Management of Opiate Misuse Flashcards
What is problematic drug use?
Problematic use of opiates (including illicit and prescribed methadone use) and/or illicit use of BZD and implies route and prolonged use as opposed to recreational and occasional drug use
What is opium?
Mixture of alkaloids (esp codeine and morphine)
What is morphine?
Morphine extracted though often codeine contaminants remain
What is diamorphine?
Addition of 2 acetyl rings to produce diacetylmorphine
How can heroin be taken?
IV Smoking Suppository Insufflation Ingestion
How is heroin metabolised?
Diacetylmorphine -> 6-monoacetyl-morphine -> morphine
What are the effects of heroin?
Euphoria Analgesia Resp depression Constipation Reduced conscious level Hypotension and bradycardia Pupillary constriction Tolerance with repeated use
Withdrawal symptoms from opiates?
Dysphoria and cravings Agitation Tachycardia and hypertension Piloerection Diarrhoea, nausea and vomiting Dilated pupils Joint pains Yawning Runny nose (rhinorrhoea), watery eyes (lacrimation)
How quickly will withdrawal symptoms appear in opiate withdrawal?
6-8 hours
What are the complications of IV opiate use?
Infections:
Local: cellulitis, abscess, thrombophlebitis, necrotising fasciitis)
Distsant: infective endocarditis
Systemic: hep B, HIV, hep C
Thrombotic/ embolic: DVT, PTE, ischaemic limb
Social consequences of heroin use?
Unemployment Neglect of family/ children Alternative interests Criminality Risk of violence Prostitution
Psychiatric complications of heroin use?
Depression
Anxiety
DOES NOT CAUSE PSYCHOSIS OR DELIRIUM
What is opiate substitution therapy (OST)?
Replacement of short acting opiate with long acting opiate
What medications are used for OST?
Buprenorphine
Methadone
Describe the pharmacology of methadone
Long acting full opioid agonist
Used with high doses of heroin are used
Liquid form
Describe the pharmacology of buprenorphine
Long acting partial opioid agonist
High affinity for opioid receptors; will displace opioids from receptors but causes withdrawal
Tablet (depot in future)
How many drug addicts who detoxity will relapse within 1 year?
70-80%
What psychosocial interventions are recommended by NICE for substance misuse?
Contingency management; rewarding positive behaviours to reduce illicit drug use/ promote engagement with methadone maintenance treatment
Behavioural couples therapy
Is CBT and psychodynamic therapy recommended for drug misuse?
No but IS appropriate for comorbid anxiety and depression
What is heroin based treatment?
Combined methadone and heroin/methadone injected in clinic under medical supervision
Does heroin based treatment work?
Yes; results in greater improvements in most other outcomes such as crime and psychosocial functioning
What are the pros of prescribing buprenorphine in comparison with methadone?
Safter (less risk of overdosing as partial agonist)
Less sedative
Blocks effect of using heroin on top
Longer effect (taken every other day)
Quicker titration (2-3 days instead of weeks/ months for methadone)
Easier to detox from
Less stigma
Cons of Buprenorphine when in comparison with methadone?
Not indicated for those on high doses of opioids
Misuse (injected/ snorted)
Risk of induced withdrawal
Less sedative
Is there a max dose of methadone?
No
How should you titrate methadone?
10mg a day
30mg a week
What is the starting dose of methadone?
10-30mgs
What is usually an effective dose of methadone?
60-120 mg
What is the 3 day rule?
If medication not collected for 3 days; pharmacist should contact prescriber
What is the right dose for maintenance?
When the patient stops using and is not experiencing any craving or withdrawal
Starting dose for Buprenorphine?
4-8mg
Second day dosing for Buprenorphine?
16mg
What is the usual effective dose for Buprenorphine?
12-16mg
Max dose for Buprenorphine?
42 mgs
24 mmgs for suboxone
18 mgs for espranor
When do you take Buprenorphine?
Morning
