppression of REM sleep• Tremor and weakness
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Alcohol Antagonists
• disulfiram (Antabuse)
• naltrexone (Revia)
• topiramate (Topamax) – not approved yet
Drug List
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disulfiram (Antabuse)
• Stops the metabolism of alcohol• Upon consumption of alcohol, side effects
are immediate:– Blurred vision – Confusion– Difficulty breathing – Chest
pain– Severe headache – Nausea– Severe vomiting – Uneasiness– Face becomes hot & scarlet – Thirst
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disulfiram (Antabuse)
• Patients must read labels to avoid ETOH:– Cough medicines– Mouthwashes– Flavorings– Salad dressings
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topiramate (Topamax)
• Anticonvulsant that can reduce cravings for alcohol
• Takes six weeks to be effective
• Topamax mixed with behavioral therapy looks promising in the treatment of alcoholism