Drugs and Substances of Misuse and Pharmacy II - unfinished

Question 1

What is the aim of drug misuse services?

Answer 1

To reduce the harms and costs arising from alcohol, prescribed and non-prescribed drug use and other substances.

To ensure that all aspects of a service user’s life are considered holistically, including substance misuse, housing, education, training, employment, offending, healthcare, family life, relationships, community participation and support networks, religion and culture.

To enable service users to take personal responsibility for their own self care and recovery, their families, children and the community.

PERSON CENTRED CARE

Question 2

Who manages the treatment of patients?

Answer 2

Local management, organisation and payment for services via Public Health England (commissioned by Local Councils)
Services provided by specialist charities and NHS mental health units
e.g. Turning Point, Addaction, KCA, WDP, Reach Out Recovery, Alcohol and Drug Abstinence Service,Iris

Question 3

How do people get referred to these services?

Answer 3

Self referral
Police
Social workers
GP and other HCPs including pharmacists
Criminal justice service

Question 4

Management of Opioid Misusers
what is detoxification
how long does it need to last

Answer 4

Ultra-rapid detoxification under general anaesthesia/ heavy sedation not recommended (NICE CG52)
High relapse rate
Duration of opioid detoxification:
up to 4 weeks (inpatient or residential setting)
up to 12 weeks in a community setting

Question 5

what is given for withdrawal symptom management of diarrhoea

Answer 5

loperamide

Question 6

what is given for withdrawal symptom management of stomach cramps

Answer 6

mebeverine

Question 7

what is given for withdrawal symptom management of muscular events and headaches

Answer 7

paracetamol and NSAID

Question 8

what is given for withdrawal symptom management of vomiting

Answer 8

metoclopramide/prochlorperazine

Question 9

what is given for withdrawal symptom management of anxiety and insomnia

Answer 9

short acting benzodiazepines or zopiclone

Question 10

Management of Opioid Misuse
Abstinence
how long should it last
dosages

Answer 10

Detoxification programme followed by relapse prevention support

Abstinence supported for at least 6 months with psychosocial and drug therapy (mildly dependent clients may only need drug therapy)

Naltrexone (Nalorex®) competitively displaces opioid agonists, blocking euphoric effects and minimising positive rewards associated with opioid use.
Licensed as an adjunctive prophylactic treatment for detoxified formerly opioid-dependent people who have remained opioid free for at least 7–10 days.
Test for opioid use with naloxone prior to starting naltrexone
25 mg naltrexone on day 1 followed by 50 mg daily thereafter for an initial period of 3 months or 3 x a week dosing

Question 11

what is Maintenance (substitution/ harm reduction) therapy
what drugs are used

Answer 11

Maintenance (substitution/ harm reduction) therapy:
Aims to provide stability by reducing craving and preventing withdrawal, eliminating the hazards of injecting and freeing the person from preoccupation with obtaining illicit opioids, and to enhance overall function.

Methadone, buprenorphine or Suboxone®
Drugs are given as part of a programme of supportive care
Prescribing of diamorphine (also dipipanone and cocaine) to treat addiction only allowed if prescriber has a Home Office license (Misuse of Drugs (Supply to Addicts) Regs 1997)

Question 12

Maintenance Therapy

Answer 12

Instalment prescriptions on form FP10MDA-methadone, buprenorphine, Suboxone and also diazepam (14 day supply maximum). Can be other schedule 2 CDs.

Prescriber writes prescription with stated daily dose and dates or days to be supplied. Convenient supplying pharmacy agreed with prescriber, key worker, client and pharmacist (4 way or shared care agreement)

Pharmacy is contacted by prescribing team (GP, keyworker, clinic Dr. etc)

Prescriptions are given to client or posted
directly to pharmacy from prescriber.

