CPOP Flashcards
What is some examples of the substance dependence criteria?
> … how to explain how addicted someone is to substance use
- Tolerance •
- \Withdrawal •
- Compulsion to use •
- Difficulties controlling use •
- Priority of use over other activities •
- Continued use despite harmful consequences
What are examples of drug related harm?
- Illness and disease –> Hep C and HIV
- Accidents and injury
- Family and social disruption
- Crime and violence
- Workplace and economic costs
What is used for opioid substitution treatment (OST)? Why is it used? Benefits?
Methadone and buprenorphine
- OST replaces short-acting opioids, such as heroin or oxycodone, with a long-acting opioid that can be taken orally
- OST is designed to have a minimal intoxicating effect, blocking the euphoria associated with use of exogenous opioids and preventing withdrawal
What are the factors involving drug use?
- Drug
- Individual
- Environment
Who is Community Program for Opioid Pharmacotherapy (CPOP) co-managed by?
Co-managed by the Medicines and Poisons Regulatory Branch and Next Step Drug & Alcohol Services to enable the provision of methadone and buprenorphine
What are some role of community pharmacotherapy program (CPP)?
- Coordinates the Clinical Advisory Service
- Arranges interstate and international transfers for opioid pharmacotherapy clients coming to and leaving from WA
- Supports CPOP prescribers, pharmacists, and clients with access, prescribing and dispensing issues
- Supports prison release arrangements for continuing pharmacotherapy treatment in the community
- Review all community applications for Community Program for Opioid Pharmacotherapy (CPOP) treatment and process to HDWA for authorisation
What is the clinical advisory service (CAS)? What can CAS doctors do?
Operates a 24/7 phone service for health professionals to access clinical advice on patient management involving alcohol and drug use issues with access to experienced medical practitioners through Next Step Drug & Alcohol Service
- CAS doctors can also provide interim CPOP prescriptions on behalf of all CPOP prescribers to ensure continuity of treatment. CPP coordinates the CAS during business hours
Medical practitioners authorised to prescribe methadone and/or buprenorphine in WA sign an agreement to comply as required by the ….
WA Schedule 8 Medicines Prescribing Code (2017)
What is the role of the clinical review committee (CRC)?
The CPOP Clinical Review Committee meets to review and endorse applications for OST that fall outside the WA Policies and Procedures, to review the management of clients with special dosing approval, and to respond to clinical management issues which may impact upon service providers and clients of the Program
What is the CPOP committee structure?
What are the two training options to become a CPOP prescriber?
- CPOP Prescriber Training enables prescribing of methadone and buprenorphine for up to 50 patients (25 for solo rural practitioners)
- Buprenorphine Prescriber Online Training enables prescribing of buprenorphine products for up to 5 patients.
> Every three years prescribers are required to complete a Reaccreditation Assessment and provide feedback on their level of confidence in areas related to CPOP treatment to continue their authorisation
Pharmacies dispensing and supervising methadone and buprenorphine treatment for opioid dependence must be authorised by the …
Department of Health
Prescribers submit an Application to Prescribe Opioid Substitution Treatment detailing: (10 steps)
- The type of application
- The patient (ID, demographics)
- Transfer (from other CPOP prescriber)
- Treatment (OST type, induction plan)
- Other treatment details (interacting meds)
- Pharmacy
- Drug use
- Patient acknowledgement (signed)
- Prescriber
- Prescriber declaration (signed)
Applications from community CPOP prescribers are reviewed by CPP for clinical issues prior to submissions to the Health Department
Patients considering CPOP Treatment must be fully aware that commencing pharmacotherapy treatment of opioid dependence results in their name being placed on the?
WA drugs of addiction record
> record restricts access to other S8 medicines
> information from the Record is only provided to health professionals who are involved in the patient’s treatment
What should the prescription of OST include?
What are the two types of methadone preparations used for opioid dependence?
- Methadone Syrup – This formulation contains 5 mg/ml methadone hydrochloride, sorbitol, glycerol, ethanol (4.75%), caramel, flavouring, and sodium benzoate.
- Biodone Forte – This formulation contains 5mg/ml methadone hydrochloride and permicol-red colouring.
What are some pharmacokinetics of methadone?
- Methadone is highly lipophilic and binds to a range of body tissues including the lungs, kidneys, liver and spleen such that the concentration of methadone in these organs is much higher than in blood
- Methadone is primarily broken down in the liver via the cytochrome P450 enzyme system
- Methadone is also secreted in sweat and saliva
What is buprenorphine? Compare it to methadone
partial opioid agonist at the μ-opioid receptors in the nervous system
- less sedation on buprenorphine than on methadone
> Buprenorphine has a higher affinity for the μ-opioid receptors than most full opioid agonists, and can block the effects of other opioid agonists in a dose-dependent fashion
How is Burpenoprhine different?
