Module 6: Opioid agonist treatment (OAT) initiation and stabilization phase Flashcards
What is the name of the Canadian guideline for OUD management?
CRISM (Canadian Research Initiative in Substance Use)
(unclear what year)
CAMH also has a guideline: Opioid Agonist Therapy: A Synthesis of Canadian Guidelines for Treating Opioid Use Disorder – Canadian Opioid Use Disorder Clinical Guidelines (2021)
Prescribing practices for narcotics
- written or faxed prescriptions only
- no refills permitted
- dose in mg (write dose in words)
- new start vs dose increase or decrease
- start and end dates (“inclusive”)
- specific days for observed doses
- specific days for carries
- for methadone: “doses should be dispensed in orange juice
- for bup/nlx: “sublingual administration”
- for bup/nlx don’t specific # of tablets, just dose, frequency, duration and allow pharmacist to figure out required number of tablets
Physician requirements for prescribing methadone
> “effective May 19, 2018, exemption is no longer required to prescribe methadone for opioid use disorder”
> CPSO: “As with all areas of practice, physicians must only prescribe methadone if they have the knowledge, skill, and judgment necessary to do so safely and effectively. Physicians and other health-care professionals can obtain the necessary training and education by completing the Centre for Addiction and Mental Health’s Opioid Use Disorder Treatment course and Opioid Dependence Treatment Certificate Program.2”
- In other words: you should do the CAMH training course
Physician requirements for prescribing bup/nlx
nothing mentioned on CPSO
Probably should have training.
Prescription practices when starting / changing dose
“Cancel previous prescriptions”
“Dose change”
What should happen to OAT prescription upon admission to hospital?
Should be cancelled at community pharmacy so that
- admission is communicated
- avoids errors in dose changes / prescriptions
What should be communicated to client at initiation
- effects / side-effects / toxicity / interaction with other opioids
- bup/nlx starts at 2-4mg, requires few weeks to optimum dose
- methadone starts 15-30mg, risk of toxicity
- withdrawal symptoms until dose optimized
- risk reduction: naloxone kit, small doses, do not use alone
- missed doses and apparent intoxication at pharmacy
- written agreement
Buprenorphine time of onset (peak plasma concentration)
1 hour
Buprenorphine half-life
32 hours on average
Initiating bup/nlx: what describes moderate withdrawal?
COWS 13+
Initiating bup/nlx: estimated wait times to moderate withdrawal?
short-acting opioids: 12h+
long-acting opioids: 12-24h+
methadone: 36h to 3-5 days
fentanyl: tricky because it accumulates in fat tissue, risk of precipitated withdrawal
What makes a high risk for precipitated withdrawal when starting bup/nlx in fentanyl users?
accumulates in fat tissue, so effective half-life is prolonged
risk of precipitated withdrawal even when moderate withdrawal sx or 12h+ since last use
initiating bup/nlx: microdosing – the big idea
avoid any moderate-severe withdrawal symptoms by gently introducing partial-agonism of bup/nlx:
1. using full agonist therapy (e.g. methadone)
2. while slowly increasing bup/nlx dose over a week
initiating bup/nlx: microdosing – the protocol
- Start with a low dose of bup/nlx (e.g. 0.5mg) overlapping with other opioid use.
- Implement small (e.g., 0.5–1 mg) daily dose increases of bup/nlx, over five to seven days.
- Cease opioid use abruptly after reaching a total daily dosage of 12 mg of bup/nlx.
initiating bup/nlx: microdosing – target populations
- use illicit fentanyl and fentanyl analogues (b/c unpredictable withdrawal)
- may not reliably attend appointments due to work commitments or social instability
- cannot tolerate moderate to severe withdrawal.
