brittnybaylor

brittnybaylor

3 Followers · 4 Following

No tracks found

Info

0 Tracks
Male
Social Links
Bio
Women's Experiences Of Using Anabolic Androgenic Steroids

Abstract

The epidemic of opioid use disorder has escalated dramatically over the past decade, resulting in significant morbidity, mortality, and societal burden. Multiple studies have delineated a steep rise in overdose deaths linked to prescription opioids, heroin, and synthetic derivatives such as fentanyl. Evidence indicates that barriers to treatment—including limited access to medication‑assisted therapy, stigma, inadequate insurance coverage, and geographic disparities—exacerbate the crisis. Recent interventions combining opioid agonist therapies (methadone or buprenorphine) with behavioral counseling have demonstrated robust efficacy in reducing illicit drug use, preventing overdose recurrence, and improving quality of life. However, persistent gaps remain: many patients initiate treatment but fail to engage long‑term, especially those in rural settings or belonging to marginalized populations. Emerging data suggest that integrating telemedicine platforms, community outreach programs, and culturally tailored education can enhance retention rates and address unmet needs. Continued research into scalable models that adapt evidence‑based treatments across diverse contexts is essential for mitigating the burden of opioid use disorder.

The content above reflects current best practices in treating substance‑abuse disorders. The information is accurate as of March 2024 and should be reviewed by a qualified clinician before applying it to specific patient cases.

---

### 1. Why this document matters

- **Clinical relevance** – The material covers the latest pharmacologic and behavioral strategies for managing opioid use disorder (OUD), which are routinely used in addiction medicine.
- **Evidence‑based** – Recommendations align with the U.S. Department of Health & Human Services’ "Clinical Practice Guideline for Treating Opioid Use Disorder" (2022) and the American Society of Addiction Medicine’s (ASAM) guidelines.
- **Practical guidance** – The content includes dosing tables, monitoring protocols, and decision‑trees that can be translated into order sets or EMR templates.

---

### 2. Scope of the content

| Section | Main Focus | Key Take‑aways |
|---------|------------|----------------|
| **Methadone** | Pharmacokinetics, induction, maintenance | • Initiate ≤30 mg/day; titrate by ≤10 mg q3–5 days.
• Monitor QTc and liver enzymes. |
| **Buprenorphine/Naloxone (Suboxone®)** | Induction window, dosing | • Start when patient is at ≥2/4 withdrawal points or 8‑12 h opioid-free.
• First dose ≤8 mg; max 24 mg/day. |
| **Dihydrocodeine** | Conversion ratio, monitoring | • Use 30–60 mg q6–8h for moderate pain.
• Watch for CNS depression in elderly. |
| **Tramadol** | Efficacy, side‑effects | • Start 50 mg BID; titrate to max 400 mg/day.
• Contraindicated with MAOIs or CYP2D6 poor metabolizers. |
| **Morphine** | Dosing schedule, precautions | • Initial dose 10–30 mg every 4 h PRN; adjust for renal function.
• Use hydromorphone in renal impairment. |

---

## 3. Pain‑Management Algorithm

1. **Assessment**
- *Pain score*, location, onset, quality.
- Functional impact (mobility, sleep).
- Concomitant symptoms (nausea, constipation).

2. **Initial Non‑Opioid Therapy**
- Paracetamol 500 mg q6h PRN (max 4 g/day).
- NSAIDs (e.g., diclofenac 50 mg q12h) if no contraindication.
- Topical agents (lidocaine patches) for localized pain.

3. **If Pain Persists or Escalates**
- Add low‑dose opioid: Tramadol 100 mg q8h PRN (max 400 mg/day).
- Monitor for side effects (nausea, dizziness).

4. **Escalation to Strong Opioid**
- If moderate/severe pain unrelieved: Morphine 10–15 mg IV/SC every 4 hours as needed.
- Titrate dose based on response and tolerance.
- Use oxycodone 5 mg PO q6h if morphine is not available.

5. **Adjunctive Therapies**
- Antiemetics (ondansetron) for nausea/vomiting.
- Hydration and electrolytes support.
- Analgesic holidays or intermittent dosing to reduce tolerance, when feasible.

