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PHAR 358 > OUD 2 - Treatment > Flashcards

OUD 2 - Treatment Flashcards

1
Q

Name the psychosocial treatments available for OUD (6)

A
  1. Structured counselling
  2. Motivational interviewing
  3. Case management and care coordination
  4. Psychotherapy
  5. CBT
  6. Contingency management
    (Psychosocial tx + pharm = more effective than either alone)
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2
Q

When treating someone with OUD, what is the bottom line?

A

Start with the person, not with the medications

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3
Q

For OUD, why do we not do withdrawal management alone typically?

A

Not an effective treatment for OUD. Clinical trials report relapse rates ranging from 53.1-66.7% at 1-month, and 61.1-89.2% at 6-months after withdrawal.

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4
Q

Detox can be an important 1st point of contact and a bridge to other treatment options. However, detox alone is associated with what? (5)

A

Increases in the following:
1. HIV transmission
2. HCV transmission
3. Relapse rates
4. Morbidity
5. Mortality

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5
Q

What is the MOA of naltrexone?

A

Opioid receptor antagonist that blocks the euphoric effects of opioids

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6
Q

What are the benefits of naltrexone? (3)

A
  1. Ease of administration
  2. No induced tolerance during prolonged treatment
  3. No potential for dependence/misuse
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7
Q

What is the negative of naltrexone?

A

Increased risk of overdose for pts who stop treatment and relapse to opioid use due to decreased tolerance
- Mortality 3-7x higher than methadone related mortality

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8
Q

What is the only formulation of naltrexone available in Canada?

A

Oral
- Limited benefit vs. placebo

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9
Q

List the withdrawal management (alone) treatments that might be used in an OUD patient (3 +/- 3)

A
  1. Tapered methadone, buprenorphine, or alpha-2 adrenergic agonist
    +/- psychosocial treatment
    +/- residential treatment
    +/- oral naltrexone
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10
Q

List the opioid agonist therapies (OAT) that might be used in OUD? (2 +/- another 2)

A
  1. Buprenorphine/naloxone (preferred)
  2. Methadone
    +/- psychosocial treatment
    +/- residential treatment
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11
Q

What is 1st line treatment for OUD?

A

Buprenorphine/naloxone (Suboxone)

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12
Q

What is 2nd line treatment for OUD?

A

Methadone

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13
Q

What is 3rd line treatment for OUD?

A

Slow-release oral morphine

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14
Q

Dosing of suboxone is based on buprenorphine content. So, what is the role of naloxone in the drug? (4)

A

To prevent diversion essentially
- Naloxone oral or sublingual is not absorbed
- No effect unless injected
- May negate opiates effects if injected

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15
Q

What are the 3 buprenorphine formulations (aside from the SL tab of suboxone)?

A
  1. Patches
    - Indicated for pain
  2. Buprenorphine/naloxone buccal films
  3. Buprenorphine extended release injection (Sublocade)
    - Indicated for OUD
    - SubQ abdominal monthly injection
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16
Q

Remember the car analogy. What categories do methadone, buprenorphine, and naltrexone/naloxone fall into?

A
  1. Methadone (full agonist) = fast car going 100km/hr - same with heroin, morphine, and codeine - not good - exceeds threshold for respiratory depression
  2. Buprenorphine (partial agonist) = slow car going 40km/hr - still have an effect but it’s safer
  3. Naltrexone/naloxone (antagonist) = dead battery - not experiencing any effects
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17
Q

True or False? Buprenorphine quickly dissociates from opioid receptors

A

False - it slowly dissociates
- The duration of action increases with increased doses
- Labelled max = 24mg/day but dosed up to 32mg/day for some

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18
Q

Describe the MOA of buprenorphine? (5)

A

1. High affinity (strong binding ability) for μ opioid receptor
2. Displaces heroin or other opiates from receptors
3. Occupies receptor and blocks other opiates’ effects
4. Partial agonist at μ opioid receptor
5. Antagonist a kappa and delta opioid receptors

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19
Q

What are the benefits of buprenorphine being a partial opioid receptor agonist? (3)

A
  1. Opiate ceiling effects
  2. No further opioid effects above a certain dose
  3. Safer in overdose
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20
Q

What are some common adverse effects of buprenorphine/naloxone? (9)

A
  1. Headache
  2. Pain
  3. Withdrawal syndrome
  4. Constipation
  5. Nausea
  6. Abdominal pain
  7. Insomnia
  8. Runny nose
  9. Sweating
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21
Q

What are some other, less common adverse effects of buprenorphine/naloxone? (10)

