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PSYCHIATRY > Management of Opiate Misuse > Flashcards

Management of Opiate Misuse Flashcards

1
Q

Have drug related deaths increased or decreased in the past 2 decades?

A

General increase

2018 - highest peak of drug related deaths

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2
Q

What government legislation is aiming to tackle the concept of drug-related deaths in Scotland?

A

Staying Alive In Scotland (2016)

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3
Q

Roughly how many “problem drug users” live in Scotland?

A

61,500 problem drug users

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4
Q

What is meant by “problem” drug use?

A
  • 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
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5
Q

What are the main effects of opiates such as heroin?

A 
Euphoria
Analgesia
Respiratory depression
Constipation
Reduced conscious level
Hypotension and bradycardia
Pupillary constriction
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6
Q

Why is tolerance of opiates dangerous?

A

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

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7
Q

What are the main withdrawal symptoms of opiates?

A
  • 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
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8
Q

Why is IV the most common method of using heroin in Scotland?

A

More potent

cheaper than smoking

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9
Q

What complications occur as a result of injecting drugs?

A

Infections:
Local: cellulitis, abscess, necrotising fasciitis
Distant: infective endocarditis,
Systemic: Hep B, HIV, Hep C

Thrombotic/embolic
DVT, PE, ischaemic limb

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10
Q

What are the non-medical complications of IV drug use?

A

Social:

  • unemployment
  • Neglect of family/children
  • criminality/ risk of violence
  • prostitution

Psychiatric

  • depression
  • anxiety
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11
Q

What psychological symptom do opioids not produce which other drugs may cause?

A

Psychosis

opiates = only sedative drug which cause an anti-psychotic effect

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12
Q

What types of drugs commonly cause psychotic symptoms?

A 
Stimulants
Cannabinoids
Hallucinogenics
Alcohol
Polyabuse
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13
Q

What are the aims of pharmacological treatment in opioid dependence?

A

Reducing harm
Promoting recovery
Maintaining abstinence

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14
Q

Why are reducing harm and promoting recovery difficult to achieve in one treatment?

A

Substance replacement therapy = giving them a less dangerous drug, but difficult to promote detox and recovery even from this safer option

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15
Q

What medications can be prescribed for opioid replacement therapy (ORT)?

A

methadone

Buprenorphine

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16
Q

What medications can be given to detox patients off of opioids (e.g. morphine)?

A

methadone
Buprenorphine
Lofexidine

17
Q

Give examples of opioid antagonists

A

Naltrexone

Naloxone

18
Q

Substitution therapy (like ORT) can also be use for benzodiazepine, stimulant OR alcohol dependence. TRUE/FALSE?

A

TRUE

- it can be used BUT has poor evidence to support it

19
Q

What should the ideal substitution medication have?

A
  • Be safe and well tolerated
  • Stop withdrawal symptoms
  • Not be addictive
  • Have a long effect (e.g. buprenorphine injection once per month)
20
Q

What medications are available as opioid replacement therapy in the UK?

A

Methadone mixture 1mg/1ml

Buprenorphine

  • Sublingual tabs = Generic, Subutex, Espranor, Suboxone (with naloxone)
  • Monthly injection = Buvidal (just licenced)
21
Q

What are the reasons FOR opioid replacement therapy?

A

3x less likely to die when on treatment (large protective factor)

  • Reduces criminality
  • Promotes pro-social activities
  • Promotes family life
  • Promotes employment
22
Q

How should you choose between using buprenorphine or methadone as the opioid replacement therapy for a patient?

A

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)

23
Q

What are the advantages of using buprenorphine over methadone if you can?

A
  • 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
24
Q

What are the disadvantages of using buprenorphine?

A
  • Not indicated for patients using high doses of opioids
  • Can be misused (injected/snorted)
  • Risk of induced withdrawal
  • Less sedative (patients sometimes prefer sedation)
25
Q

What is a normal methadone induction dose and how much can it be increased in the first week?

A
  • Starting dose 10-30 mgs
  • 1st week increase by:
    max 10 mgs/day
    max 30 mgs/week
26
Q

How long does it take for a patient to reach steady state on their methadone dose?

A

5 days/ 5 half lives to the steady state

=> on the same dose, the blood level and the effect will increase for 5 days

27
Q

What is a normal maintenance dose for methadone and what is the maximum dose?

A

Usual effective dose: 60-120 mg

No maximum dose

28
Q

What is the usual induction dose of Buprenorphine and how quickly can this dose be increased?

A

Starting dose 4-8mg

Can increase as soon as second day
=> up to 16mg

29
Q

What is the normal effective buprenorphine dose and is there a maximum daily dose?

A

Usual effective dose 12-16 mg

Maximum dose 32 mg/day
24 mg for Suboxone, 18 mg for Espranor

30
Q

How do we work out what maintenance dose is right for each patient?

A
  • Maintenance dose = where the patient stops using and is not craving
  • Can be much higher than the dose needed to suppress withdrawal symptoms
31
Q

What test should patients receive if they are on over 100mls methadone daily?

A

ECG for the increased risk of arrhytmia (QTc prolongation)

32
Q

Why is opioid replacement therapy supervised?

A
  • avoid diversion/ illegal selling

- Allow healthcare professionals to be sure of the level of tolerance to the medication

33
Q

What is the “3 Days Rule”?

A
  • 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

PSYCHIATRY (35 decks)

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