Substance abuse and pharmacy Flashcards
What is the most abused illicit substance?
But what misused substance causes the most harm? (particularly in society)
Cannabis
Alcohol
what % does alcohol account for in the global disease burden and injury?
5%
What amendments now allow some cannabis products (except synthetic cannabinoids/resin) to be in schedule 2?
Misuse of drugs amendments - cannabis and license fees regulations 2018
This means that it can be supplied and prescribed legally in the UK and enables more research to be done, but currently a list of specialist importers.
What is food grade CBD oil?
Available in pharmacies and can be sold as health food. supplements. (regulated by food standard agency) - they cannot make any health/medicinal claims and pharmacy must get a certificate of analysis from supplier to ensure there is no THC present in the oil. Must not contain THC (no more than. 0.2% legal)
what are the 3 requirements for cannabis based medicinal products?
- Is or contains cannabis, resin, cannabinol derivatives
- Produced for medicinal use in humans
- Regulated as a medicinal product or ingredient is a medicinal product
Unlicensed in the UK
What is sativex?
Cannabis extract. - only licensed medicinal product in the UK schedule 4 CD (but subject to CD register requirements). Used for muscle spasticity in multiple sclerosis
What is Nabilone?
Synthetic cannbinoid licensed in the UK for nausea and vomiting (associated with chemotherapy) (Sch 2)
What is epidiolex?
Pure CBD - approved by the FDA and only available in the UK by the extended access scheme and supply as an unlicensed special (children with rare forms of epilepsy e.g. Dravet, lennox-gaustat syndrome). CB1 agonist cannabidiol
What is dronabinol?
Synthetic version of THC - schedule 2 CD, approved by the FDA
What is the current prescribing status for cannabis based medicinal products?
Only clinicians on the GMC register can prescribe on a named patient basis (GPs CANNOT prescribe).
There are only 2 indications approved:
- Children with rare forms of epilepsy e.g. dravet syndrome, lennox gaustat syndrome
- Adults with nausea and vomiting associated with chemotherapy
What is the legal requirements for these CBPMs?
Legal and CD requirements for sch 2
PRIVATE prescription only using FP10PCD
Patients MUST be involved in the decision
Patients MUST be aware that the product is unlicensed
What act is nitrous oxide covered in?
Psychoactive substances act 2016 = illegal to possess NPS with intent to supply/import/export/product/ intended for human consumption capable of producing a psychoactive effect
Mechanism of action of morphine?
Morphine in opium is converted to deacetyl morphine (heroin) via deacetylation. Heroin is converted to 6-MAM and morphine in the brain and has effects on mu, kappa and delta opioid receptors.
Activate opioid receptors on GABA neurons which causes disinhibition and dopamine release from VTA synapses terminating in the nucleus accumbens
= reinforcement, reward, euphoria, hallucinations
What is the most potent opioid?
Fentanyl
What symptom is the most common cause of death in. street use overdose of opiates?
Respiratory depression
Symptoms of acute overdose of opiates?
Respiratory depression
Sedation
Nausea and vomiting.
Symptoms of opioid withdrawal?
Yawning Anxiety Rapid breathing Tremor Runny nose Confusion Muscle aches diarrhoea Cramps Salivation Vomiting Increased HR and BP
How do you treat acute overdose of opioids?
Naloxone opioid antagonist (IV or SC) - will displace the morphine at receptors to reverse the respiratory depression&sedation.
What is take home naloxone?
Legislative change in 2015. - exemption from POM requirements when supplied by a drug service commissioned by a local authority for the purpose of saving a life in an emergency - given to someone using/previously used and at. risk of OD, carer/family, named individuals in a hostel (autoinjector)
What is the detox therapy for opioid misuse?
Can use methadone. or buprenorphine substitution. then withdrawal if previously in maintenance therapy or as patient. choice
Lofexidine used (britloflex 200mcg) - young people, mild/uncertain dependence, short history or rapid detox. (Alpha2 adrenergic agonist) alleviating physical symptoms of withdrawal but not reducing craving.
Manage withdrawal symptoms e.g. loperamide for diarrhoea, paracetamol for pain, mebevarine anti-spasmodic for stomach cramps, metoclopramide for vomiting, benzodiazepines or zopilone for anxiety/insomnia
What is abstinence?
Relapse prevention support for at least 6 monhs in combination with psychosocial interventions
Use of NALTREXONE. (nalorex) - licensed for adjunctive therapy. Prophylactic for detoxified formerly opoioid dependent people who have remained opioid free for 7-10days. (competitively displaces opioid agonist to block. euphoric effects and minimise positive rewards associated with opioid misuse)
What is maintenance/substitution therapy?