A
  1. Flu-like symptoms
  2. Muscle aches
  3. Tooth disorder
  4. Dyspepsia
  5. Depression
  6. Anxiety
  7. Nervousness
  8. Somnolence
  9. Dizziness
  10. Paresthesia
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22
Q

What are some buprenorphine/naloxone drug interactions to be aware of? (2)

A
  1. Opioids for analgesia
    - Diminished effect
    - May require reassessment in acute pain
  2. Alcohol and benzos
    - Increase risk of respiratory depression
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23
Q

What are the advantages of using buprenorphine/naloxone over methadone? (5)

A
  1. Decreased risk of OD
  2. Decreased side effects
  3. Decreased risk of diversion
  4. Decreased drug interactions
  5. Milder withdrawal symptoms when discontinued
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24
Q

Compare suboxone vs. methadone in terms of treatment retention and decreases in illicit opioid use.

A
  1. At medium/high doses, suboxone does not significantly differ from methadone in terms of treatment retention
  2. No difference between suboxone and methadone in decreasing illicit opioid use
25
Q

Suboxone vs. methadone. Which is safer?

A

Suboxone

26
Q

How would you counsel someone taking a bup/nal sublingual tab? (4 important administration points)

A
  1. Dissolve under tongue
  2. May take up to 10 minutes to dissolve
  3. Avoid eating + drinking during that time
  4. No therapeutic effect if swallowed
27
Q

What is precipitated withdrawal? (3)

A
  1. May occur 30 to 60 min after 1st dose
  2. Displaces full opiate agonist from opioid receptors
  3. Buprenorphine partially activates receptor compared to full agonists
    - Overall net ↓ in receptor activation –> withdrawal sxs
28
Q

How can you minimize the risk of precipitated withdrawal? (5)

A
  1. Delay 1st dose until moderate withdrawl
    - Clinical Opiate Withdrawal Scale above 12
  2. Start with low dose
  3. Communicate risk
  4. Monitor patient
  5. Micro-dosing induction
29
Q

COWS score ≥__ is when we do suboxone induction

A

12

30
Q

Describe how microdosing of bup/nal works (3)

A
  1. Repetitive administration of very small bup doses should not precipitate opioid withdrawal
  2. Bup will accumulate at the receptor due to long t1/2
  3. Over time, an increasing amount of the full agonist will be replaced by bup at the receptor
31
Q

Go through the Bernese Method of bup/nal microdosing

A

Day 1:
- Bup Dosing = 0.5 mg SL once daily
- Methadone Dosing = Full dose
Day 2:
- Bup Dosing = 0.5 mg SL twice daily
- Methadone Dosing = Full dose
Day 3:
- Bup Dosing = 1 mg SL twice daily
- Methadone Dosing = Full dose
Day 4:
- Bup Dosing = 2 mg SL twice daily
- Methadone Dosing = Full dose
Day 5:
- Bup Dosing = 4 mg SL twice daily
- Methadone Dosing = Full dose
Day 6:
- Bup Dosing = 8 mg SL once daily
- Methadone Dosing = Full dose
Day 7:
- Bup Dosing = 8 mg SL in AM and 4 mg SL in PM
- Methadone Dosing = Full dose
Day 8:
- Bup Dosing = 12 mg SL once daily
- Methadone Dosing = Stop

32
Q

When is methadone significantly more effective?

A

Significantly more effective than non-pharm treatment for treatment retention and suppressed heroin use

33
Q

Compared to suboxone, methadone has potentially better retention rates in those with: (3)

A
  1. Moderate-severe OUD
  2. Heroin addiction
  3. Long history of OUD
34
Q

When may methadone be considered over suboxone?

A

In certain pts who are severely unstable and who would be at great risk for harm (e.g., HIV, HCV transmission) if lost to follow up

35
Q

Methadone vs. Suboxone. Which is safer in pregnancy?

A

Methadone at the moment (although new evidence might be showing Sub is okay)

36
Q

What is the onset, duration, and half-life of methadone?

A
  1. Onset = 0.5-1 hour
  2. Duration
    - Analgesia ~4-8 hours
    - OAT 22-48 hours
  3. T1/2 = 24-36 hours (can accumulate)
37
Q

How is methadone metabolized?

A

Hepatically by P450 system

38
Q

What are some ADEs of methadone? (10)

A
  1. QT prolongation
  2. Somnolence
  3. Agitation
  4. Mild cognitive dysfunction
  5. Hormonal dysfunction
  6. Weight gain
  7. Nausea
  8. Sweating
  9. Constipation
  10. Tooth decay
39
Q

What are some DIs of methadone? (4)

A

Numerous and clinically significant
- CYP3A4 and 2D6
- Additive QT prolongation
- Serotonin syndrome
- Additive CNS depression

40
Q

What doses of methadone seem to be most effective/optimal?