---

## 4. Practical Guidance for Field Implementation

| Situation | Action |
|-----------|--------|
| **Limited IV access** | Use SC or IM routes; if unavailable, use oral formulations. |
| **No morphine available** | Oxycodone, hydrocodone, or fentanyl (if accessible) can be substituted at equipotent doses. |
| **Pain >moderate to severe** | Start with a lower dose; titrate every 30–60 min until pain relief. |
| **Rapid deterioration / emergency** | Administer the highest safe dose immediately; monitor for respiratory depression, especially in opioid-naïve patients. |
| **No monitoring equipment** | Observe clinically: breathing rate, oxygen saturation (if pulse oximeter available), level of consciousness. |
| **Limited supplies** | Use the minimal effective dose; re-evaluate pain regularly and adjust accordingly. |

---

## 3. Practical Dosing Guidelines for Common Pain Intensities

> **Important:** These tables are only a starting point. Always consider patient factors, local protocols, and available monitoring resources.

### A. Mild Pain (Score 1–3)

| Opioid | Initial Dose | Frequency |
|--------|--------------|-----------|
| Hydromorphone | 0.5 mg IV | every 4 h PRN; repeat if needed after 30 min |
| Morphine | 2.5 mg IV | every 4 h PRN; repeat if needed after 30 min |
| Oxycodone | 1–2 mg PO | every 6 h PRN; repeat if needed after 1 h |

### B. Moderate Pain (Score 4–6)

| Opioid | Initial Dose | Frequency |
|--------|--------------|-----------|
| Hydromorphone | 1 mg IV | every 4 h PRN; repeat if needed after 30 min |
| Morphine | 5 mg IV | every 4 h PRN; repeat if needed after 30 min |
| Oxycodone | 5–10 mg PO | every 6 h PRN; repeat if needed after 1 h |

### C. Severe Pain (Score ≥7)

| Opioid | Initial Dose | Frequency |
|--------|--------------|-----------|
| Hydromorphone | 2 mg IV | every 4 h PRN; repeat if needed after 30 min |
| Morphine | 10 mg IV | every 4 h PRN; repeat if needed after 30 min |
| Oxycodone | 15–20 mg PO | every 6 h PRN; repeat if needed after 1 h |

*Notes:*
- **IV administration** should be given slowly over 5‑10 minutes to avoid tolerance or adverse effects.
- **Oral dosing** requires adequate gastric function; use liquid preparations for patients with swallowing difficulty.
- If the patient is on a **transdermal patch**, continue patch application as per manufacturer instructions; do not combine patch with IV opioids unless specifically indicated and monitored.

---

## 4. Potential Drug–Drug Interactions & Contraindications

| Medication | Known Interaction/Contraindication | Monitoring/Action |
|------------|------------------------------------|-------------------|
| **Opioids** (e.g., morphine, oxycodone) | **MAO inhibitors** – risk of serotonin syndrome.
**SSRIs/SNRIs** – increased sedation/respiratory depression.
**CYP3A4 inhibitors** (ketoconazole, ritonavir) – ↑ opioid levels. | Avoid concomitant use or monitor closely; consider dose reduction. |
| **Dexamethasone** | **Anticoagulants** – increases bleeding risk.
**Glucocorticoids + NSAIDs** – GI ulceration. | Use gastroprotection (PPI) if on NSAIDs/anticoagulants. |
| **Antivirals** (e.g., remdesivir) | Hepatotoxicity; monitor liver function. | Monitor LFTs regularly. |

---

## 6. Patient‑Specific Considerations

| Issue | Recommendations |
|-------|-----------------|
| **Obesity** | Higher risk of severe COVID‑19 and VTE. Use higher weight‑based dosing for anticoagulants if needed (e.g., LMWH). Ensure adequate hydration to mitigate renal clearance issues. |
| **Hypertension & Diabetes** | Tight control reduces complications; consider ACEI/ARB continuation unless contraindicated by acute kidney injury or hypotension. |
| **Medication Review** | Avoid drug‑drug interactions: e.g., CYP3A4 inhibitors (ketoconazole, clarithromycin) can increase lopinavir/ritonavir levels; adjust accordingly. |
| **Vaccination Status** | Ensure influenza and pneumococcal vaccination to reduce respiratory co‑infection risk. |

---

## 5. Monitoring & Follow‑Up

| Parameter | Frequency | Thresholds / Actions |
|-----------|------------|----------------------|
| Vital signs (T, HR, RR, BP, SpO₂) | Every 4 h in ward; q12h if stable | SpO₂ <92% → supplemental O₂; >100 % FiO₂ or RR>30 → consider ICU |
| Oxygen requirement | Continuous | Increase stepwise; consider HFNC/CPAP if plateau |
| Labs (CBC, CMP, CRP, D‑dimer, ferritin) | Baseline, then every 48–72 h | ↑CRP >100 mg/L or rising trend → adjust steroids/infliximab |
| Chest X‑ray | Every 3–5 days | New infiltrates → consider antibiotics or escalation |
| Clinical status (SOFA score) | Daily | Increase in organ dysfunction → ICU transfer |

