Management of Opiate Misuse Flashcards
what is the definition of problematic drug use
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
what are the effects of opioids
euphoria analgesia resp depression constipation reduced conscious level hypotension bradycardia pupillary constriction tolerance develops with repeated use
what pharamcological properties make heroin addictive
rapidity of onset of action
short half life
availability
how can you take heroin
IV smoking suppository insufflation ingestion
(in order of popularity)
what is the metabolic pathway of heroin
diacetylmorphine (heroin) -> 6- mono-acetyl morphine -> morphine
what are the withdrawal symptoms of heroin
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)
what type of reinforcement causes addiction
negative- want to prevent withdrawal
what are the complications of IV drug use
infections:
local- cellulitis, abscess, thrombophlebitis, necrotising fascitis
distant- infective endocarditis
thrombotic / embolic: DVT, PTE, ischaemic limb
what is happening to the number of drug related deaths
is increasing
what are the social consequences of heroin use
unemployment, neglect of family/ children, alternative interests, criminality, risk of violence, prostitution
what are the psychiatric consequences of heroin use
depression, anxiety
does heroin cause psychosis
no
what is prescribed for opioid replacement therapy
methadone
buprenorphine
what is prescribed for opioid detox
methadone
buprenorphine
lofexidine
what opioid antagonists can be used and what for
natrexone- blocks opioid receptors so you cant get high
naloxone- used in overdose
what is opiate substitution therapy
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
what should the ideal opiate substitution therapy be
safe well tolerated stop withdrawal symptoms not be addictive have long effect (levoacetylmethadol, buprenorphine depot)
what are the pros of opiate substitution therapy (OST)
reduced mortality reduced HIV/ HCV infections Reduces criminality Promotes pro social activities Promotes family life Promotes employment
what are the cons of OST
daily visits to chemists
stigma
side effects
what drugs are used for opiate substitution therapy
methadone - long acting full agonist, tablet or liquid (liquid used, 1mg/1ml)
buprenorphine - long acting partial agonists, tablet, different preparations
what is opiate detoxification
achieve complete abstinence from ALL opiates
what are the risks of opiate detoxification
high death rate after completion- more likely to overdose
70-80% of detox completers will relapse within a year
what psychosocial interventions exist for opiate misuse
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
what is heroin assisted treatment
when heroin in administered (in clinic) alongside oral methadone = very effective
how do you choose between methadone or buprenorphine
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
what are the doses for methadone
10-30 mg starting dose
effective dose usually 60-120mg
no max dose
increase by max 10mg/ day and 30 mg/week
what are the doses for buprenorphine
starting dose 4-8 mg second day up to 16 mg effective dise 12-16 mg maximum dose 32 mg/ day taken in morning
what is the right dose for maintenance
the dose where the patient stops using and is not experiencing cravings
what is the three days rule
if patient doesn’t collect medication pharmacist needs to get advice as patients tolerance may be reduced
