EXAM 4 Opioid Use Disorder Dr. Thomason Flashcards
Which diseases are associated with OUD and should be checked on patients?
HIV and Hepatitis C
What should be checked on a patient’s visit?
!!!
-prescription drug monitoring (check PDMP if they are taking something else like benzos or other opioids)
-physical exam (withdrawal, intoxication, injection when measuring BP)
-labs:
CBC (infection from injection use)
metabolic profile (check electrolytes, LFT (hepatitis risk), thyroid (hypothyroid causes anxiety and depression and may lead to self-eating
HIV test
urine drug test (the substance they are using may be contaminated with something else)
How does buprenorphine reduce cravings and block the effects of illicit drugs?
it is a partial agonist -> stops withdrawal and cravings
-give it only if the patient has withdrawal, if they are still using buprenorphine will put them into withdrawal!
-has to be abstinent for 7-10
-it has a high affinity to mu-receptors -> kicks off other opioids and prevents them from binding
How does Naltrexone work?
opioid antagonist
Vivitrol (injectable) preferred
-it can push patients into withdrawal if they are still using
-patients must stay abstinent for 7-10 days from opioids because it causes precipitated withdrawal (precipitated = induced by meds)
Why do people tend to use more Methadone over time?
because the effect doesn’t last as long as it binds to the receptor -> causing ACCUMULATION
-long half-life: 15-150hr
-effective dose range: 60-120 mg/day
max starting dose: 30 mg
-only available through opioid treatment program
What is the starting dose of methadone?
20-30 mg
max dose is 30 mg
total max dose is 40 mg
Adverse effects of Methadone
-Qtc prolongation!!! need ECG
most common:
-constipation, dry mouth
-sedation, dizziness
-diaphoresis (sweating) at night time
-sexual dysfunction (long-term decreases testosterone)
How much should the dose of Methadone be increased?
by 5-10 mg
steady-state occurs after 4-6 half-lives or 1 week
Disadvantages of Methadone use
-need close monitoring
-risk for mortality in the first 2 weeks
-Qtc prolongation
-multiple DDIs
What is the highest effective dose of Buprenorphine?
24 mg/day
How is Buprenorphine initiated?
called induction: start when they are in withdrawal
low dose: <2mg (microdosing) while they are still on opioids
high dose: 16-24 mg
Which tool is used to assess for withdrawal symptoms?
COWS
Clinical Opioid Withdrawal Scale
What is recommended if a patient on buprenorphine needs an opioid for pain treatment (ex after surgery)?
instead of giving a high dose of the opiod to overcome the blockade of buprenorphine
->use buprenorphine as the pain med (increase the dose)
Contraindication of Buprenorphine
-liver failure
-concurrent use of benzo, alcohol or opioids
How is XR Naltrexone given
380 mg IM every 4 weeks
-have to be abstinent from opioids
-can also be used for concomitant alcohol disorder
Who might use Naltrexone
professionals (physicians, pharmacists, pilots) with OUD who are not allowed to work with opioids or be on an opioid
How long do patients have to be abstinent to use Naltrexone?
if they are on a short-acting opioid like heroin, fentanyl, oxycodone, or hydrocodone: 5-7 days
long-acting: 7-10 days
before Naltrexone or naloxone use they take a urine drug test to see if it’s still in the system
patients often cant handle the craving and wait until they are off the opioid
Precautions with Naltrexone
-bleeding risk if they have thrombocytopenia or coagulation disorder
-check liver functions -> liver toxic
-don’t use if they are on an opioid -> precipitated withdrawal
-don’t use if they are in a withdrawal
What are complications of OUD in pregnancy?
-early labor
-fetal growth restriction
-stillbirth
-neonatal abstinence syndrome (NAS) - baby goes into withdrawal
-maternal complications
How should pregnant women on opioids be managed during pregnancy?
-don’t taper off, it causes withdrawal for the mother and the baby
-reduce the maternal opioid use
Txt:
-methadone
-buprenorphine mono
-buprenorphine-naloxone (recent evidence supports efficacy)
MOTHER-trial showed better outcomes for the baby with buprenorphine VS methadone
Dose adjustment during pregnancy with OUD
-higher metabolism of the mother -> may need to increase the dose
-breastfeeding is encouraged, opioids is in the milk and may prevent withdrawal of the baby
When to use Clonidine or Lofexidine (alpha-2agonists)
autonomic hyperactivity
-muscle twitching
-hot flushes or chills
-restlessness