Ensures stability, reduces craving, prevents withdrawal, removes the hazards of injecting, not obtaining illicit opioids.
Prescribed to patients as substitution with installments on an FP10MDA Rx - methadone, buprenorphine, suboxone.
Includes shared care of - prescriber, client, pharmacist, key worker
Have supervised consumption for a minimum of 3months
What is the minimum amount of time patients need to have supervised consumption for when having substitution therapy?
3months
What is the dose of methadone substitution and schedule?
Schedule 2
Initially 10-40mg a day, increased by 10mg increments daily, max 30mg weekly titration.
Usual dose is 60-120mg a day.
What colour is the methadone non-sugar free oral solution 1mg/ml?
Green
What colour is the methadone oral liquid 10mg/ml for dilution with diluent (methadose)?
Blue
What does the Road traffic act of 1988 highlight in regards to methadone therapy?
It is an offence to dive while under the influence BUT NOT IF the medicine is prescribed to treat a medical problem, it is taken according to the instructions by the prescriber, and is not affecting the ability to drive safely.
What schedule is buprenorphine? what is the dose?
Schedule 3- partial opoioid agonist (blocks effects of top up heroin).
Dose 0.8-6mg a day. Usually 8.24mg a day, max 32mg a day, once daily dose.
What is suboxone?
Sublingual buprenorphine in combination with naloxone (opioid antagonist) when patients are likely to. misuse the SL via the IV route and will precipitate withdrawal if injected to reduce IV misuse.
What situation can you. NOT use buprenorphine in?
Liver dysfunction - test LFTs prior to starting therapy
What drug has less risk of overdose - methadone or buprenorphine, why?
Buprenorphine as partial opioid agonist - limited by the ceiling effect
What is the max period of treatment on a prescription FP10MDA for methadone/bup?
14 days
if a patient has missed 3 or more consecutive days of their substitution therapy- what are the pharmacist actions?
Do not supply the next dose and refer back to the prescriber as tolerance may have changed. come back with new Rx
If the patient doesn’t collect for >1 days medication on the appointed day, what are the pharmacists actions?
Only give todays dose and carry on as usual. Only give the missed days if the prescriber has given authorisation/stated. Otherwise do not give missed day
If the patient does not come in for their substitution therapy - what records does the pharmacist make?
Write not collected / not dispensed and take it off the PMR. (must write out in full - not enough to just write nd/nc)
What is the packed dose fee?
Receive 55p for every additional bottle supplied in addition to the dose that day. (every extra dose they do not take in the pharmacy)
What are the automatic fees a pharmacy receives for dispensing methadone/bup?
Automatic £2.50 methadone fee
CD sch 2 fee of. £1.28 for methadone
CD Sch 3 fee of 0.43p for buprenorphine
What are some harm reduction strategies pharmacies provide to drug misusers?
Needle exchange programmes (locally commissioned) - provision of sterile needles, syringes, sharps containers to return used. This reduces the harm associated with injection e.g. BBV from sharing needles, infections, environmental sharps waste hazards
Condoms, citric acid, vitamin C, water for injection, swabs
Harm reduction information e.g. safe injection technique
BBV testing in. some places - opportunistic, dried blood spot
What are the 3 drugs for maintenance/abstinence/relapse prevention in alcohol addiction? (after withdrawal)
- Acamprosaet (NMDAR) - 666mg
- Oral naltrexone (opioid antagonist) maintenance 50mg/day (starting at 25mg/day).
- Disulfiram (aldehyde dehydrogenase inhibitor) but side effects
Stop treatment if drinking persists 4-6 weeks after starting
What drug is used for alcohol withdrawal/detox?
Chlordiazepoxide - must drink at least 3L a day - water - risk of seziures - sleep disturbance Reduce chlordiazepoxide over 7-10days to avoid withdrawal. occurring
what are 4 behavioural therapies for addiction?
Family therapies
CBT
contingency management interventions
motivational enhancement therapy
What are the 3 main withdrawal symptom s of heroin that are the most dangerous?
Diarrhoea
Vomiting
Sweating
Will get dehydrated - can lead to death so need to do withdrawal in controlled conditions
Side effects of methadone
N&V urticaria itching, rash Vertigo sweating mood changes Constipation Drowsiness/dizzy bradycardia or tachycardia
Why does ritalin have abuse potential?
Methylphenidate - intranasally - it has a major effect in the basal ganglia stimulating rapid release of dopamine from the synapse - get euphoria and instant high. (the binding to DA pathways is the same as cocaine)
What is the legal schedule of ritalin?
CD schedule 2
What do amphetamines do?
They are structurally similar to NA and DA, they cause release of biogenic amines Na/DA and reverse the actions of the transporters. This increases alertness, euphoria, cognition but short effects lead to binging which is toxic