Client calls in for supervised administration
daily thereafter for 3 months minimum

Pharmacy is paid by submission of Rx to
NHSBSA and also by local council (locally
commissioned service, paid for
by PHE)

Question 13

Role of Pharmacies in Maintenance Therapy

Answer 13

Significant point of contact with the client
Provide information and advice
Monitor for ADRs, interactions
Monitor for other health issues (mental health, onset of problems relating to drug misuse or unrelated health issues)
Encourage participation in harm reduction strategies
Refer back to drug misuse team or prescriber where necessary
Service Specification from local council (PHE) describing contracted duties

Question 14

maintenance therapy:
methadone
dose

Answer 14

Initially 10-40mg daily
Increase by up to 10mg daily (max 30mg weekly titration) until no signs of withdrawal or intoxication
Usual dosage range 60-120mg daily
Usually single dose-large doses may be twice daily e.g. 80mg supervised, 40mg to take home.
Long t½ (15-60 hours) so no ‘rush’ and withdrawal onset 1-3 days, peak 3-6 days unlike heroin (t½ 2-3 minutes, withdrawal onset 6-12 hours, peak at 36-72 hours)

Question 15

maintenance therapy:
methadone presentation
dose

Answer 15

Methadone Presentation
1mg/1ml oral solution sugar free (SF) and non SF (green liquid)
10mg/1ml oral liquid for dilution with diluent (Methadose)(blue)
Tablets 5mg (Physeptone) (unlicensed)
Injection:
10mg/ml 1ml amps
10mg/ml 2ml amps
50mg/2ml amps
50mg/1ml amps

Question 16

what is the side effects of methadone?

Answer 16

Side Effects:
Nausea and vomiting
Urticaria, pruritis, rashes
Vertigo
Sweating
Bradycardia or tachycardia
Mood changes
Constipation
Drowsiness/dizziness

Question 17

can you drive whilst taking methadone?

Answer 17

Methadone is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988:
It is an offence to drive while under the influence of this medicine but patients would not be committing an offence if:
The medicine has been prescribed to treat a medical problem and
It was taken according to the instructions given by the prescriber and in the information provided with the medicine and
It is not affecting the ability to drive safely

Question 18

what are the stages of Management of Drug Misuse (4)

Answer 18

Initial review: interviews and testing for substance misuse-urine (e.g. Eco cups) and blood testing, use of Clinical Opiate Withdrawal Scale (COWS)

Psychosocial and Pharmacological interventions
provided in the community and criminal justice system:
include inpatient, residential, day-patient and outpatient services.

Psychosocial treatment
Cognitive behavioural / psychodynamic therapy
Behavioural couples therapy
Contingency management-key worker
Treat comorbid depression and anxiety

Pharmacological treatment-opioids/benzodiazepines
Detoxification
Abstinence
Maintenance (substitution/ harm reduction) therapy

Question 19

Buprenorphine
dose
moa
side effect

Answer 19

Buprenorphine

Initially 0.8-6mg daily
Increased at intervals until no signs of withdrawal or intoxication
Usual dosage range 8-24mg daily, maximum 32mg daily
Once daily dosage
t½ 12 hours, duration 12-72 hours.
Partial opioid agonist
Blocks effects of ‘top up’ heroin
Side effects similar to methadone but not those related to histamine release

Presentation
Sublingual tablets (Subutex and generic, 0.4, 2 and 8mg strengths)
Temgesic S/L tabs unlicensed for substance misuse (0.2 and 0.4mg)

Suboxone® is SL buprenorphine with naloxone (opioid antagonist to reduce iv misuse-precipitates withdrawal if injected but ineffective orally or SL) 8/2mg and 2/0.5mg strengths

Espranor oral lyophilisate (freeze-dried wafer that dissolves rapidly on the tongue)
2 and 8mg strengths-not interchangeable with S/L formulation

Question 20

how do you choose whether to use methadone or buprenorphine

Answer 20

Methadone
first choice: works well for clients misusing multiple drugs/alcohol and better for clients with anxiety during withdrawal but depends on many factors e.g. :
History of opioid dependence
Engagement and motivation with therapy
Risks (overdose, diversion, family and/or homelife situation i.e. lack of support)
Patient preference
Prescriber’s experience

Buprenorphine :
Less sedating
Safer in conjunction with other sedating drugs
Fewer drug interactions
Dose reductions easier as withdrawal symptoms are milder
Faster titration to steady state for maintenance (minimum 1 week)
Less risk of overdose

BUT-cannot be given if liver dysfunction (LFTs measured prior to use)

Suboxone used for non-supervised clients likely to misuse SL tablets via iv route

Question 21

how can you support someone with alcohol problems

Answer 21

Person-centred care
Treatment and care should take into account people’s needs and preferences

Supporting patients and carers

Identification (community good option) and assessment (specialist treatment centres for accurate assessment)

