Opioid Use Disorder Flashcards
What are the psychosocial treatments of opioid use disorder?
Structured counselling
Motivational interviewing
Case management and care coordination
Psychotherapy
Cognitive Behavioural Therapy
Contingency management
Which is more effective: psychosocial tx or pharm?
Psychosocial tx + pharm = more effective than either alone
Describe the interaction of trauma, mental health and addictions
Most pt’s will have co-occurring mental health disorders or untreated trauma
When caring for an individual with opioid use disorder, what should the focus be on?
Start with the person not with the medications
Every individual is a human being: Open to caring for them and meeting the where they are at
What are some of the Canadian OUD guidelines?
2017 British Columbia Centre on Substance Use Guidelines
2018 Canadian Research Initiative in Substance Misuse (CRISM) Guidelines
Injectable Opiod Agonist Treatment - More severe spectrum of opioid use disorder
Describe the clinical management of OUD
Describe withdrawal management of OUD
Withdrawal management alone is not an effective treatment for opioid use disorder, and offering this as astandalone option to patients is neither sufficient nor appropriate
Similar to tapering off opioids with methadone, agonist taper involving buprenorphine/naloxone appears to reduce the severity of withdrawal symptoms, but the majority of patients still relapse to opioid use if a strategy involving only withdrawal management is employed.
Low intensity treatment is withdrawal management RARELY DO WITHDRAWAL MGT ALONE
–> Referring to completely withdrawing someone with OUD from opiods
Describe the evidence of withdrawal management alone for OUD?
Withdrawal management alone is not an effective treatment for OUD and offering as a stand alone is inappropriate or sufficient
Relapse and rates of drop out to opiod use are high regardless of tx modality
Risks of serious harms, including fatal and non-fatal overdose and HIV and Hep-C transmission are higher for individuals who have recently completed withdrawl mgmt compared to individuals who recieved no tx
Withdrawal mgmt, if indicated by patient, should be provided with clear and concise info on the known risks to personal and public safety and be engaged in supportive, constructive discussion about safer tx options
Withdrawl mgmt alone is not recommended unless a discharge plan is in place for refrral to ongoing addiction tx
Much lower abstinence with withdrawal vs. ongoing OAT: instance, participants in the Prescription Opioid Addiction Treatment Study demonstrated significantly lower sustained abstinence rates eight weeks after tapering off buprenorphine/naloxone (8.6%) compared to abstinence rates during buprenorphine/naloxone treatment (49.2%).23
Chronic disease
We can’t just take them off the problematic opioid Most patients will relapse if just withdrawal them from tx
What medication can be used for withdrawal management with OUD?
Clonidine
Describe a clonidine taper used in OUD wityhdrawal management
Clonidine Taper
Help with physical sx –> Relapse risk is high –> Rarely do this anymore
For most patients with mod-severe (even mild for the most part) will go onto opioid agonist therapy
Describe the benfits and risks of withdrawal management alone
Detox can be an important 1st point of contact and a bridge to other treatment options
However, detox alone associated with:
↑ HIV-transmission
↑ HCV-transmission
↑ Relapse rates
↑ Morbidity
↑ Mortality
Withdraw in hospital for 10 days –> May be extremely desperate to seek opiods if just on RX
Lost tolerance –> Use same amount as before; risk of toxicities
Describe the OUD treatment options
Naltrexone –> Opioid antagonist: More use in alcohol use disorder
Describe the evidence of Naltrexone in OUD
Endogenous deficit of opioids –> Need some supplemental opiod –> Not making up deficit of opiods here
Shown that is not helpful for most pt’s in treating SUD
Describe the MOA of naltrexone in OUD
Opioid receptor antagonist that blocks the euphoric effects of opioids
Describe the benefits and risks of naltrexone in OUD
Benefits:
Ease of administration
No induced tolerance during prolonged tx
No potential for dependence/misuse
Risks:
↑ risk of overdose for patients who stop tx and relapse to opioid use due to ↓ tolerance
mortality 3-7x higher than methadone related mortality
Describe the formulations and evidence of the various formulations of naltrexone
Only oral naltrexone available in Canada
Limited benefit over placebo
2011 meta-analysis found no significant difference in retention or abstinence rates vs. placebo
Extended-release naltrexone monthly IM injections available in US
Improved adherence vs. oral naltrexone
Several RCTs should ↑ retention in tx, ↑ abstinence rates, and ↓ opioid cravings
What is the main-stay of OUD treatment?
