Opioid Use Disorder Treatments Flashcards
Psychosocial treatments for OUD may include…
Psychotherapy
CBT
Structured counselling + motivational interviewing
Case+ + contingency management, care coordination
Addictions and substance use disorders are often associated with…
Trauma and psychiatric disorders
Substance is often used as a coping mechanism for trauma + psych conditions
For any substance use disorder, we should start with…
The person - underlying conditions, rather than the medications
Withdrawal management is simply…
Helping the individual to deal with withdrawal symptoms
Withdrawal management alone is ____, because..
Not effective and is associated with risks
Withdrawal management alone may be a potential option for someone with…
Mild OUD, and is undergoing proper psychosocial supports (and does not want to undergo long-term agonist treatment
Withdrawal mangement/detox alone is associated with…
Increased HIV and HCV transmission
Increased relapse rates
Increased morbidity and mortality
Naltrexone affects opioid receptors by…
Being a full opioid receptor antagonist that blocks euphoric effects of opioids
Oral formulation of naloxone
Oral naltrexone could be considered as…
An adjunct treatment upon cessation of opioid use
This is a weak recommendation with low quality evidence; if patient is deficient of endogenous opioid, this would not be helpful to treat that deficit.
Benefits of using naltrexone for OUD include…
Ease of administration
No induced tolerance during prolonged treatment
No potential for dependence/misuse
Risks with using naltrexone involve…
A higher risk of overdose for patients who stop treatment, and relapse to opioid use due to decrease in tolerance
A meta-analysis found that oral naltrexone found ____ compared to placebo.
No significant difference in retention or abstinence rates
ER-naltrexone monthly did show increased retention in tx, increased abstinence rates, and decreased opioid cravings
The most desired treatment for OUD is…
Opioid agonist therapy (OAT)
Give patient safe levels of opioid to try and help reduce cravings/withdrawal
The dose of suboxone is based on…
The buprenorphine component
1st line treatment for OUD is…
Buprenorphine/naloxone (Suboxone)
2nd line for OUD treatment is…
Methadone
3rd line for OUD treatment is…
Slow-release oral morphine
The purpose of naloxone in the suboxone formulation is to…
Prevent diversion of suboxone - cannot be crushed/snorted for effect, has no effect unless injected and may negate opiate effect if injected
Oral/sublingual naloxone is NOT absorbed
Buprenorphine is available in different formulations, such as…
Patches - indicated for pain, not OUD
Buccal films or sublingual tablets, + naloxone (suboxone)
XR injection (Sublocade), OUD monthly injection
Buprenorphine has ____ affinity for Mu opioid receptors, which affects other opiates by…
High affinity (strong binding ability). Will displace heroin/other opiates from their receptors and block their effects, also protecting from overdose
Buprenorphine is a ____ at the Mu opioid receptors and an ____ at the Kappa and Delta opioid receptors
Partial agonist at Mu opioid-receptor
Antagonist at Kappa + Delta opioid receptors
Antagonism at kappa + delta may benefit mood
Buprenorphine has a slow dissociation from the opioid receptor which means…
Duration of action increases with increases in dose
Partial agonism of buprenorphine means…
Opiate has a ceiling effect - no further opioid effect above a certain dose.
Also safer in overdose
Overdose still possible if patient is opioid naive
Common AE’s with bup/nal include…
Headache, pain, withdrawal syndrome
Nausea, constipation, abdominal pain,
Insomnia
Runny nose, sweating
Similar to other opioids, usually better tolerated
Withdrawal symptoms are involved due to partial agonism (especially when switching from a full agonist opioid
Some rarer AE’s that may occur with bup/nal include…
Flu-like symptoms, muscle aches
Tooth disorder, dyspepsia
Psych - Depression, anxiety, nervousness, somnolence, dizziness, paresthesia
Notable DI’s with bup/nal include…
Usage of opioids for analgesia: diminished effect and may require reassessment in acute pain
Alcohol, BZD’s - increased risk of respiratory depression (less than full opioid agonists)
Diminished analgesia due to Mu-receptor occupation
Advantages of bup/nal over methadone include…
Lower risk of overdose, better safety profile
Less AE’s
Lower risk of diversion
Less DI’s
Milder withdrawal sx’s when discontinued
Methadone is a CYP drug
Slow dissociation means milder withdrawal symptoms
Suboxone efficacy compared to methadone is…
No significant difference in terms of treatment retention at medium/high doses of suboxone.