---

### 4. Criteria for Escalation to ICU

| Parameter | Threshold/Indicator |
|-----------|---------------------|
| **Respiratory** | • PaO₂/FiO₂ <200 despite HFNC/CPAP
• FiO₂ >60% on HFNC or CPAP for >48 h
• Increasing work of breathing, use of accessory muscles |
| **Hemodynamic** | • MAP <65 mmHg or lactate >2 mmol/L unresponsive to fluids
• Vasopressor requirement (e.g., norepinephrine ≥0.1 µg/kg/min) |
| **Neurologic** | • GCS <8, inability to protect airway |
| **Metabolic** | • Persistent acidosis (pH <7.25), hyperglycemia >250 mg/dL unresponsive to insulin |
| **Respiratory** | • PaO₂/FiO₂ ratio <100 despite high FiO₂ (>80%) and PEEP ≥10 cm H₂O
• SpO₂ <90% on room air |

---

### 3. Ventilatory Modes & Titration

| Mode | Indications in COVID‑19 ARDS | Key Parameters to Set/Titrate |
|------|-----------------------------|--------------------------------|
| **PCV (Pressure Control Ventilation)** | Primary mode for hypoxemic patients; limits tidal volume and allows PEEP titration. | *PIP* → set 30–35 cm H₂O, *PEEP* → start 10 cm H₂O, *Respiratory Rate (RR)* → 12–18/min, *Inspiratory Time (Ti)* ≈ 0.8 s. |
| **VCV (Volume Control Ventilation)** | Use when tidal volume is required to be fixed; less favored due to risk of barotrauma. | Set tidal volume 6 mL/kg PBW → adjust RR to maintain minute ventilation; monitor peak pressures. |
| **APRV (Airway Pressure Release Ventilation)** | For severe hypoxemia, allows spontaneous breathing while maintaining alveolar recruitment. | P_high ≈ 25–30 cmH₂O; T_high ≈ 5–6 s; P_low ≈ 0 cmH₂O; T_low ≈ 1 s; adjust to achieve adequate oxygenation and CO₂ elimination. |
| **PEEP Adjustments** | Incremental PEEP titration using recruitment maneuvers: 30 cmH₂O for 10 seconds, then decrementally lower by 5 cmH₂O while monitoring SpO₂ and PaCO₂. | Observe for improvements in oxygenation; stop if plateau pressure >30 cmH₂O or signs of barotrauma. |

---

## 3. Management of Complications

| Potential Complication | Early Detection | Immediate Intervention |
|------------------------|-----------------|------------------------|
| **Barotrauma (pneumothorax/pneumomediastinum)** | Sudden drop in SpO₂, increased work‑of‑breathing, chest pain, subcutaneous emphysema; auscultation of absent breath sounds. | Immediate reduction of PIP/PEEP; consider needle decompression if tension pneumothorax suspected; surgical consult. |
| **Hypoxia due to V/Q mismatch** | Continuous SpO₂ monitoring; arterial blood gas (PaO₂ <60 mmHg). | Adjust ventilator settings: increase FiO₂, optimize PEEP, consider recruitment manoeuvres; evaluate for pulmonary embolism. |
| **Barotrauma from high tidal volume** | Similar signs as barotrauma; also monitor plateau pressure (>30 cm H₂O). | Switch to low‑tidal volume ventilation (<6 ml/kg), reduce inspiratory time, ensure adequate exhalation time. |
| **Acute respiratory distress syndrome (ARDS)** | Radiograph shows bilateral infiltrates; PaO₂/FiO₂ ratio <300 mmHg. | Use protective lung ventilation strategy: low tidal volume, higher PEEP, prone positioning if severe. |

