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Therapeutics (Fall 2024) > OUD Treatment > Flashcards

OUD Treatment Flashcards

1
Q

What are the psychosocial treatments of SUD? (6)

A
  • Structured counselling
  • Motivational interviewing
  • Case management and care coordination
  • Psychotherapy
  • Cognitive Behavioural Therapy
  • Contingency management
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2
Q

What is the most effective form of treamtnet with regards to treatment?

A

Psychosocial tx + pharm = more effective than either alone

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3
Q

What is important in terms of the treatment of OUD>?

A

Start with the person not wit hthe medications

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4
Q

Canadian OUD that are utilized? (2)

A

2017 British Columbia Centre on Substance Use Guidelines

2018 Canadian Research Initiative in Substance Misuse
(CRISM) Guidelines

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5
Q

What are the ways we can provide withdrawal management in terms of OUD?

A
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6
Q

What is important about withdrawal management alone?

A

Not effective treatment. This is a standalone option to patients is neither sufficient nor appropiate

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7
Q

What does withdrawal management alone lead to?

A

relapse rates of 55-67% at 1 month and 61-89% at 6 months

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8
Q

What is important in terms of monitoring with clonidine?

A

Blood pressure changes, therefore BP prior to each dose and withold dose if the BP is less than 90/60

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9
Q

What is an important 1st point of contact and a bridge to other treatment options?

A

Detox

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10
Q

Detox is associated with

A

– ↑ HIV-transmission
– ↑ HCV-transmission
– ↑ Relapse rates
– ↑ Morbidity
– ↑ Mortality

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11
Q

What is Naltrexone?

A

Naltrexone is a full antagonist and can be used for maintenance therapy

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12
Q

What is the MOA of naltrexone?

A

Opioid receptor antagonist that blocks the euphoric effects of opioids

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13
Q

What are the three benefits of Naltrexone?

A

Ease of administration
No induced tolerance during prolonged tx
No potential dependence/misuse

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14
Q

What is the risk of utilizing naltrexone? (2)

A

– ↑ risk of overdose for patients who stop tx and relapse to
opioid use due to ↓ tolerance
* mortality 3-7x higher than methadone related mortality Australian Study

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15
Q

What is the only available naltrexone available in canada?

A

Oral, limited benefit over placebo though

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16
Q

Why were the opioid effects higher in Canada during the pandemic

A

Mental health, coping, lack of access and lack of care

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17
Q

What did ER naltrexone IM injection do?

A

– Improved adherence vs. oral naltrexone
– Several RCTs should ↑ retention in tx, ↑ abstinence
rates, and ↓ opioid cravings

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18
Q
A
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19
Q

Why were the opioid effects higher in Canada during the pandemic

A
  • International trade shut down and drug dealers needed to start lacing
    Mental health, coping, lack of access and lack of care
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20
Q

What are the OAT therapies available?

A
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21
Q

What is first line for OUD?

A

Buprenorphine/naloxone (Suboxone) now 1st line for OUD treatment

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22
Q

What is second line for OUD txtmnt?

A

Methadone

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23
Q

What is third line for OUD?

A

3rd line: slow-release oral morphine

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24
Q

What is the formulation of Suboxone?

A
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25
Q

What is buprenoprhine patches?

A

These are indicated for pain,

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26
Q

What is the indication of sublocade?

A
  • Indication: OUD
  • Subcutaneous abdominal monthly injection
  • Saskatchewan pharmacists with injection training can administer
    Sublocade!
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27
Q

What is the MOA of buprenorphine?

A

HIgher affinity for the mu opioid receptor (Partial agonist)

Antagonist effect at kappa and delta opioid receptor
Duration of action increased with increased dose

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28
Q

What are the partial agonist at mu opioid receptor drugs?

A

Buprenorphine

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29
Q

What is the labelled max dose of buprenorphine in a day for a patient?

A

Labelled max =24mg/day but dosed up to 32mg/day for some

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30
Q

The duration of action ____ with ___ dose

A

Increase with increased

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31
Q

Does buprenorphine have a high or low Ki range of Ki value

A

Low

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32
Q

The ___ the Ki for a particular drug at a particular receptor, the STRONGER its binding affinity for that receptor.

A

lower

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33
Q

The HIGHER the Ki for a particular drug at a particular receptor, the ___ its binding affinity for that receptor.

A

weaker

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34
Q

What is the partial agonism of buprenorphine pharmacology>

A

Partial agonism, therefore leads to a opiate ceiling effects

Safer in overdose

35
Q

Why is suboxone formulated with naloxone? (3)

A

– Naloxone oral or sublingual is not absorbed
– No effect unless injected
– May negate opiates effects if injected

36
Q

What are the common AE of Suboxone? (4)

A
  • Common
    – Headache, pain, withdrawal syndrome
    – Constipation, nausea, abdominal pain
    – Insomnia
    – Runny nose, sweating
37
Q

What are the other AE of suboxone? (Lots)

A

– Flu-like symptoms, muscle aches
– Tooth disorder, dyspepsia
– Depression, anxiety, nervousness, somnolence, dizziness, paresthesia

38
Q

What are some interaction of suboxone?

