Substance Abuse- Opiate Withdrawal and Maintenance Flashcards
Opiate effects
Euphoria
Dysphoria
Apathy
Motor retardation
Sedation
Slurred speech
Attention impairment
Miosis
Constipation
Opiate withdrawal effects
Lacrimation
Rhinorrhea
Mydriasis
Piloerection
Diaphoresis
Diarrhea
Yawning
Fever
Insomnia
Muscle ache/pain
“Kicking the habit”
Opiate OD treatment
Supportive care, Narcan
Narcan MoA
Pure opioid receptor antagonist that competes with and displaces narcotics at opioid receptor sites
Treatments for opiate withdrawal
methadone, buprenorphine, clonidine, lofexidine
Methadone MoA
binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception of and response to pain; produces CNS depression
Goal of methadone in maintenance
Suppress signs and symptoms of opiate withdrawal, extinguish opiate craving, block reinforcing effects of illicit opiates
Initial dose of methadone should be no greater than ____on day 1.
30-40mg
While taking methadone, complete physical exam and labs within ___days.
14
When patients take methadone, they have to go to a clinic and take the dose there. When can they take their dose home and take it independently?
2 days a week in the first 90 days, 1 month after 2 years
What factors go into letting a patient take home their methadone dose?
Capable of handling and taking unsupervised, abstinence from illegal drugs, regular attendance, absence of behavioral or criminal issues, stable home and social environments, can be safely stored
Methadone is a major substrate of what CYP enzyme?
3A4
Buprenorphine MoA
high-affinity binding to mu opiate receptors in CNS; displays partial mu agonist and weak kappa antagonist activity
Buprenorphine metabolite
norbuprenorphine
Buprenorphine goal
provide a transition for an opiate physically dependent state to an opiate-free state, induction, and dose reduction
Buprenorphine: induction
Switching patients from opiates to buprenorphine, finding minimum dose at which the patient’s D/C’s or markedly diminishes use of opiates, experiences no withdrawal, minimal or no side effects and no cravings
Buprenorphine: stabilization
marked by patient experiencing no withdrawal, minimal or no side effects, no longer uncontrolled cravings, patients are seen weekly
Buprenorphine: maintenance
may be indefinite, attention to psychosocial issues, seen/toxed monthly
Candidates for buprenorphine
Not merely physically dependent, but also addicted
No CIs
Interested
Expected to be reasonably compliant
Willing to follow safety precautions
Willing after review of therapy
Unlikely candidates for buprenorphine
Comorbid dependence on other CNS depressants
Significant unrelated psych
Active/chronic SI/HI
Multiple treatments/relapses
Poor response to Suboxone
Complex medical history
Suboxone contains…
…buprenorphine and naloxone
Role of naloxone in Suboxone
Abuse deterrent
Sublocade is what formulation of buprenorphine
Injectable
Who qualifies for Sublocade?
Patients whose dose of buprenorphine is >8mg/day and was previously stable on a transmucosal buprenorphine-containing product
How often is Sublocade dosed?
Once monthly (technically every 28 days-ish)
Sublocade counseling points
Rotate injection site each time
Subsequent precipitation following injection results in a solid depot, the patient may have a lump for a few weeks but don’t rub/massage the site
True or false: Sublocade is in the REMS program
True
Sublocade BBW
serious harm or death could result if administered IV. Sublocade forms a solid mass upon contact with body fluids. Occlusion, local tissue damage, and thromboembolic events, including life-threatening pulmonary emboli, could result if administered
Buprenorphine is a major substrate of what CYP enzyme?
3A4
Clonidine MoA
stimulates alpha-2 adrenoreceptors in the brainstem, thus activating an inhibitory neuron, resulting in reduced sympathetic outflow from the CNS
Clonidine side effects
drowsiness, dizziness, dry mouth, headache, orthostatic hypotension, fatigue, abdominal pain, xerostomia, bradycardia
Lofexidine (Lucemyra) MoA
Same as clonidine
Lofexidine side effects
orthostatic hypotension, bradycardia, hypotension, insomnia, dizziness, drowsiness, xerostomia
Naltrexone MoA
Markedly attenuates or completely blocks, reversibly, the subjective effects of IV-administered opioids by competitive binding at opioid receptors
In order to start naltrexone, you must be opiate free for how long?
At least 7-10 days
Naltrexone dosing: PO
25mg QD
Naltrexone dosing: IM
380mg q4w/qmonth
Naltrexone PO side effects
GI upset, withdrawal
Naltrexone IM side effects
Injection site reactions, withdrawal
Naltrexone BBW
acute hepatitis and hepatocellular injury
Naltrexone XR brand name
Vivitrol
Criteria for Vivitrol
Must meet DSM criteria for opiate dependence, recently received opiate detox and opiate free for at least 7 days
Exclusion criteria for Vivitrol
acute hepatitis or liver failure
receiving opiate analgesics
current opiate dependence
in acute opiate withdrawal
positive urine screen for opiates
known previous allergic response to naltrexone
failed naltrexone challenge test
