Opioid Dependence Flashcards
What is an opioid?
Any substance (natural or man-made) that binds to opioid receptors in the brain?
What are examples of natural substances?
Codeine
Morphine
Heroin
What are examples of synthetic substances?
Fentanyl
Methadone
What are examples of semi-synthetic substances?
Oxycodone (Oxycontin)
What is an opiate?
Naturally-occurring narcotics derived from natural-source only
eg. morphine, codeine + heroin (opium plant)
What prevention is put in place?
Codeine should be limited to NO more than 3 days (OTC)
Watch for overuse in paracetamol
How quickly can physical + psychological dependence develop?
2-10 days
What patient risk factors should be screened for with opioid prescriptions?
Depression, anxiety + common mental health
Previous history of alcohol/substance misuse
Previous history of opioid misuse
What drug risk factors should be screened with opioid prescriptions?
High doses
Multiple opioids
Multiple formulation of opioids
More potent opioids
Concurrent benzodiazepines/sedative drugs
What is consider a extremely high opioid dose?
Dose greater than oral morphine 120mg/day
What do you need to be careful with when changing formulation/administration route with opioids?
Oral = 1st pass effect = only 30% received
IV = 100% bioavailability = whole dose received
= WOULDN’T give the same dose for IV as oral
What needs to be understood when reducing opioid dose?
That once you go down you CAN’T go back up
=go at the patient’s pace
What does OA stand for?
Osteoarthritis
What does L THR stand for?
Left total hip replacement
What does MST stand for?
Morphine sulphate tablet
What does BD stand for?
Twice daily
What does TTO stand for?
To take out = discharge medications
What does PRN stand for?
When required
What would cause scratch marks?
Urticaria = itchy reaction to opioids
What are some risk factors for opioid dependence?
Current or past psychiatric illness
Reports of concern by family
Concerns expressed by pharmacists = going through prescription too fast
What can be the first option for deprescribing of opioids?
Keep modified release dose stable + wean down PRN dose
= keep same frequency of immediate release dose + decrease dose each week
OR
= maintain same dose BUT reduce frequency each week
What can be the second option for deprescribing opioids?
Reduce MR dose first by 10% per week + keep PRN IR dose steady
BUT have to caution patient against increase PRN frequency
What is the MAX you can reduce an opioid dose by?
10%
What can also be helpful for when tapering opioid doses?
Exercise
Coping mechanisms = meditation
Acupuncture
What can you consider when tapering a dose if it is really hard for the patient?
Conversion to methadone/buprenorphine
Involving drug/alcohol services
What are the opioid withdrawal signs?
Shivers
Diarrhoea
Difficulty sleeping
Sweating
Widespread/increased pain
Body aches
Irritability/agitation
Nausea + vomiting
What needs to happen with patients who are receiving opioid substitution therapy (OST)?
Need on-going reassurance that their pain will be assessed
OST does NOT provide analgesia
Existing OST should be continued
Opioid for analgesia need to be prescribed in addition
Larger doses than usual = tolerant
May have increased pain sensitivity = long term exposure
What should happen for patients on methadone?
Split dose + administer 2-3x a day
Titrate additional analgesia to effect
What should happen for patients on buprenorphine?
Split dose + administer 2-3x a day
Titrate additional analgesia
OR
Discontinue + provide alternative analgesia
Change to methadone
What may occur in patients taking opioids?
Tolerance + opioid-induced hyperalgesia
= decrease pharmacological response
= increase in pain perception
When can be patients be at most risk to addiction?
Post-operative opioids
What must be done to manage the risk of addiction post-surgery?
Patients taking opioids identified before surgery
Identify risk factors for opioid misuse
Ensure communication between patient + GP on deprescribing mechanisms
Ensure chronic post-surgical pain is recognised
What is the goal of maintenance therapy?
Harm reduction + stabilisation of lifestyle
Detoxification to come off opioids all together
How does supervised methadone work in practice?
1mg/ml used
Observed whilst taking dose
Designated area of supervision = privacy
Identity of patient confirmed
Usually 3 months minimum
What are the risks of long term opioid use?
Serious bodily harm, overdose + death
Increased pain levels
Hormone changes = infertility
Drowsiness
Increased risk of physical dependence
Decrease immune function
Increased risk of fall/fractures
Depression/anxiety
Dry mouth = dental cavities