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Pharmaceutical Care of Drugs (Mis)users > Opiate substitution therapy (OST) > Flashcards

Opiate substitution therapy (OST) Flashcards

1
Q

What is the main principle of OST?

A

Replace the illicit (short half life drug like heroin) with a prescribed long half life drug such as methadone or buprenorphine.

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2
Q

What is the activity of methadone?

A

Opiate agonist with main activity at mu receptor; antagonist of NMDA receptors -> dysphoria.

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3
Q

What is buprenorphine?

A

Opiate receptor partial agonist at mu receptor at adequate doses.

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4
Q

Methadone is an antagonist of

A

NMDA receptors -> dysphoria.

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5
Q

What is the main receptor that methadone acts at?

A

mu receptor.

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6
Q

What is an opiate receptor partial agonist at mu receptors?

A

Buprenorphine when given at adequate doses.

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7
Q

What is the difference between methadone and buprenorphine WRT to cognitive effects?

A

Methadone: fuzzy
Buprenorphine: Racing mind

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8
Q

When the risk of Opioid Overdose is high, we would use _________ in OST.

A

Burprenorphine.

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9
Q

How dose buprenorphine prevent the use of heroin on top of OST?

A

Above 12mg, due to partial agonist effect at mu receptor.

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10
Q

Broadly, what are the aims of OST for patients?

A
  1. Reduce harm: improve health (BBVs, mental health, physical wellbeing) and social functioning (e.g. facilitate education, training, employment, reconcile families etc)
  2. Prevent overdose and overdose deaths
  3. Assist the person to stop using illicit opiates
  4. Support the person is reversing their tolerance and dependence on illicit opiates through gradual dose reduction (detoxification)
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11
Q

Broadly, what are the OST aims for society?

A
  1. Reduce drug related crime so improve community safety and reduce fear
  2. Save money spent within criminal justice system on drug related crime
  3. Save money on health costs
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12
Q

New UK Clinical Guidelines for drug misuse and dependence are expected

A

This year.

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13
Q

For maintenance studies, what is often the primary outcome studied?

A

Retention in the treatment program.

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14
Q

For maintenance studies, what are secondary outcomes often studied?

A

Reducing illicit drug use.
Injecting risk behaviours.
BBV transmission prevention.
Improved physical health, mental health, social functioning, reduced involvement in crime.

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15
Q

The most recent UK clinical guidelines are from

A

2007.

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16
Q

What are the two drugs licensed for OST?

A

Methadone

Buprenorphine

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17
Q

According to Cochrane Systematic review 2014, only high dose ______________ (>16mg) was more effective than placebo in suppressing illicit opiod use.

A

Buprenorphine.

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18
Q

________ seems to be less effective than _______ in retaining participants in treatment.

A

Buprenorphine less effective than methadone. Probably the problem of Doctors.

Because the buprenorphine causes withdrawal symptoms due to partial agonist activity.

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19
Q

Partial agonist activity at mu opiate leads to

A

Withdrawal symptoms: buprenorphine.

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20
Q

When should buprenorphine be initiated?

A

Only when a patient has begun a withdrawal period already - because otherwise it will cause acute withdrawal symptoms.

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21
Q

Why do more people drop out of buprenorphine OST than methadone?

A

Presciber incorrectly initiating treatment: should only be begun when a withdrawal period is already occuring.

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22
Q

With regard to dosing how does methadone vs buprenorphine compare with regards to participant retention in programs?

A

Low dose methadone > low dose buprenorphine.

No difference between medium/high dose of either.

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23
Q

Studies consistently show that oral substitution treatment with methadone or buprenorphine is associated with ________ _______ ________ in illicit opioid use, injecting use and sharing of injecting equipment.

A

Studies consistently show that oral substitution treatment with methadone or buprenorphine is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment.

24
Q

What is the impact of OST on health?

A

People on methadone or buprenorphine are less likely to die than those on placebo or no therapy

Crude mortality rates: 0.7 per 100 person years on OST vs 1.3 per 100 person years off treatment

25
Q

Opiate substitution treatment has a >__% chance of reducing overall mortality among opiate users if the average duration of treatment approaches or exceeds __ months

A

Opiate substitution treatment has a >85% chance of reducing overall mortality among opiate users if the average duration of treatment approaches or exceeds 12 months

26
Q

Higher doses of MMT (__mg or more) are more effective than doses of less than __mg for improving retention on treatment.

A

60mg MMT is better than <50mg for retention.

27
Q

Doses of MMT higher than __mg were more effective than doses of less than __mg in reducing self-reported illicit opioid use

A

Doses of MMT higher than 50mg were more effective than doses of less than 50mg in reducing self-reported illicit opioid use

28
Q

What is the ideal MMT dose?

A

Depends on patient, evidence suggests greater than 60mg best but depends.

29
Q

According to Drug Treatment Outcomes Research Study (DTORS), for every £1 spent on treatment, how much is saved on health and criminal justice costs?

A

£2.50.

