OUD Treatment Flashcards
What are the psychosocial treatments of SUD? (6)
- Structured counselling
- Motivational interviewing
- Case management and care coordination
- Psychotherapy
- Cognitive Behavioural Therapy
- Contingency management
What is the most effective form of treamtnet with regards to treatment?
Psychosocial tx + pharm = more effective than either alone
What is important in terms of the treatment of OUD>?
Start with the person not wit hthe medications
Canadian OUD that are utilized? (2)
2017 British Columbia Centre on Substance Use Guidelines
2018 Canadian Research Initiative in Substance Misuse
(CRISM) Guidelines
What are the ways we can provide withdrawal management in terms of OUD?
What is important about withdrawal management alone?
Not effective treatment. This is a standalone option to patients is neither sufficient nor appropiate
What does withdrawal management alone lead to?
relapse rates of 55-67% at 1 month and 61-89% at 6 months
What is important in terms of monitoring with clonidine?
Blood pressure changes, therefore BP prior to each dose and withold dose if the BP is less than 90/60
What is an important 1st point of contact and a bridge to other treatment options?
Detox
Detox is associated with
– ↑ HIV-transmission
– ↑ HCV-transmission
– ↑ Relapse rates
– ↑ Morbidity
– ↑ Mortality
What is Naltrexone?
Naltrexone is a full antagonist and can be used for maintenance therapy
What is the MOA of naltrexone?
Opioid receptor antagonist that blocks the euphoric effects of opioids
What are the three benefits of Naltrexone?
Ease of administration
No induced tolerance during prolonged tx
No potential dependence/misuse
What is the risk of utilizing naltrexone? (2)
– ↑ 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
What is the only available naltrexone available in canada?
Oral, limited benefit over placebo though
Why were the opioid effects higher in Canada during the pandemic
Mental health, coping, lack of access and lack of care
What did ER naltrexone IM injection do?
– Improved adherence vs. oral naltrexone
– Several RCTs should ↑ retention in tx, ↑ abstinence
rates, and ↓ opioid cravings
Why were the opioid effects higher in Canada during the pandemic
- International trade shut down and drug dealers needed to start lacing
Mental health, coping, lack of access and lack of care
What are the OAT therapies available?
What is first line for OUD?
Buprenorphine/naloxone (Suboxone) now 1st line for OUD treatment
What is second line for OUD txtmnt?
Methadone
What is third line for OUD?
3rd line: slow-release oral morphine
What is the formulation of Suboxone?
What is buprenoprhine patches?
These are indicated for pain,
What is the indication of sublocade?
- Indication: OUD
- Subcutaneous abdominal monthly injection
- Saskatchewan pharmacists with injection training can administer
Sublocade!
What is the MOA of buprenorphine?
HIgher affinity for the mu opioid receptor (Partial agonist)
Antagonist effect at kappa and delta opioid receptor
Duration of action increased with increased dose
What are the partial agonist at mu opioid receptor drugs?
Buprenorphine
What is the labelled max dose of buprenorphine in a day for a patient?
Labelled max =24mg/day but dosed up to 32mg/day for some
The duration of action ____ with ___ dose
Increase with increased
Does buprenorphine have a high or low Ki range of Ki value
Low
The ___ the Ki for a particular drug at a particular receptor, the STRONGER its binding affinity for that receptor.
lower
The HIGHER the Ki for a particular drug at a particular receptor, the ___ its binding affinity for that receptor.
weaker
What is the partial agonism of buprenorphine pharmacology>
Partial agonism, therefore leads to a opiate ceiling effects
Safer in overdose
Why is suboxone formulated with naloxone? (3)
– Naloxone oral or sublingual is not absorbed
– No effect unless injected
– May negate opiates effects if injected
What are the common AE of Suboxone? (4)
- Common
– Headache, pain, withdrawal syndrome
– Constipation, nausea, abdominal pain
– Insomnia
– Runny nose, sweating
What are the other AE of suboxone? (Lots)
– Flu-like symptoms, muscle aches
– Tooth disorder, dyspepsia
– Depression, anxiety, nervousness, somnolence, dizziness, paresthesia
What are some interaction of suboxone?