Heart of treatment of opiod use disorder
Suboxone is first line, methadone is 2nd, and slow-release morphine is 3rd line
Rank the treatments for OUD: 1st line, 2nd line and 3rd line
Buprenorphine/naloxone (Suboxone) now 1st line for OUD treatment
2nd line: methadone
3rd line: slow-release oral morphine
Describe the opiate agonist effect of the treatment options for OUD
Partial Agonist effect of buprenorphine
What is suboxone? What is the dose based upon?
Suboxone = buprenorphine + naloxone
Dose based on buprenorphine component
Describe the available formulations of suboxone
Most will be on SL tabs (buccal film available)
Describe the components of suboxone and why they are included?
Naloxone – Cant inject it, snort it, or crush it
Prevents diversion–> Fully in there as a diversion mechanism
Buprenorphine is the main drug
Naloxone has 0% bioavailability from the gut
Describe the available buprenorphine formulations
Buprenorphine patches (Butrans)
Available in Canada
Indication: pain
Buprenorphine/naloxone buccal films (Suboxone)
Newer on the Canadian market as of Jan 2021
Buprenorphine extended release injection (Sublocade)
Indication: OUD
Subcutaneous abdominal monthly injection
Saskatchewan pharmacists with injection training can administer Sublocade!
For initiation of Sublocade….
Sublocade: patient must be stabilized on buprenorphine containing products
Describe the risk of switching between the formulations of Suboxone? Why?
Suboxone (buprenorphine and naloxone) and the risk of overdose or underdose when switching between dosage forms or routes of admin
Slight difference in dosing; slight different bioavailability –> need to look at recommendation in product monograph
Start on SL tabs then move to the film
Slight differences in dosing – check cdose on monograph and have close monitoring in place when transitioning
Describe the pharmacology of buprenorphine
High affinity (strong binding ability) for μ opioid receptor
Displaces heroin or other opiates from receptors
Occupies receptor and blocks other opiates’ effects
Partial agonist at μ opioid receptor
Antagonist a kappa and delta opioid receptors
Slow dissociation (leaving) from opioid receptor
Duration of action increases with increased dose
Describe the labelled max of buprenorphine
Labelled max =24mg/day but dosed up to 32mg/day for some
Describe the duration of action of buprenorphine doses and the duration of action
Dose-related increase in duration of action
Describe the moa of buprenorphine and an opioid
Mu Opiod Receptor: Purple
Sending signals out – withdrawal sx
If give opiod, takes away withdrawal
Yellow: Buprenorphine
Not full effect (euphoria), takes time to get out of the receptor –> protects them from overdose –> people can overcome the effects by using high amounts of substances
But protective safety measure
Describe buprenorphine pharmacology agonism and its associated response
Partial agonism –> opiate ceiling effects
No further opioid effects above a certain dose
Safer in overdose
What is suboxone formulated with? Why?
Suboxone formulated with naloxone
Naloxone oral or sublingual is not absorbed
No effect unless injected
May negate opiates effects if injected
What are some of the common and other adverse effects of bup/nal?
Common:
Headache, pain, withdrawal syndrome
Constipation, nausea, abdominal pain
Insomnia
Runny nose, sweating
Other:
Flu-like symptoms, muscle aches
Tooth disorder, dyspepsia
Depression, anxiety, nervousness, somnolence, dizziness, paresthesia
What opioid agonist therapy is the most effective?
Suboxone is better tolerated than full opioid agonist therapy
