I.
An 18-year-old man is brought into the emergency department after being found on the street
unresponsive. He is lethargic and does not answer questions. He has been given 1 ampoule of Dextrose
intravenously without result. On examination, his heart rate is 60 /min, and respiratory rate is 8/min
and shallow. His pupils are pinpoint and not reactive. There are multiple intravenous track marks on
his arms bilaterally. The emergency physician concludes that the patient has had a drug overdose.
a) What is the most likely diagnosis?
b) What is the most appropriate medication for this condition?
c) How will you treat morphine dependence?
Answers
a) The most likely diagnosis is opioid overdose - supported by the patient's pinpoint pupils, reduced
respiratory rate (respiratory depression), lethargy, and the presence of intravenous track marks,
which suggest a history of drug injection.
b) Naloxone 0.4–0.8 mg i.v. repeated every 2–3 min till respiration picks up, is the specific antagonist
of choice because it acts rapidly, does not have any agonistic action and does not per se depress
respiration.
c) OPIOID SUBSTITUTION THERAPY
Methadone Based Opioid Substitution Therapy
➔ Induction phase: The first dose of methadone usually is 15 – 20 mg / day.
o A doctor should reassess the patient every four days to ensure the dose is adequate.
o The patient should not suffer opioid withdrawals and craving for an entire day with the
methadone dose provided.
o The dose can be increased by 5 – 10 mg every fourth day until withdrawal symptoms are
controlled. Doses of 40 – 60 mg of methadone per day is sufficient for most patients.
➔ Once a comfortable dose is reached, the patient remains on it for the maintenance phase, which
may last from months to years, based on individual needs.
➔ Methadone must not be stopped abruptly, as otherwise the patient would experience
withdrawals.
o Tapering can be done over 2 – 3 months duration.
o The tapering can be done in units of 10 mg of methadone every 7 days, till it reaches a
dose of 40 mg of methadone.
o Further tapering can be done in units of 5 mg of methadone every 7 days till the dose of
20 mg/day is reached. The final tapering can be achieved in units of 2.5 mg methadone
every week.
➔ Buprenorphine can also be used as Substitution therapy
To prevent Relapse: Tab. NALTREXONE 50 mg daily for 2-3 months
II. Sam is a 43-year-old man who first started smoking cigarettes when he was in college. Over time,
his smoking increased to the point where he felt like he needed to smoke throughout the day. In
recent years, he has become self-conscious about his smoking habit and now he wants to quit
smoking. Comment on the pharmacological management
1. Nicotine Replacement Therapy (NRT)
Nicotine Gum: Treatment is usually started by using 2 mg gum. Heavy smokers may start the
treatment by using 4 mg gum.
➔ Chewing one piece of gum every 1-2 hours at first, or by chewing one piece of gum
whenever there is an urge to use tobacco
➔ Decrease the chewing time with each piece from the normal 30 minutes to 10-15 minutes
for 4- 7 days. Then gradually decrease the total number of pieces used per day
➔ Start decreasing the total number of nicotine gum pieces being used per day by about one
piece in every 4-7 days
➔ Gradually reduce the amount of nicotine gum use after 2-3 months, which prevents nicotine
withdrawal symptoms
Nicotine patches are available - comes in three strengths (7 mg, 14 mg, 21 mg).
Nicotine inhalers and nasal sprays are the other formulations.
2. Non-Nicotine Replacement Therapy:
i) Bupropion:
➢ Dose: 150mg OD for 3days followed by 150mg BD for 7 to 12 weeks.
➢ It is an atypical antidepressant that has both dopaminergic and adrenergic actions.
ii) Varenicline:
➢ Dose: Initially 0.5 mg once daily for the first three day → increased to 0.5 mg twice daily
for the next four days → then increased to 1mg twice daily for 12 weeks.
➢ The person can quit one week after initiating Varenicline.
➢ A partial nicotine agonist that selectively binds to the α4β2 nicotinic acetylcholine
receptors in the brain. It lessens the physical pleasure from taking in nicotine and helps
lessen the symptoms of nicotine craving.
1. What do you understand by drug dependence?
2. Management of Alcohol dependence
• Initial short- term management phase (also known as detoxification)
• Long- term management phase
Short- term management phase
• REPLACEMENT THERAPY: Replace with another CNS depressant with long half-life.
o Long-acting benzodiazepines (such as chlordiazepoxide and diazepam) are preferred
over short acting benzodiazepine for this purpose.
o Helps to prevent symptoms of Alcohol withdrawal.
o Short acting benzodiazepines (such as oxazepam and lorazepam) are preferred in liver
damage, in elderly people.
o Dose to be used depends on the severity of withdrawal symptoms - 10 mg three times a
day to 25 mg three times a day of diazepam / Lorazepam 2mg
o The dose reduction is made usually over 7 to 10 days
• THIAMINE SUPPLEMENTATION –
o All patients in alcohol withdrawal should receive at least 250 mg thiamine by the
parenteral route once a day for the first 3-5 days
o Give oral thiamine for minimum of three months
Long-term management phase
• This phase begins after the initial withdrawal management from alcohol has been achieved.
• The aim is to maintain abstinence from alcohol and to prevent and delay relapse.
• Acamprosate - an anti-craving medication
o Dose: 1332 mg/day if body weight < 50 kg, 1998 mg/ day if body weight> 50 kg
o Tab. Acamprosate 333mg 2-2-2 for one year
• Naltrexone - an anti-craving medication
o 50 mg/day OD for one year
• ALCOHOL AVERSION THERAPY: Disulfiram 250mg/day OD for one year
o The first dose of disulfiram should be administered at least 24 hours after the last dose
of alcohol.
o It inhibits acetaldehyde dehydrogenase; when alcohol is ingested after taking disulfiram,
the concentration of acetaldehyde in tissues and blood rises and a number of highly
distressing symptoms (aldehyde syndrome) - flushing, burning sensation, throbbing
headache, perspiration, uneasiness, tightness in chest, dizziness, vomiting, visual
disturbances, are produced promptly.
o Effective only in well-motivated subjects