Pretty good return on investment.

30
Q

What impact does MMT have on the length of dependence?

A

Does not increase it.

MMT produces long-term abstinence as often as drug-free residential treatment.

31
Q

What is the optimal daily dose range for MMT?

A

(60) 80-120mg but depends on the person.

32
Q

What impact does the flexibility of take-home doses have on OST outcomes?

A

IF there is flexibility in take-home doses it increases positive outcomes.

33
Q

What keeps people engaged with OST?

A

Orientation towards social rehabilitation.
Sufficient duration of treatment.
Detoxification only of willing, well stabilised patients with established abstinence.
Goal of maintenance as primary goal not detox

34
Q

What are the factors associated with poor outcomes from OST?

A
  1. Barriers to treatment.
  2. Restriction of methadone daily dose.
  3. Low wuality medical services, untrained staff etc.
  4. Controlling and administrative rather than supportive and empathic
  5. Shorter duration treatment.
35
Q

Patients on <60mg were _____ as likely to leave treatment as those on 60-80mg and _x as lilkely to leave as those on >80mg.

A

Twice,
4x,
Better response to treatment is observed when higher rather than lower fixed doses are used but (higher) flexible dosing is even better.

36
Q

The maintenance dose is the dose that achieves steady state plasma levels with no ________ or ________ between doses.

A

Maintenance dose achieves steady state plasma level with no intoxication or withdrawal between doses

“One size fits all” doesn’t work because of individual differences (DMPK, tolerance, BMI)

Titration over a number of days/weeks normally used –may take 8 weeks to stabilise on methadone. HDB quicker.

Start low and titrate up in steps because of differences in tolerance and accumulation with repeated doses (PK!)

Methadone toxicity related to blood plasma concentrations

37
Q

What OST is quicker? What has to happen before this can be initiated?

A

High Dose Buprenorphine is quicker to achieve correct dose.
However, the patient has to enter withdrawal before we give it as it causes withdrawal symptoms leading to patient discontinuation in those who are initiated without withdrawal already having begun.

38
Q

Which OST has less risk of OD?

A

Buprenorphine as it is a partial antagonist/agonist effect. NB. counsel patients on avoiding trying to overcome the ‘block’.

39
Q

Men using opiates have approx _____ the risk of death of women.

A

Twice the risk.

40
Q

What is naloxone?

A

Naloxone is a very commonly used ‘competitive opioid antagonist’. This means that it binds with the opioid receptors in the brain/body without activating them.

41
Q

What is the riskiest time for death during OST?

A

Titration phase.
Post detox.
Naloxone training and supply is critical.

42
Q

What are the risks associated with detox?

A
  1. Loss of tolerance = dangerous.
  2. Higher death rate in recently detoxed patients than untreated patients.
  3. Mortality in maintenance treatment is very low, reduces heroin deaths.
43
Q

What is the importance of urine sampling?

A

Important for medico-legal purposes and patient safety to verify self reported drug use.

Reduces illicit drug use especially if related to take-home doses.

44
Q

What are the poor prognostic indicators for OST?

A

Poor mental health
Polydrug use
Dose diversion

45
Q

Is methadone alone an effective OST?

A

Yes, but outcomes are enhanced by case management/psychosocial interventions.

‘Wraparound services’

However, mandatory counselling does not produce better outcomes.

46
Q

What level of counselling for OST patients is associated with the cheapest ‘cost per abstinent-from-illicit-use patient’?

A

Moderate levels.

Intensive: less optimal outcomes.

47
Q

How can we retain people in treatment? [6]

A
  1. Long term treatment philosophy and agreed goals/expectations.
  2. Accessibility and convenience.
  3. Higher doses.
  4. Take home doses (when safe to do so)
  5. Availability of ancillary services
  6. Optional counselling, especially at the start of treatment.
48
Q

What is one reasont the government has proposed for an increase in numbers of MMT patients dying of drug related deaths?

A

They are an aging population. With all the associated risk that entails.

49
Q

Men using opiates have approx _______ the risk of death of women.

A

Twice.

50
Q

Why is naloxone training and supply critical?

A

Helps reduce OST deaths.

And detox deaths.

51
Q

What are the risks of detoxification?

A
  1. Loss of tolerance

2. Higher death rate in recently detoxed patients than untreated patients.

52
Q

Poor mental health, polydrug use and drug diversion are what?

A

The poor prognistic indicators for OST.

53
Q

What levels if counselling produce the cheapest ‘cost per abstinent-from-illicit-use patient’ on MMT?

A

Moderate rather than intensive.

54
Q

What are the contributions community pharmacists can make to OST?

A
  1. Support during titration and stabilisation
  2. Monitoring treatment.
  3. Harm reduction
  4. Responding to related, and other, health issues.
55
Q

Methadone or buprenorphine?

A

Patient choice.

56
Q

What is the t1/2 of methadone?

A

24-36hrs

Pharmaceutical Care of Drugs (Mis)users (12 decks)

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