Interventions for:
hazardous & harmful drinking
mild, moderate & severe dependence alcohol dependence

Interventions after successful withdrawal for:
moderate alcohol dependence
severe alcohol dependence

Question 22

what is Hazardous and harmful drinking: Alcohol Brief Intervention (BI)
2 components
how effective
where

Answer 22

Two components:
Screening questions e.g. Alcohol Use Disorder Identification Test (AUDIT)
Brief motivating discussion (approx. 10 mins)

Opportunistic

How effective?
BI reduced consumption compared to control group (-38 grams/week for 1 year or longer) (Kaner et al, 2007)

Where?
GP practices
A&E
Emerging research in community pharmacies

Question 23

BI opportunities in the pharmacy?

Answer 23

Self referral
View poster/read flyer
Health query linked to alcohol use

Pharmacy services
Smoking cessation
Harm minimisation (needle exchange, supervised consumption, instalment dispensing)
Medication review service
Health check
Emergency Hormonal Contraception

Counter Purchases
Smoking cessation
GIT remedies
Sleep aids
Other CNS depressants

Prescribed medications
Gastric problems
Cardiovascular or heart problems
Mental Health (e.g. addiction, depression) Diabetes

Question 24

Interventions for mild, moderate and severe alcohol dependence
how is this measured

Answer 24

Assessed if consuming typically more than 15 units alcohol/day or score 20 or more on Alcohol Use Disorder Identification Test (AUDIT)

Treatment setting options:
Outpatient assisted withdrawal or
Specialist alcohol services if there are safety concerns about community-based withdrawal

Mild to moderate, 2–4 meetings per week over the first week

Mild to moderate dependence and complex needs, or severe dependence, offered a more intensive community programme following assisted withdrawal in which the patient may attend a day programme lasting between 4 and 7 days per week over a 3-week period

Complex needs and severe dependence, inpatient or residential assisted withdrawal

Question 25

what is Alcohol withdrawal treatment

Answer 25

Treatment regimens:
Fixed dose or symptom-triggered medication regimens

Preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam)

In a fixed-dose regimen, titrate the initial dose of medication to the severity of alcohol dependence and/or regular daily level of alcohol consumption

In severe alcohol dependence higher doses will be required to adequately control withdrawal and should be prescribed according to the Summary of Product Characteristics (SPC)

Should be adequate supervision if high doses are administered

Benzodiazepine gradually reduced over 7–10 days to avoid alcohol withdrawal recurring

Question 26

Relapse prevention after withdrawal and doses and advices

Answer 26

Not responded to psychological interventions alone, or who have specifically requested a pharmacological intervention:

Pharmacological treatment to start after assisted withdrawal:
Acamprosate (start soon as possible after withdrawal)
666mg (2 tabs) three times a day up to 6 months, or longer with at least monthly supervision
Stop if drinking persists 4–6 weeks after starting treatment

Oral naltrexone
Start at 25 mg per day (half-tab)
Maintenance dose of 50 mg per day
Highlight information card about opioid-based analgesics
Supervised monthly up to 6 months, or longer for those benefiting
Stop if drinking persists 4–6 weeks after starting treatment

Disulfiram (not gold standard treatment)
Start treatment at least 24 hours after last alcoholic drink
Usually prescribe at a dose of 200 mg per day (1 tab)
Test liver function, urea and electrolytes to assess for liver or renal impairment
Check SPC for ‘disulfiram-alcohol reaction’ and contraindications in pregnancy and in the following conditions: a history of severe mental illness, stroke, heart disease or hypertension.

Combination with psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies)

Question 27

How could pharmacists support drinkers?

Answer 27

Discuss possible interactions and contraindications of alcohol with their medicines (OTC, POM, food herbal remedies)

Highlight and explain UK Government Guidelines on alcohol limits and explore if they are exceeding this

Advise them to see their GP and/or access other services (alcohol treatment centre ‘drop-in’ service or online information e.g. AA, DownYourDrink)

Provide motivating psychosocial support:
Explore how the patient feels about their drinking (positive and negative aspects)
If they want to reduce, if so, how? What could be feasible?
Have they tried to reduce before, what worked or did not work?
What would they like to do now about their drinking or in the near future?

Question 28

what is the most common drug for maintenance therapy?

Answer 28

methadone or buprenorphine