Pharmacology, part 22: Nervous System Medications for ADHD & Substance Abuse
by Cathy Parkes March 02, 2021 Updated: December 29, 2021 8 min read
In this article, we cover the most important medications you need to know for ADHD, and substance abuse (alcohol, opioids, nicotine). The Nursing Pharmacology video series follows along with our Pharmacology Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
When you see this Cool Chicken, that indicates one of Cathy's silly mnemonics to help you remember. The Cool Chicken hints in these articles are just a taste of what's available across our Level Up RN Flashcards for nursing students!
CNS stimulants for ADHD & conduct disorder - Methylphenidate (Methylin, Ritalin), Amphetamine mixtures (Adderall)
ADHD is a psychiatric condition characterized by inattentiveness, hyperactivity, and impulsivity. Conduct disorder is the term for a spectrum of disorders characterized by repetitive, aggressive behavior that violates the rights of others. Both of these disorders, including their risk factors, signs/symptoms, treatments, nursing care, and family teaching are covered in depth in our Psychiatric Mental Health flashcards for nursing students!
Mode of action
CNS stimulants like methylphenidate and amphetamine mixtures stimulate the central nervous system to increase mental alertness and increase attention span in patients who have ADHD.
Just like methamphetamines, methylphenidate and amphetamine mixtures will amp you up (due to CNS stimulation).
Black box warning
CNS stimulants like methylphenidate and amphetamine mixtures carry a black box warning because drug abuse and dependence are common with these ADHD medications.
CNS stimulants like methylphenidate and amphetamine mixtures should not be given at night because, as stimulants, they cause insomnia. Most immediate release ADHD medications are given upon awakening and again in the very early afternoon.
These medications should be administered 30-45 minutes before meals.
What to monitor
If you have a patient on methylphenidate or amphetamine mixtures, make sure to monitor the patient's weight during therapy. This is important because of the risk for decreased appetite and weight loss with these medications.
In children taking these medications, it is especially important to monitor their height and weight over time to ensure the medication is not stunting their growth.
Children taking these medications are often instructed to take "drug holidays," where the medication is stopped over breaks from school in order to allow the brain and body time to develop without the medication on board.
Alcohol abuse maintenance medications - Disulfiram (Antabuse), naltrexone (Vivitrol), and acamprosate
Disulfiram, naltrexone, and acamprosate are alcohol abuse maintenance medications. In the case of alcohol abuse, maintenance therapy is a pharmacological therapy that helps to promote abstinence.
It's important to note that these medications help with longer term alcohol abstinence, and they are not for acute alcohol withdrawal. If a patient is undergoing acute alcohol withdrawal, then it's more important to decrease vital signs and prevent seizures. Medications that can be used for acute alcohol withdrawal are benzodiazepines, beta blockers and antiepileptics, which are also covered in this series.
Modes of action
Disulfiram works for alcohol abuse as an alcohol deterrent by increasing the levels of acetaldehyde. If a patient ingests alcohol while taking disulfiram, it will trigger a very unpleasant reaction which includes vomiting, palpitations, sweating and hypotension.
Naltrexone is an opioid antagonist that suppresses cravings for alcohol to decrease the relapse rate.
Acamprosate makes abstaining from alcohol more comfortable for the patient by decreasing abstinence symptoms, which can include anxiety and restlessness.
I was sent to a camp to stop drinking alcohol, and I was given acamprosate to decrease my withdrawal symptoms.
Opioid dependence maintenance medications - Buprenorphine (Subutex) and methadone (Methadose, Dolophine)
Buprenorphine and methadone are medications that can be used for opioid dependence maintenance therapy, as well as in the management of chronic severe pain.
What are opioids?
Shorter-acting opioids are a class of drugs that include the illegal drug heroin, and opioid analgesics like fentanyl, morphine, dilaudid, and oxycodone. They have a high potential for addiction and as you probably already know, the United States is facing an opioid overdose epidemic (external link) with the number of opioid overdose deaths increasing each year. Buprenorphine and methadone are also opioids, but they are much longer acting and do not cause the same euphoric effects.
What is maintenance therapy?
In the case of drug addiction, maintenance therapy is a pharmacological therapy available for opioid addiction, and is also called replacement therapy—because the more dangerous, shorter-acting, euphoria-inducing opioids like heroin or fentanyl are replaced with the safer, longer-acting opioids of methadone or buprenorphine.
We cover opioid addiction in depth in our Psychiatric Mental Health Nursing flashcards, including intoxication and withdrawal signs and symptoms, treatment therapies, and key points!
Methadone is very tightly controlled, and when used for maintenance therapy, is usually only given under supervision at a clinic. Buprenorphine has fewer restrictions.
Mode of action
Buprenorphine and methadone work by binding to opioid receptors in the central nervous system, which helps to decrease pain and reduce withdrawal symptoms and cravings, but also results in central nervous system depression.
Buprenorphine and methadone can result in side effects like sedation, confusion, constipation, hypotension, and respiratory depression. These side effects are often seen with drugs that bind to opioid receptors, so you see these same side effects in opioid analgesics as well.
Black box warning
Buprenorphine and methadone carry a black box warning because they can cause respiratory depression. They can also cause cardiac depression, resulting in prolonged QT intervals.
Antidote - Narcan
The antidote to buprenorphine and methadone is naloxone (Narcan). Naloxone blocks the effects of opioids, so it is used as the antidote for buprenorphine and methadone as well as what it is more well-known for, which is the antidote for a heroin or opioid analgesic overdose.