---

## 2. Common Causes of Acute Respiratory Failure and Their Management

| Condition | Pathophysiology (Key Point) | Initial Treatment Steps |
|-----------|----------------------------|-------------------------|
| **Acute bronchospasm / asthma exacerbation** | Airway smooth‑muscle constriction → airflow obstruction & hyperinflation. | • SABA inhaler (albuterol).
• Systemic corticosteroid.
• Oxygen to maintain SpO₂ ≥ 94%. |
| **COPD Exacerbation** | Bacterial infection or environmental trigger → increased inflammation and mucus hypersecretion. | • Bronchodilators (SABA + SAMA).
• Oral steroids if not already on.
• Antibiotic if productive cough & purulent sputum. |
| **Upper airway obstruction (e.g., laryngospasm, foreign body)** | Airway blockage → sudden dyspnea and wheezing. | • Immediate assessment of breathing.
• If foreign body suspected, attempt removal via back blows or Heimlich maneuver. |
| **Pulmonary embolism** | Vascular occlusion → acute respiratory distress. | • Rapid evaluation; consider anticoagulation if confirmed. |
| **Asthma exacerbation** | Bronchospasm & inflammation → wheeze and difficulty breathing. | • Inhaled bronchodilator (albuterol) + systemic steroids. |

---

## 4. Management of the Patient’s Wheezing

### A. Immediate Interventions
1. **Positioning**
- Upright, sitting or standing to optimize lung expansion.

2. **Oxygenation**
- Provide supplemental O₂ via nasal cannula (3–5 L/min) to maintain SpO₂ ≥ 94%.

3. **Airway Clearance**
- Encourage deep breathing and coughing; consider incentive spirometry if tolerated.

4. **Pharmacologic Therapy**
- **Bronchodilator**: Albuterol nebulizer or metered‑dose inhaler with spacer.
- **Systemic Corticosteroid**: Prednisone 40–60 mg PO once daily for 5 days (or equivalent IV methylprednisolone if unable to take PO).
- **Anticholinergic**: Ipratropium bromide nebulizer can be added if wheezing predominant.

5. **Monitoring**
- Repeat peak expiratory flow or spirometry after bronchodilator.
- Monitor oxygen saturation; consider supplemental O₂ if SpO₂ < 92 % or symptomatic hypoxia.

6. **When to Escalate**
- Persistent tachypnea, wheezing, or dyspnea despite bronchodilators and steroids.
- Development of accessory muscle use, cyanosis, or decreased consciousness → urgent evaluation for acute asthma exacerbation requiring nebulized high‑dose albuterol (10 µg/kg), magnesium sulfate 2 g IV, possibly epinephrine.

---

## 4. Follow‑up & Prevention

| Step | Frequency | Purpose |
|------|-----------|---------|
| **Baseline labs**: CBC, CMP, fasting glucose/ HbA1c, lipid profile, thyroid panel, vitamin D | Within 6–12 weeks of diagnosis | Detect comorbidities that may worsen weight or glycemic control. |
| **Weight & waist circumference** | Every clinic visit (3–4 months) | Monitor success and adjust therapy. |
| **HbA1c** | Every 3 months until stable; then every 6 months | Assess glycemic control. |
| **Lipid profile** | Every 12 months (or sooner if high‑risk) | Detect dyslipidemia for cardiovascular risk reduction. |
| **Blood pressure** | At each visit | Hypertension is common with obesity. |
| **Screening for depression & anxiety** | At baseline and annually | Mental health influences weight management success. |
| **Bone density screening** | If prolonged glucocorticoid therapy (>6 months) or risk factors present | Glucocorticoids can cause osteoporosis. |

---

## 4. Evidence‑Based Recommendations (2024)

### A. Weight‑Loss Management

| Intervention | Efficacy (Relative Risk Reduction/Weight Loss) | Key Points |
|--------------|-----------------------------------------------|------------|
| **Intensive lifestyle program** (diet, exercise, behavioral therapy; ≥3–5 sessions/month for 6–12 mo) | ~4–8 kg loss at 1 yr; ~20–30% achieve ≥5% weight loss | Strongest evidence in adults with obesity; requires trained staff |
| **Prescription diet (e.g., low‑calorie meal replacements)** | Additional 2–3 kg over lifestyle alone | Useful adjunct; monitor for nutrient adequacy |
| **GLP‑1 RA (semaglutide 2.4 mg weekly)** | ~8–10 kg loss at 68 wk in trials; similar efficacy to bariatric surgery | FDA approved for weight management (2021) |
| **SGLT2 inhibitor** | ~3–4 kg loss over 24 wk | Modest effect; primarily used for diabetes |
| **Bariatric surgery (RYGB, sleeve)** | ~25–30% excess body weight loss at 1 yr | Gold standard for severe obesity; requires surgical risk assessment |