A
  • Higher doses (60-120mg/day) more so than lower doses
  • Most studies suggest doses >80mg/day have optimal outcomes
    – Doses >120mg/day may be needed to prevent withdrawal
41
Q

Dosing of methadone should be based off what? (3)

A
  1. Clinical judgement due to differences in metabolism
  2. Comorbidities (e.g., liver disease, QT prolongation)
  3. Drug interactions
42
Q

How often should methadone dosing be adjusted and why?

A

Adjust dose no sooner than every 5 days due to long half-life (risk of accumulation)

43
Q

What happens if a person misses their methadone dose? (2)

A
  • Missing 1-2 days of any dose is fine
  • Missing 3+ days of doses will likely lead to need for adjustment of dose to avoid causing opioid toxicity due to loss of tolerance
44
Q

What are the 2 methadone (Methadose) formulations?

A
  1. 10mg/mL red, cherry-flavored oral concentrate (can be administered undilute)
  2. 10mg/mL dye-free, sugar-free, unflavored oral concentrate (dilute using ~100mL of Tang to discourage diversion)
45
Q

How do you calculate the amount of Methadose to dispense in mls?
For example, If 90mg of metahdone is prescribed, what would you calculate?

A

Divide the prescribed dose in mg by the conc of the product
90mg/10mg/mL = x ml
x = 9ml of Methadose

46
Q

What is the specialist-led alternative approach to OUD management? (1 +/- 2)

A

Slow-release oral morphine
+/- psychosocial treatment
+/- residential treatment

47
Q

What seem to be the benefits of slow-release oral morphine (SROM) compared to methadone? (4)

A
  1. May provide similar benefits to methadone
  2. Shorter QTc intervals
  3. Decreased heroin cravings
  4. Reduced dysthymic symptoms
48
Q

What is the brand name of the slow-release oral morphine that has been studied?

A

Kadian

49
Q

Individuals with severe OUD who inject opioids may not adequately benefit from oral OAT medications for a variety of reasons. Such as? (4)

A
  1. Cravings despite optimal OAT dosing
  2. Unable to reach therapeutic dose
  3. Insufficient improvements in health, social functioning, quality of life
  4. Opting not to initiate oral OAT
50
Q

What have studies found regarding iOAT? (6)

A

Individuals that are treatment refractory to methadone, prescription injectable diacetylmorphine, administered under the supervision of a trained HCP in a clinic setting is beneficial in reducing:
1. Illicit opioid use
2. Premature treatment discontinuation
3. Criminal activity
4. Incarceration
5. Mortality
6. Also improves overall health and social functioning

51
Q

Summary of clinical practice guidelines:
What are the general considerations to think about for using iOAT?

A

Individuals with severe OUD who inject opioids and have continued to experience significant health and/or social consequences who have not benefitted from previous attempts at oral OAT, or other circumstances and risks that indicate they may benefit from iOAT.

52
Q

Summary of clinical practice guidelines:
Describe eligibility of iOAT

A

Recommended considerations for eligibility in concert with clinical judgement and precautions

53
Q

Summary of clinical practice guidelines:
Medication selection for iOAT

A

Both hydromorphone and diacetylmorphine are reasonable choices, based on availability, patient choice, and prescriber judgement

54
Q

Summary of clinical practice guidelines:
Titration process of iOAT

A

The titration protocol should be followed

55
Q

Summary of clinical practice guidelines:
iOAT pre-injection assessment

A

Performed by a qualified health professional or other trained staff member supervised by a health professional to ensure the pt is not intoxicated or in any other contraindicated acute clinical condition

56
Q

Summary of clinical practice guidelines:
iOAT post-intake assessment

A

Performed by a qualified health professional or other trained staff memeber supervised by a health professional to ensure safety and attend to dose intolerance or other adverse event

57
Q

Summary of clinical practice guidelines:
iOAT co-prescription of oral OAT

A

Consider co-prescription of slow release oral morphine or methadone to prevent withdrawal and cravings between iOAT doses, particularly overnight

58
Q

Summary of clinical practice guidelines:
iOAT missed doses

A

The short-acting nature of iOAT medications requries adequate supervision for missed doses. Refer to missed doses protocol

59
Q

Summary of clinical practice guidelines:
Ongoing substance use while on iOAT

A

Ongoing substance use while on iOAT may be an indication to intensify treatment, which may include dose increases, transferring to a more intensive model of care, and/or increasing psychosocial and other supports.

PHAR 358 (16 decks)

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