Unlike methadone which is a full opioid agonist, the effect of buprenorphine on respiratory depression reaches a ceiling
What are the two buprenorphine preparations are available for opioid dependence treatment?
- Subutex sublingual tablets – The tablets come in 0.4mg, 2mg or 8mg strengths of buprenorphine hydrochloride
- Suboxone sublingual film – The films come in 2mg or 8mg strengths of buprenorphine hydrochloride with 0.5mg or 2mg naloxone respectively (a ratio of 4:1).
> Subutex HDWA authorities are generally for a shorter period than other treatments
- subutex given for six months to assist withdrawal from OST program
- subutext during pregnancy/breastfeeding authorised for 12 months
> Most clients prescribed suboxone formulation unless there is a specific condition where doctor will prescribe the subutex preparation.
What are some pharmacokinetics for buprenorphine?
- Peak plasma concentrations are achieved 1 to 2 hours after sublingual administration
- When given sublingually it bypasses the liver and is able to reach the bloodstream to have a therapeutic effect –> naloxone administered orally or sublingually has no detectable pharmacological activity
- By stimulating the mu (u) receptor only partially, buprenorphine creates those effects with less intensity than heroin, morphine, or methadone, all of which stimulate the receptor fully
- buprenorphine provides a positive but moderate psychoactive effect that reduces craving and blocks the effects of other opioids
- Buprenorphine displaces other agonists from opioid receptors, and may not produce sufficient agonist effects initially to compensate for the displaced methadone or heroin. The client may experience opioid withdrawal within 1-4 hours after first administration
How does burprenorphine disassociate from u receptor?
slowly, leading to a long duration of action
- Typical effects will continue to be experienced for up to 12 hours at low sublingual doses (2mg), and as long as 48 to 72 hours at higher doses (16-32mg)
- The prolonged duration of effect at high doses enables alternate-day, and even third daily dispensing regimes with sublingual dosing
> Depot buprenorphine products: buvidal –> transforms from low viscous solution to highly viscous liquid crystal gel when injected
In addition to its high-affinity partial agonist effect at μ opioid receptors buprenorphine is also a high-affinity ….?
antagonist at the δ (delta) and κ (kappa) opioid receptors, and a moderate-affinity partial agonist at the nociception opioid receptors
> effect on k opioid receptors: assists reduction of withdrawal symptoms associated with opioid dependence:
- block stress-induced potentiation of drug consumption
- prevent stress-induced relapse during abstinence period
- prevent stress-induced relapse during abstinence period
- less anxiety and agitation
> effect on δ receptors: moderate the effect of opioid intoxication and overdose
When can takeaway doses be provided?
- takeaway doses should not be considered until the patient has been in six months of continuous treatment
- Limitations on takeaway doses ensure that treatment is not compromised if takeaways are lost or stolen and reduces the potential for misuse
NO MORE THAN 2 DOSES AT A TIME
What do if patients has missed no more than two consecutive days of dosing?
CPOP pharmacists can dose the patient on their regular dose if a stabilised patient has missed no more than two consecutive days of dosing
What do if patients has missed more than three or more consecutive days of dosing?
The pharmacist must consult with the prescriber before providing the dose. CAS can be consulted the prescriber is not available.
What is the reintroduction schedule of missed doses?
What incidents require reporting by CPOP pharmacists?
- Missed doses (>2 days) •
- Diversion of dose •
- Intoxicated presentation •
- Abusive behaviour or theft •
- Other behaviour indicating instability •
- Payment issues •
- Dosing errors (script is written in mg but we deal in mL)
- Expired prescriptions
> Community Pharmacotherapy Program staff and Clinical Advisory Service specialists respond to pharmacy incident details are provided to the CPOP prescriber
> Dosing errors and interim prescriptions Script are reported to HDWA
What is done for a dosing error?
require the completion of a Recommended Action Plan documenting the details of he client and pharmacist, the nature of the error, the advice sought, response taken and outcome
What do when transferring to a new pharmacy?
Prescribers must provide current endorsed photographic ID of the patient and a prescription to the new pharmacy and cancel or suspend previous scripts
> The prescriber must also fax a completed Pharmacy Transfer Notification form to
- the current pharmacy
- the new pharmacy
- Community Pharmacotherapy Program
What is used for overdose? What is the commonly used one?
Naloxone is a medication that is given for the temporary reversal of the effects of opioids. This should be given in any emergency situation where is it known or suspected that an overdose has occurred and that opioid drugs may be involved
- the most commonly available for use being Prenoxad Injection (naloxone hydrochloride 1mg/ml solution for injection).
> Prescriptions for Prenoxad can be given to CPOP clients to increase the availability of naloxone within at risk groups. CPP can provide information on accessing training and resources for overdose prevention
Taking methadone or buprenorphine overseas requires careful consideration of the?
stability of the patient and the rules and customs of the country being visited
- CRC provides an avenue for CPOP prescribers to seek approval for additional takeaways to cover international trave