---

## 2. Treatment Recommendations

### Overall Goal
Achieve a **≥5 kg** weight reduction within the first year while improving metabolic markers and reducing cardiovascular risk.

| Step | Intervention | Rationale & Evidence |
|------|--------------|---------------------|
| **1** | **Comprehensive Lifestyle Program** (diet, physical activity, behavior therapy) | Core of all obesity management; leads to modest but clinically meaningful weight loss. |
| **2** | **Pharmacotherapy** – start with GLP‑1 RA or dual‑agonist if lifestyle alone insufficient | Strong evidence for >5 % weight loss and cardiovascular benefit. |
| **3** | **Consider bariatric surgery** after ≥6–12 months of medical therapy failure (BMI ≥ 40 kg/m² or BMI ≥ 35 with comorbidities) | Superior long‑term outcomes; recommended when other measures fail. |

---

## 2. Core Lifestyle Management

| Component | Recommendations |
|-----------|-----------------|
| **Diet** | • Calorie deficit of ~500–750 kcal/day (≈ 1–1.5 lb weight loss/wk).
• Focus on whole‑food, plant‑based pattern: vegetables, fruits, legumes, nuts, whole grains.
• Limit processed foods, added sugars, refined carbs; moderate saturated fat (<10 % of calories).
• Use Mediterranean or DASH‑style templates as models. |
| **Physical Activity** | • ≥150 min/wk moderate‑intensity aerobic (e.g., brisk walking) + 2–3 days/week strength training.
• Include at least 10 min of brisk walking daily; aim for 30–60 min most days. |
| **Behavioral Support** | • Self‑monitoring: food diary, weight log.
• Goal setting: realistic short‑term targets (e.g., 0.5–1 kg/month).
• Social support: family, friends, or structured groups. |
| **Medical Monitoring** | • Regular check‑ups for diabetes control and cardiovascular risk markers. |

---

## 3. Practical Guidance & Common Pitfalls

| What to Do | Why It Helps | Potential Pitfall / How to Avoid |
|------------|--------------|-----------------------------------|
| **Plan meals ahead of time.** Write a weekly menu, shop accordingly, and prep ingredients in bulk. | Reduces impulsive food choices; keeps portion sizes controlled. | Relying on "last‑minute" orders or eating out frequently—limit to 1–2 times per week. |
| **Use smaller plates & bowls.** This tricks the brain into thinking you’re serving more. | Helps with portion control without feeling deprived. | Overeating because food seems scarce—fill plate, but keep portions moderate. |
| **Check nutrition labels for calories, fat, sodium.** Aim for lower amounts; choose foods labeled "low" or "reduced." | Keeps overall intake in line with goals. | Ignoring labels may lead to hidden excesses (e.g., sugary drinks). |
| **Plan meals ahead of time.** Write a weekly menu & grocery list. | Avoids impulsive, calorie‑dense choices when hungry. | Spontaneous decisions often mean more calories. |
| **Use smaller plates/containers.** They create the illusion of fullness. | Helps reduce portion sizes without feeling deprived. | Overcompensating by eating more later can undo gains. |

---

## 4. Practical Eating Plan (Sample)

### Breakfast
- **Option A:**
- 1 cup rolled oats cooked with water or skim milk
- ½ cup blueberries or sliced banana
- 1 tablespoon chopped walnuts

- **Option B:**
- 2 boiled eggs + 1 slice whole‑grain toast + a side of mixed fruit

### Lunch
- Grilled chicken breast (≈4 oz) over a large mixed green salad with cherry tomatoes, cucumber, bell pepper. Dress with lemon juice and a teaspoon olive oil.

### Snack
- Greek yogurt (6 oz, low‑fat) with 1 tablespoon honey or fresh berries.

### Dinner
- Baked salmon (≈4 oz) seasoned with herbs + steamed broccoli + quinoa or brown rice.

### Evening Snack (optional)
- Apple slices with 1 tablespoon peanut butter.

---

#### How to Use the Chart

1. **Select the meal type** – breakfast, lunch, dinner, snack, etc.
2. **Choose a food item** from that category.
3. **Look up its nutritional values** – calories, fat, protein, carbs, sodium.
4. **Add it to your daily total** – keep an eye on overall macros and calories.

The chart is meant for quick reference; you can print it out or keep it in a digital note for easy access while grocery shopping or meal prepping. Feel free to adjust portions or swap items as needed to meet your specific dietary goals. Enjoy planning and cooking!
https://git.obo.cash/priscillahargi