Opiate Replacement Therapy

Question 1

Opioids

Answer 1

include naturally occurring and synthetic (man-made) drugs

Question 2

Naturally occurring opioids

Answer 2

derived from the poppy
– ex. morphine, codeine, opium

Question 3

Semi-synthetic opioids

Answer 3

change the chemical structure of naturally occurring opioids
– ex. hydromorphone (Dilaudid), oxycodone (Oxycontin), heroin

Question 4

Synthetic opioids

Answer 4

made entirely from chemicals
ex. meperidine (Demerol), methadone (Methadose), fentanyl (Sublimaze)

Question 5

T3

Answer 5

Codeine – combined with acetaminophen is T3’s

Question 6

Percocet

Answer 6

oxycodone

Question 7

How Did The Addiction Even Start?

Answer 7

• Prescription pills…usually first used orally, then moves to crushing crushing/snorting, smoking, injecting
• Prescribed by physician
• The two most common chronic conditions for which opioids are prescribed are back pain and osteoarthritic
• Tried it a party
• Took it from my parents
• Heroin…usually try smoking first, then injecting
• Seems to be geographic, not a lot of heroin in Winnipeg and now BC
• In all cases the opiate provides the individual with a euphoric, good feeling, like a nice warm blanket
• Not everyone who takes opiates experiences this type of feeling

Question 8

DPIN

Answer 8

Drug Program Information Network

Question 9

Recognizing An Overdose

Answer 9

Unresponsive to stimulus such as someone yelling their name, a light shake or a sternal rub
Breathing is slow, erratic or not breathing at all
Body is very limp
Fingernails and lips are blue
Skin is cold and/or clammy
Pulse is slow, erratic, or not there at all
Choking sounds or a snore-like gurgling noise
Vomiting and/or Seizures
Loss of consciousness
Pupils are tiny

Question 10

Naloxone

Answer 10

• Safe and effective antidote to opioid overdose – prevents or reverses the effects of opioids by blocking the opioid receptor sites in the central nervous system
• The only contraindication is hypersensitivity to naloxone
• No potential for misuse - it does not get a person stoned/high
• It has no effect if opioids are not present
• Once administered intramuscularly it starts to work in approximately 2 to 5 minutes
• When the naloxone kicks in, the person may be disoriented, agitated, angry and want to use drugs again. Try to explain to them what happened, tell them EMS are on their way and urge them not to use
• Effects wear off within 30–60 minutes so critical to call 911
• Should be stored between 15-30C and protected from light

Question 11

Physician Assisted Taper

Answer 11

instead of prescribing 30 Percocet a month prescribe 25. Have th person pick up the meds evey day

Question 12

Detox

Answer 12

• Opioid withdrawal is unpleasant physically and emotionally, but rarely medically risky (see next slide for w/d sx’s)
• Some to it at home, others with medical assistance (worried about w/d)
• They leave the detox emotionally unstable and craving – no new skills – tolerance is decreased which puts the person at higher risk of OD if relapse occurs
• Very high relapse rate with detox alone
• Detox without a recovery plan can be dangerous
• They won’t die. Can die from malnutrition or dehydration
• They can say they’ll feel like theyre dying but they won’t
  It’s like COVID but 20x worse. Can’t go to work or school
• Very high relapse rate with detox alone – no coping skills and the pain comes back so they go and use the same dose as before and die from overdose

Question 13

Withdrawal Symptoms

Answer 13

Agitation
Anxiety
Aggression
Restlessness
Muscle and bone pain
Pupil dilation
Insomnia
Diarrhea
Vomiting
Cold flashes
Sweating
Involuntary leg movements
Piloerection (goose bumps)

Question 14

Barriers To ORT

Answer 14

• Difficult to access ORT (wait list or location)
• Stigma of Methadone/Suboxone (because it’s not true abstinence as in a 12 step. You’re still getting an opiod )
• Reluctance to long term treatment
• No funding to start treatment*

Question 15

Methadone

Answer 15

• Methadone is a synthetic opiate designed to reduce or eliminate withdrawal symptoms and cravings in individuals who struggle with addiction to opiates.
• A therapeutic dose of methadone does not produce euphoric effects.
• Clients who are started on Methadone have made attempts to quit opiates, however have been unable to do so on their own.
• Once on a stable dose, Methadone provides a person with an opportunity to ‘feel normal’, therefore allowing them to work toward goals and to develop life skills to decrease the likelihood of further relapses.
• High dose opiate users
• Methadone doesn’t get you high at a therapeutic dose.
• Sabozone is more for lomethadone but some popele stay on methadone forever
  wer dose users. Methadone is for higher dose users so more so IV users.
• Idealy we taper off the