No difference between the two in decreasing illicit opioid use
Notable counselling points regarding suboxone administration include…
Dissolve under tongue, which may take up to 10 minutes. Avoid eating + drinking during this time
No therapeutic effect if swallowed
Precipitated withdrawal is anticipated when switching a patient from full opioid agonist to bup/nal because…
Buprenorphine displaces full opiate agonists from their receptors and partially activates receptor compared to full agonists - overall net decrease in receptor activation will cause withdrawal symptoms
Precipitated withdrawal can occur ____ after the 1st dose of bup/nal.
30-60 minutes
Ways to minimize risk of precipitated withdrawal include…
Delaying 1st dose until moderate withdrawal is experienced
Start with low dose, communicate risk, and monitor patient
Micro-dosing induction
COWS is…
Clinical Opiate Withdrawal Scale
When waiting for a patient to experience moderate withdrawal to induce bup/nal, their COWS score should be…
Greater than 12
Adjuvant agents could be given to help patient with withdrawal sx’s
Does require patient to be moderately uncomfortable and may decrease buy-in to treatment
In general, the duration of time between last opioid dose and onset of moderate withdrawal (COWS greater than 12) is usually…
Short-acting: 12-16 hours
Intermediate-acting: 17-24 hours
Long-acting: 30-36 hours or more
Microdosing bup/nal is a strategy to avoid precipitated withdrawal by…
Accumulation of buprenorphine at receptor due to long t1/2 - very small doses should not precipitate withdrawal.
Overtime, an increasing amount of full agonist will be replaced by buprenoprhine at receptor
Full opioid dose they have been using is usually continued
Most regimens involved with microdosing suggest increasing the dosage of bup/nal daily for ____ days, and stopping full agonist on…
7 days. Stopping full agonist on the 8th day
Methadone MOA is…
Full opioid agonist
Methadone should be tried for individuals who…
Respond poorly to bup/nal, or when bup/nal is not the preferred option
Compared to suboxone, methadone has potentially better retention rates in people with…
Moderate-severe OUD
Long history of OUD
Heroin addiction
May also be considered for those who are severely unstable and would be at great risk for harm if lost to follow up
Onset of methadone is…
0.5-1 hour
Duration of action for methadone is…
For analesia ~4-8 hours
OAT 22-48 hours with repeated dosing
Half life of methadone is ____, which is significant because…
24-36 hours (range of 8-59), drug can accumulate and cause opioid toxicity if doses are increased too fast
AE’s of methadone include…
Typical opioid AE’s - full agonist
CNS depression (somnolence, mild cognitive dysfunction), agitation
Nausea, constipation
Hormonal dysfunction
Weight gain, tooth decay
QT prolongation
Notable DI’s with methadone involve…
Anything with CYP3A4 and 2D6
Additive QT prolongation and CNS depressive agents
Anything that increases risk of serotonin syndrome
____ doses of methadone are more effective, but dosing should be based on…
Higher doses - should be based on clinical judgement due to differences in metabolism, co-morbidities, and DI’s
Example of co-morbidities = liver disease, QT prolongation
Methadone doses should not be adjusted sooner than ____ due to…
Every 5 days, due to long half-life (risk of accumulation
Methadone dose titrations need to be restarted after missing ____ days, due to…
3 days: due to loss of tolerance, avoid opioid toxicity
Methadone formulations are available as…
AKA methadose
10 mg/mL oral concentrates
One is red, cherry-flavoured and the other is dye-free, sugar-free, unflavoured
Slow-release oral morphine (SROM) can be considered for patients…
When 1st and 2nd line treatment options are ineffective or CI
Efficacy of SROM compared to methadone…
Is similar; no difference in tx retention but higher AE’s
Less overall evidence available for SROM
The only SROM that has been studied is the ____ release product, and should be adjusted no sooner than…
24 hour release product; adjusted no sooner than q48 hours
Due to elimination half-life of 11-13 hours
To reduce risk of diversion of SROM, it should first be prescribed as…
Once-daily witnessed doses
Individuals with severe OUD who inject opioids may not adequately benefit from oral OAT for a variety of reasons, such as…
Having cravings despite optimal OAT dosing
Inability to reach therapeutic dose
Insufficient improvements in health, social fx, or QoL
Opting not to initiate oral OAT
Meta-analyses found that in individuals that are tx refractory to methadone, Rx injectable diacetylmorphine is beneficial in reducing…
Canada = IV hydromorphone
Illicit opioid use
Premature tx discontinuation
Criminal activity
Incarceration
Mortality
Improvement in overall health + social functioning