Nursing care & patient teaching
If you have a patient on methadone or buprenorphine, it's important to monitor their vital signs, their pain level, and their respiratory status.
When it comes to patient teaching, advise your patient on methadone or buprenorphine to increase their fiber and fluids intake to help prevent constipation, which is very common with these medications
Nicotine agonist - Varenicline (Chantix)
Varenicline is a nicotine partial-agonist used to promote smoking cessation.
Note that the antidepressant bupropion can be used for smoking cessation as well. Bupropion is covered in our article on medications for depression. There are also over-the-counter nicotine replacements that are available, including gums, patches, and nasal spray.
Mode of action
Verenicline works by binding to nicotine receptors, which in turn decreases the desire to smoke.
Varenicline - makes your veins clean of nicotine.
Varenicline can cause anxiety, depression, irritability, GI upset, insomnia, and muscle pain.
Black box warning
Varenicline used to carry a black box warning for neuropsychiatric events, like suicidal thoughts. The FDA removed the black box warning in 2016.
If you have a patient on varenicline, you will need to monitor them for depression or suicidal thoughts.
Okay. In this video, we are going to cover the remaining Mental Health medications that are part of our Pharmacology Flashcards Edition 2.0.
We're going to talk about ADHD medications, medications for alcohol abuse and opioid dependence, as well as medications to help with smoking cessation. If you are following along with cards, we are on card 65 in the nervous system.
First, let's talk about central nervous system stimulants, which are used to treat ADHD as well as conduct disorder. Medications that fall within this class include methylphenidate and amphetamine mixtures.
These medications stimulate the central nervous system as well as the respiratory system to increase mental alertness and to increase attention span in patients who have ADHD.
So when I look at these drug names, which are, again, methylphenidate and amphetamine mixture, it really just reminds me of methamphetamines, right, or meth, which will amp you up if you took those. So that's basically what these medications do. They really stimulate the central nervous system as well as the respiratory system to help people with their alertness and their ability to concentrate. So I find it fairly easy to remember what these medications do, just based on the drug names.
In terms of side effects, side effects can include insomnia, dysrhythmias, and then perhaps most importantly, decreased appetite and weight loss.
These medications also carry a black box warning because drug abuse as well as dependence is common with these ADHD medications.
In terms of teaching, we're not going to want to give this medication at night because of that side effect of insomnia, so giving it in the morning would definitely be better for the patient.
We would give the medication about 30 to 45 minutes before meals, and we're definitely going to want to monitor the patient's weight during therapy because weight loss is a very common and important side effect to remember with ADHD medications.
Okay, let's now talk about maintenance medications for alcohol abuse. Medications that fall within this class include disulfiram, naltrexone and acamprosate.
Keep in mind these medications are not for an acute alcohol withdrawal situation, so if a patient is undergoing acute alcohol withdrawal, then our attention is really focused on trying to decrease their vital signs and prevent seizures.
So we would give them medications such as benzodiazepines, beta blockers and anti-epileptics.
These medications that I'm going to go over are really for long-term abstinence from alcohol, so they work a little differently.
So disulfiram works as a deterrent because if the patient ingests alcohol while they're taking disulfiram, they will get this very unpleasant reaction which includes vomiting, palpitations, sweating, and hypotension.
In terms of how naltrexone works, it works by helping to suppress the patient's craving for alcohol.
And acamprosate helps to decrease abstinence symptoms, which can include anxiety and restlessness.
So one way that I remember acamprosate is I think of someone being sent to a camp to try to stay off of alcohol and at that camp, they were given acamprosate. So that's just my little tip for remembering what this medication is for.
Okay, now let's talk about maintenance medications that are used for opioid dependence, so this includes medications such as buprenorphine and methadone. These medications are not only used for opioid withdrawal and maintenance, they can also be used in the management of patients who have chronic severe pain.
They work by binding to opioid receptors in the CNS which helps to decrease pain but also results in and central nervous system depression.
Because it is binding to opioid receptors, we're going to get the same type of side effects that we would see with opioid analgesics, so this includes sedation, confusion, constipation, hypotension, and respiratory depression.
There is a black box warning for this medication because it can cause respiratory depression. It can also result in prolonged QT intervals, so it does cardiac depression as well.
Keep in mind that the antidote for these medications is naloxone, okay, or Narcan is the brand name.
So it's important that if a patient is going to be on one of these medications that you really keep an eye on their vital signs, their pain level, as well as their respiratory status.
And then you want to advise your patient to increase their fiber and fluid intake to help prevent constipation, which is very common with this medication.
Now, let's talk about a nicotine agonist, which is varenicline or Chantix.
This medication is used to promote smoking cessation.
It works by binding to nicotine receptors, which in turn decreases an individual's desire to smoke.
So the little Cool Chicken hint that's on this card here is, "Varenicline, make sure veins clean of nicotine." So, hopefully, that will help you remember what this medication is for, as well.
In terms of side effects, varenicline can cause anxiety, depression, irritability, GI upset, insomnia, and muscle pain.
This medication did carry a black box warning for many years due to neuropsychiatric events.
So if your patient is on this medication, you'll just want to monitor them for depression or suicidal thoughts.
Also, keep in mind there's one other medication that we talked about when we covered medications for depression that also helps with smoking cessation, and that is bupropion, and you can find that on card number 58.
Also, keep in mind that there are nicotine replacements that are available over the counter, including gums, patches, and nasal spray.
Okay. That is it for the mental health medications in our nervous system section. Next up, we will be talking about analgesics. Thanks so much for watching!
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