Management of Opiate Misuse Flashcards
Have drug related deaths increased or decreased in the past 2 decades?
General increase
2018 - highest peak of drug related deaths
What government legislation is aiming to tackle the concept of drug-related deaths in Scotland?
Staying Alive In Scotland (2016)
Roughly how many “problem drug users” live in Scotland?
61,500 problem drug users
What is meant by “problem” drug use?
- problematic use of opiates (including illicit/prescribed methadone) and/or the illicit use of benzodiazepines
- implies routine and prolonged use as opposed to recreational and occasional drug use
What are the main effects of opiates such as heroin?
Euphoria Analgesia Respiratory depression Constipation Reduced conscious level Hypotension and bradycardia Pupillary constriction
Why is tolerance of opiates dangerous?
If patient is abstinent for even a short period of time, their tolerance decreases
=> using the same high dose for their high tolerance could cause them to overdose and potentially die
What are the main withdrawal symptoms of opiates?
- occur within 6-8 hours due to increased Nor-adrenergic effect
- Dysphoria and cravings
- Agitation
- Tachycardia and hypertension
- Diarrhoea, N+V
- Dilated pupils
- Joint pains
- Yawning
- Runny nose/watery eyes
Why is IV the most common method of using heroin in Scotland?
More potent
cheaper than smoking
What complications occur as a result of injecting drugs?
Infections:
Local: cellulitis, abscess, necrotising fasciitis
Distant: infective endocarditis,
Systemic: Hep B, HIV, Hep C
Thrombotic/embolic
DVT, PE, ischaemic limb
What are the non-medical complications of IV drug use?
Social:
- unemployment
- Neglect of family/children
- criminality/ risk of violence
- prostitution
Psychiatric
- depression
- anxiety
What psychological symptom do opioids not produce which other drugs may cause?
Psychosis
opiates = only sedative drug which cause an anti-psychotic effect
What types of drugs commonly cause psychotic symptoms?
Stimulants Cannabinoids Hallucinogenics Alcohol Polyabuse
What are the aims of pharmacological treatment in opioid dependence?
Reducing harm
Promoting recovery
Maintaining abstinence
Why are reducing harm and promoting recovery difficult to achieve in one treatment?
Substance replacement therapy = giving them a less dangerous drug, but difficult to promote detox and recovery even from this safer option
What medications can be prescribed for opioid replacement therapy (ORT)?
methadone
Buprenorphine
What medications can be given to detox patients off of opioids (e.g. morphine)?
methadone
Buprenorphine
Lofexidine
Give examples of opioid antagonists
Naltrexone
Naloxone
Substitution therapy (like ORT) can also be use for benzodiazepine, stimulant OR alcohol dependence. TRUE/FALSE?
TRUE
- it can be used BUT has poor evidence to support it
What should the ideal substitution medication have?
- Be safe and well tolerated
- Stop withdrawal symptoms
- Not be addictive
- Have a long effect (e.g. buprenorphine injection once per month)
What medications are available as opioid replacement therapy in the UK?
Methadone mixture 1mg/1ml
Buprenorphine
- Sublingual tabs = Generic, Subutex, Espranor, Suboxone (with naloxone)
- Monthly injection = Buvidal (just licenced)
What are the reasons FOR opioid replacement therapy?
3x less likely to die when on treatment (large protective factor)
- Reduces criminality
- Promotes pro-social activities
- Promotes family life
- Promotes employment
How should you choose between using buprenorphine or methadone as the opioid replacement therapy for a patient?
Methadone = Pure Agonist
=> if patients have been using high doses of heroin they will need methadone as buprenorphine will not be strong enough
Buprenorphine = only a Partial Agonist (but with very high affinity for opioid receptors)
What are the advantages of using buprenorphine over methadone if you can?
- Safer (less risk of overdosing on a partial agonist)
- Less sedative (clear head)
- More likely to block effect of using on top
- Longer effect (can be taken every other day)
- Quicker titration (2-3 days instead of weeks/months for methadone)
- Easier to detox
- Less stigma
What are the disadvantages of using buprenorphine?
- Not indicated for patients using high doses of opioids
- Can be misused (injected/snorted)
- Risk of induced withdrawal
- Less sedative (patients sometimes prefer sedation)
What is a normal methadone induction dose and how much can it be increased in the first week?
- Starting dose 10-30 mgs
- 1st week increase by:
max 10 mgs/day
max 30 mgs/week
How long does it take for a patient to reach steady state on their methadone dose?
5 days/ 5 half lives to the steady state
=> on the same dose, the blood level and the effect will increase for 5 days
What is a normal maintenance dose for methadone and what is the maximum dose?
Usual effective dose: 60-120 mg
No maximum dose
What is the usual induction dose of Buprenorphine and how quickly can this dose be increased?
Starting dose 4-8mg
Can increase as soon as second day
=> up to 16mg
What is the normal effective buprenorphine dose and is there a maximum daily dose?
Usual effective dose 12-16 mg
Maximum dose 32 mg/day
24 mg for Suboxone, 18 mg for Espranor
How do we work out what maintenance dose is right for each patient?
- Maintenance dose = where the patient stops using and is not craving
- Can be much higher than the dose needed to suppress withdrawal symptoms
What test should patients receive if they are on over 100mls methadone daily?
ECG for the increased risk of arrhytmia (QTc prolongation)
Why is opioid replacement therapy supervised?
- avoid diversion/ illegal selling
- Allow healthcare professionals to be sure of the level of tolerance to the medication
What is the “3 Days Rule”?
- If ORT medication is not collected for 3 consecutive days, pharmacist must contact the prescriber.
- This is due to the patients tolerance having potentially decreased over these days, and an adjustment in their methadone dose may be required