Opioids for analgesia and pain, diminished effects
Alcohol and benzo usage increase risk of respiratory depression
What are the advantages of suboxone over methadone? (5 major)
- ↓ risk of overdose
- ↓ side effects
- ↓ risk of diversion
- ↓ drug interactions
- Milder withdrawal symptoms when discontinued
At medium to high doses suboxone ___ significantly differ from methadone in terms of treatment retention
Does not
No difference between suboxone and methadone in ___ illicit opioid use
decreasing
What is the suboxone vs methadone safety?
Relative to one another, greater deaths on methadone comparred to suboxone
Bup/Nal administration
➢Dissolve under tongue
➢May take up to 10 minutes to dissolve
➢Avoid eating + drinking during that time
➢NO therapeutic effect if swallowed
Do we do withdrawal mangement with OUD?
No, only do it when someone shows up on the door and has issues
What happens when you provide Bup-Nal is given following the use of a full agonist (Heroin or morphine)
If we go from Full opiod agonist to Suboxone
What is precipitated withdrawal
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
How do we minimize the risk of of precipitated withdrawal
– Delay 1st dose until moderate withdraw
* Clinical Opiate Withdrawal Scale above 12
– Start with low dose
– Communicate risk
– Monitor patient
– Micro-dosing induction
What is methadone?
It is a full mu agonist
What is the indication of methadone
Why is microdosing becoming more common?
It is trying to prevent the risk of withdrawal
What is the COWS scale?
Clinical Opiate Withdrawal Scale
Example of a PPO for a inpatient bup-nal induction order
PPO
What is the theory of Low-dose/microdosing Bup/Nal
– 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
Is suboxone better tolerated or methadone longterm?
Suboxone
How would be micodose Bup-nal using the bernese method?
What is methadone more effective than?
non-pharm tx for tx retention and suppressed
heroin use
Compared to suboxone, methadone may be better for (3)
– moderate-severe OUD
– heroin addiction
– long history of OUD
The long history is unclear
What may be a benefit of methadone?
Flexible in dosing
Methadone may be considered over subxone in certain individuals who are at greater risk of
harm (e.g. HIV, HCV transmission) if lost
to follow up
Methadone dosing is
flexible
Methadone may be safer in pregnancy comparred to subxone
True, but growing evidence suboxone is become safe
What are the DI of methadone?
CYP3A4 and 2D6, additive QT prolongation, serotonin syndrome, additive CNS depression
What are the ADE of methadone?
ADEs: QT prolongation, somnolence,
agitation, mild cognitive dysfunction,
hormonal dysfunction, weight gain, nausea,
sweating, constipation, tooth decay
What is the effective dose range of methadone?
60-120mg/day
What are most studies that have optimal outcomes?>
> 80MG/day
Why would we use doses of 120mg of methadone
Aids with withdrwawal
What should dosing of methadone be based on? (3 categories)
clinical judgement
due to differences in metabolism, co-morbidities
(e.g. liver disease, QT prolongation) and drug
interactions
What is the minimum number of days taht a dose adjustment can occur for methadone?
every 5 days due to the half life
What is the suggested protocol for methadone missed doses? (1-2 consecutive days)
What is the suggested protocol for missed doses for days 3-4 of methadone?
What is the suggested dose range for individuals with 5 or more missed days of methadone?
What is SROM?
Slow release oral morphine
How is SROM prescibred?
Once daily witnessed doses
What is iOAT?
Injectable opiod antagonist therapy
Why might iOAT be used?
What drug is ioat?
Diacetylmorphine (Heroin)
What is thought to be the benefits of iOAT? (5)
Reducing:
What was the SALOME Trial?
Study to assess longer term opioid medication effectiveness
What were the results of the SALOME trial?
Non-inferiority of hydromorphone was confirmed in the per protocol analysis
In what type of order should every patient with pain be initiated with agents?
Topical agents
Acetaminophen
NSAIDs
Duloxetine, Pregab, gabapentin
With regards to opioid use disorder what is the general rule of thumb?
Use lower doses, slower titrations when increasing doses
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