Question 16

Suboxone

Answer 16

• Suboxone (buprenorphine and naloxone) - synthetic opiate; taken orally; lower side effect profile than methadone; and decreased risk of overdose if mixed with other opiates.
• A client must be in active withdrawal to start on Suboxone.
• Low dose opiate users - Suboxone has what is called a ‘ceiling effect’, which means that it may not offer enough therapeutic value for someone who has a very large tolerance to opiates.
• Put both meds together to lower the street value
• A wafer you put in your check or tounge
  Safer because it’s only a partial agonist

Question 17

Sublocade

Answer 17

SC injection q
To start you must have been on Suboxone for 7 days – they want you to already be in the withdrawl phase
“Depot”
Not safe for women who are pregnant  the nalozone in suboxone is contraindicated in pregnancy

Question 18

ORT Side Effects

Answer 18

Constipation
Dry mouth
Drowsiness
Loss of appetite
Decreased sex drive
Impotence, or difficulty having an orgasm
Sleep problems
Nausea
Anxiety
Restlessness

Question 19

Drug Interactions

Answer 19

Benzodiazepines

Alcohol

Antiretrovirals

Some antidepressants

Some antibiotics - CIPRO

Benzo, alcohol and opiate is Russian rullete where you don’t know which is going to stop your breathing
CIPRO can actually increase the dose (they’re taking 100mg but it feels like 150mg and can lead to overdose)

Question 20

Methadone Induction AndStabalization Phase

Answer 20

• Start Low and Go Slow” Initial dose, then increased according to withdrawal symptoms (5 mg q 3-5 days)
• Potential for overdose is most common during the first week on the program
• During the stabilization phase, clients learn to recognize physical addiction vs. mental addiction.
• Nurses monitor for decreased drug use, mental health concerns and build relationships with clients.
• Daily witnessed drink 6 days a week
  If your gonna use on methadone, use a couple hurs after the methadone and take ½ the dose you’d normally take
• Role modelling time where dosing times in the morning
  1-2 months to get to a stabilized methodone dose (sabozone only 1-2 weeks)

Question 21

Suboxone Induction AndStabalization Phase

Answer 21

• Pre-Suboxone Withdrawal Process - Before administering a first dose, the client will need to be in withdrawal or else it could cause precipitated withdrawal
• taking Suboxone while your body is not in sufficient withdrawal will cause precipitated withdrawal. The symptoms associated with precipitated withdrawal are severe.
• Need to be in withdrawl before they start suboxone because if they have opiod in their system the naloxone will blast them into withdrawl right in your office

Question 22

Termination Phase

Answer 22

• General rule of thumb: a client will most likely be on ORT for half the time that they have been using
• Once the time has come the rule is to taper slowly…the slower the taper the more successful the outcome. If the taper is too fast, clients will go through painful withdrawals that many times leads to relapse. We are trying to avoid this!
• The lower the dose gets, the less mg’s are decreased. For example if a client is at 20 mg of methadone, decreasing by 10 mg per month cuts their dose in HALF…Withdrawals = moderate – severe HIGH CHANCE OF RELAPSE
• Therefore, once you get below 50 mg the decreases are smaller, and even smaller once you get to 20 mg. The rate of titration depends on the client’s ability to tolerate the withdrawals symptoms. Its Ok for clients to call their nurse and ask to go back up a few mg’s if they are feeling very uncomfortable. We would rather do that than chance a relapse.
• The last 5 mg is usually the hardest for clients, we can titrate 0.5 mg Q weekly or monthly, the client gets to decide
• IS IT SAFE?? Yes! However, clients over the age of 60 need to have regular EKG’s as methadone can increase the QT interval

Question 23

Pregnancy And Ort

Answer 23

• Methadone (or buprenorphine) maintenance is the treatment of choice for opioid use disorder during pregnancy
• Opioid withdrawal can result in premature labour or fetal stress.
• Opiate replacement therapy helps to stabilize the individual’s withdrawal symptoms, which in turn, reduce risk of harm to the baby in utero.
• Change of spontatneous abortion from tapering off the Percocet is reallt high
• We want to keep the withdrawl steady
• Breastfeeding is NOT contraindicated while taking methadone or buprenorphine.
• Small amounts of the medication may enter the breast milk, however the possible effects of the medication does not outweigh the benefits of breastfeeding
• Methadone dose may need to be increased in pregnancy as it is often metabolized more quickly in pregnant women.
• After delivery, the dose will likely need to be readjusted to a lower dose again.

Question 24

Carry Doses

Answer 24

• Once a client has been on the program for a minimum of two months and is on a stable dose of Methadone or Suboxone, they may begin earning ‘carries’ (take-home doses of their ORT medication),.
• Clients must leave 3 consecutive weekly urine drug screens to earn each carry dose (up to a maximum of 6 carries).
• If a client is also being prescribed a benzodiazepine or opiate alongside their ORT medication, they must witness dose at their pharmacy a minimum of 2 times per week.
• If a client relapses, misses frequent physician appointments or is otherwise unstable, carries may be removed for safety reasons.