Management of Opiate Misuse

Question 1

what is the definition of problematic drug use

Answer 1

the problematic use of opiates (including illicit and prescribes methadone) and/ or the illicit use of benzodizepines.
implies routine and prolonged use as opposed to recreational and occasional drug use

Question 2

what are the effects of opioids

Answer 2

euphoria 
analgesia
resp depression 
constipation 
reduced conscious level 
hypotension 
bradycardia 
pupillary constriction 
tolerance develops with repeated use

Question 3

what pharamcological properties make heroin addictive

Answer 3

rapidity of onset of action
short half life
availability

Question 4

how can you take heroin

Answer 4

IV
smoking
suppository 
insufflation 
ingestion 

(in order of popularity)

Question 5

what is the metabolic pathway of heroin

Answer 5

diacetylmorphine (heroin) -> 6- mono-acetyl morphine -> morphine

Question 6

what are the withdrawal symptoms of heroin

Answer 6

typically occur within 6-8 hours 
dysphoria and cravings 
agitation 
tachycardia and hypertension 
piloerection 
diarrhoea, nausea and vomiting 
dilated pupils 
joint pains 
yawning 
rhinorrhea and lacrimation (watery eyes)

Question 7

what type of reinforcement causes addiction

Answer 7

negative- want to prevent withdrawal

Question 8

what are the complications of IV drug use

Answer 8

infections:
local- cellulitis, abscess, thrombophlebitis, necrotising fascitis
distant- infective endocarditis

thrombotic / embolic: DVT, PTE, ischaemic limb

Question 9

what is happening to the number of drug related deaths

Answer 9

is increasing

Question 10

what are the social consequences of heroin use

Answer 10

unemployment, neglect of family/ children, alternative interests, criminality, risk of violence, prostitution

Question 11

what are the psychiatric consequences of heroin use

Answer 11

depression, anxiety

Question 12

does heroin cause psychosis

Answer 12

no

Question 13

what is prescribed for opioid replacement therapy

Answer 13

methadone

buprenorphine

Question 14

what is prescribed for opioid detox

Answer 14

methadone
buprenorphine
lofexidine

Question 15

what opioid antagonists can be used and what for

Answer 15

natrexone- blocks opioid receptors so you cant get high

naloxone- used in overdose

Question 16

what is opiate substitution therapy

Answer 16

the replacement of a short acting opiate with a long action opiate (used in alcohol dependence)

• buprenorphine or methadone
• once daily dosing
• initially taken under supervision

Question 17

what should the ideal opiate substitution therapy be

Answer 17

safe
well tolerated
stop withdrawal symptoms 
not be addictive 
have long effect (levoacetylmethadol, buprenorphine depot)

Question 18

what are the pros of opiate substitution therapy (OST)

Answer 18

reduced mortality 
reduced HIV/ HCV infections
Reduces criminality
Promotes pro social activities
Promotes family life 
Promotes employment

Question 19

what are the cons of OST

Answer 19

daily visits to chemists
stigma
side effects

Question 20

what drugs are used for opiate substitution therapy

Answer 20

methadone - long acting full agonist, tablet or liquid (liquid used, 1mg/1ml)

buprenorphine - long acting partial agonists, tablet, different preparations

Question 21

what is opiate detoxification

Answer 21

achieve complete abstinence from ALL opiates

Question 22

what are the risks of opiate detoxification

Answer 22

high death rate after completion- more likely to overdose

70-80% of detox completers will relapse within a year

Question 23

what psychosocial interventions exist for opiate misuse

Answer 23

contingency management- rewarding positive behaviours ro reduce illicit drug use and/ or promote engagement with services receiving methadone maintenance treatment

behavioural couples therapy

CBT and psychodynamic therapy - not indicated for drug misuse but for co morbid anxiety and depression

Question 24

what is heroin assisted treatment

Answer 24

when heroin in administered (in clinic) alongside oral methadone = very effective

Question 25

how do you choose between methadone or buprenorphine

Answer 25

methadone more potent (as full agonists) so used when higher doses of heroin being taken. higher risk of overdose so takes longer to titrate dose up, more stigma.

buprenorphine less potent but has high affinity for opioid receptors- this can either provide a protective effect (block effect of using heroin) or cause withdrawal as it removes other opioids from the receptors. this is the safer drug (less risk of overdosing as partial agonist), less sedative, longer effect, quicker titration (2-3 days instead of weeks months for methadone), easier to detox, less stigma.
however can be misued (injected/ snorted), risk of induced withdrawal

Question 26

what are the doses for methadone

Answer 26

10-30 mg starting dose
effective dose usually 60-120mg
no max dose
increase by max 10mg/ day and 30 mg/week

Question 27

what are the doses for buprenorphine

Answer 27

starting dose 4-8 mg
second day up to 16 mg
effective dise 12-16 mg 
maximum dose 32 mg/ day 
taken in morning

Question 28

what is the right dose for maintenance

Answer 28

the dose where the patient stops using and is not experiencing cravings

Question 29

what is the three days rule

Answer 29

if patient doesn’t collect medication pharmacist needs to get advice as patients tolerance may be reduced