A

Opioids for analgesia and pain, diminished effects

Alcohol and benzo usage increase risk of respiratory depression

39
Q

What are the advantages of suboxone over methadone? (5 major)

A
  • ↓ risk of overdose
  • ↓ side effects
  • ↓ risk of diversion
  • ↓ drug interactions
  • Milder withdrawal symptoms when discontinued
40
Q

At medium to high doses suboxone ___ significantly differ from methadone in terms of treatment retention

A

Does not

41
Q

No difference between suboxone and methadone in ___ illicit opioid use

A

decreasing

42
Q

What is the suboxone vs methadone safety?

A

Relative to one another, greater deaths on methadone comparred to suboxone

43
Q

Bup/Nal administration

A

➢Dissolve under tongue
➢May take up to 10 minutes to dissolve
➢Avoid eating + drinking during that time
➢NO therapeutic effect if swallowed

44
Q

Do we do withdrawal mangement with OUD?

A

No, only do it when someone shows up on the door and has issues

45
Q

What happens when you provide Bup-Nal is given following the use of a full agonist (Heroin or morphine)

A
46
Q

If we go from Full opiod agonist to Suboxone

A
47
Q

What is precipitated withdrawal

A

Occurs 30-60 minutes after

Disaplces full opiate agonist from receptor, Buprenorphine being a partial agonist will lead to net decrease in receptor activation and increased withdrawal sxs

48
Q

How do we minimize the risk of of precipitated withdrawal

A

– Delay 1st dose until moderate withdraw
* Clinical Opiate Withdrawal Scale above 12
– Start with low dose
– Communicate risk
– Monitor patient
– Micro-dosing induction

49
Q

What is methadone?

A

It is a full mu agonist

50
Q

What is the indication of methadone

A
51
Q

Why is microdosing becoming more common?

A

It is trying to prevent the risk of withdrawal

52
Q
A
53
Q

What is the COWS scale?

A

Clinical Opiate Withdrawal Scale

54
Q

Example of a PPO for a inpatient bup-nal induction order

A

PPO

55
Q

What is the theory of Low-dose/microdosing Bup/Nal

A

– Repetitive administration of very small buprenorphine doses should not precipitate opioid withdrawal
– Buprenorphine will accumulate at the receptor due to long t1/2
– Over time, an increasing amount of the full agonist will be replaced by buprenorphine at the receptor

56
Q

Is suboxone better tolerated or methadone longterm?

A

Suboxone

57
Q

How would be micodose Bup-nal using the bernese method?

A
58
Q

What is methadone more effective than?

A

non-pharm tx for tx retention and suppressed
heroin use

59
Q

Compared to suboxone, methadone may be better for (3)

A

– moderate-severe OUD
– heroin addiction
– long history of OUD

The long history is unclear

60
Q

What may be a benefit of methadone?

A

Flexible in dosing

61
Q

Methadone may be considered over subxone in certain individuals who are at greater risk of

A

harm (e.g. HIV, HCV transmission) if lost
to follow up

62
Q

Methadone dosing is

A

flexible

63
Q

Methadone may be safer in pregnancy comparred to subxone

A

True, but growing evidence suboxone is become safe

64
Q

What are the DI of methadone?

A

CYP3A4 and 2D6, additive QT prolongation, serotonin syndrome, additive CNS depression

65
Q

What are the ADE of methadone?

A

ADEs: QT prolongation, somnolence,
agitation, mild cognitive dysfunction,
hormonal dysfunction, weight gain, nausea,
sweating, constipation, tooth decay

66
Q

What is the effective dose range of methadone?

A

60-120mg/day

67
Q

What are most studies that have optimal outcomes?>

A

> 80MG/day

68
Q

Why would we use doses of 120mg of methadone

A

Aids with withdrwawal

69
Q

What should dosing of methadone be based on? (3 categories)

A

clinical judgement
due to differences in metabolism, co-morbidities
(e.g. liver disease, QT prolongation) and drug
interactions

70
Q

What is the minimum number of days taht a dose adjustment can occur for methadone?

A

every 5 days due to the half life

71
Q

What is the suggested protocol for methadone missed doses? (1-2 consecutive days)

A
72
Q

What is the suggested protocol for missed doses for days 3-4 of methadone?

A
73
Q

What is the suggested dose range for individuals with 5 or more missed days of methadone?

A
74
Q

What is SROM?

A

Slow release oral morphine

75
Q

How is SROM prescibred?

A

Once daily witnessed doses

76
Q

What is iOAT?

A

Injectable opiod antagonist therapy

77
Q

Why might iOAT be used?

A
78
Q

What drug is ioat?

A

Diacetylmorphine (Heroin)

79
Q

What is thought to be the benefits of iOAT? (5)

A

Reducing:

80
Q

What was the SALOME Trial?

A

Study to assess longer term opioid medication effectiveness

81
Q

What were the results of the SALOME trial?

A

Non-inferiority of hydromorphone was confirmed in the per protocol analysis

82
Q

In what type of order should every patient with pain be initiated with agents?

A

Topical agents
Acetaminophen
NSAIDs
Duloxetine, Pregab, gabapentin

83
Q

With regards to opioid use disorder what is the general rule of thumb?

A

Use lower doses, slower titrations when increasing doses

84
Q

Take some time to look at the next slide

A

Therapeutics (Fall 2024) (11 decks)

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