Substance Dependence Flashcards
Untreated heroin dependence shows early withdrawal symptoms within __________, with peak symptoms at ____________; symptoms subside substantially after ________ days
8 hours
36–72 hours
5
Compared to heroin withdrawal, methadone or buprenorphine withdrawal occurs __________ (earlier/later) with ___________ (longer/shorter)-lasting symptoms
Later
Longer
Opioid substitution therapy involves using ___________ and ___________ to substitute heroin or other opioids in dependence
Methadone
Buprenorphine
Opioid substitute medication should be commenced with a short period of stabilisation, followed by either a ____________ regimen or by ___________ treatment.
withdrawal
maintenance
What is the aim of maintenance treatment in patients who are recovering from opioid addiction?
Enables patients to achieve stability, reduces drug use and crime, and improves health; it should be regularly reviewed to ensure the patient continues to derive benefit
Why is enforced withdrawal from opioids ineffective for sustained abstinence?
Increases the risk of patients relapsing and subsequently overdosing because of loss of tolerance
Complete withdrawal from opioids usually takes up to ____________ in an inpatient or residential setting, and up to ___________ in a community setting.
4 weeks
12 weeks
If abstinence from opioids is not achieved, illicit drug use is resumed, OR the patient cannot tolerate withdrawal, the ___________ regimen should be stopped and ___________ therapy should be resumed at the optimal dose.
withdrawal
maintenance
Following successful withdrawal treatment from opioids, further support and monitoring to maintain abstinence should be provided for a period of at least _____________
6 months
*This includes medical, social, and psychological support
Patients who miss _________ or more of their regular prescribed dose of opioid maintenance therapy are at risk of overdose because of loss of tolerance.
3 days
Patients who miss 3 days or more of their regular prescribed dose of opioid maintenance therapy are at risk of ___________ because of loss of tolerance.
Overdose
Consider reducing the dose in these patients
If the patient misses _____ or more days of opioid maintenance therapy, an assessment of illicit drug use is also recommended before restarting substitution therapy
If the patient misses 5 or more days of treatment, an assessment of illicit drug use is also recommended before restarting substitution therapy
*this is particularly important for patients taking buprenorphine because of the risk of precipitated withdrawal
If the patient misses 5 or more days of treatment, an assessment of ___________ is also recommended before restarting substitution therapy
illicit drug use
*this is particularly important for patients taking buprenorphine because of the risk of precipitated withdrawal
Buprenorphine is preferred by some patients because it is less __________ than methadone hydrochloride
sedating
What is the mechanism of action of buprenorphine?
Partial agonist at mu receptors (ie partially activates opiate receptors) to cause a potent analgesic effect on the CNS
____________ (buprenorphine/methadone) may be more suitable for employed patients or those undertaking other skilled tasks such as driving
Buprenorphine (less sedating)
_____________ (buprenorphine/methadone) is safer than _____________ (buprenorphine/methadone) when used in conjunction with other sedating drugs, and has fewer drug interactions
Buprenorphine
Methadone
Dose reductions may be easier than with ______________ (buprenorphine/methadone) because the withdrawal symptoms are milder, and patients generally require fewer adjunctive medications
Methadone
There is a lower risk of overdose with _____________ (buprenorphine/methadone)
Methadone
Buprenorphine can be given on alternate days in higher doses and it requires a shorter drug-free period than methadone hydrochloride before induction with _____________ for prevention of relapse.
naltrexone hydrochloride
What is “precipitated withdrawal” in the context of opioid dependence?
When patients are dependent on high doses of opioids, withdrawal can occur if buprenorphine (a partial agonist) is administered when other opioid agonist drugs are in circulation
Precipitated opioid withdrawal, if it occurs, starts within __________ of the first buprenorphine dose and peaks at around _________.
1–3 hours
6 hours
Non-opioid adjunctive therapy, such as ______________, may be required if symptoms of precipitated withdrawal are severe.
lofexidine hydrochloride
To reduce the risk of precipitated withdrawal, the first dose of buprenorphine should be given when _______________, or ___________ after the last use of heroin (or other short-acting opioid), or ___________ after the last dose of methadone hydrochloride.
the patient is exhibiting signs of withdrawal
6–12 hours
24–48 hours
Suboxone is a combination preparation containing _____________ and ____________
Buprenorphine
Naloxone
Where there is a risk of diversion of opioid substitution medicines, or difficulties with adherence to daily supervised opioid substitution medication, buprenorphine _______________ may be an option.
prolonged-release injection
Methadone is a __________(long/short)-acting opioid agonist
Long
Methadone is usually administered in a ________-daily dose as an _________ of 1 mg/mL
Once
Oral solution
Patients with a long history of opioid misuse, those who typically abuse a variety of sedative drugs and alcohol, and those who experience increased anxiety during withdrawal of opioids may prefer ___________ (methadone/buprenorphine) to ____________ (methadone/buprenorphine) because it has a more pronounced sedative effect
Methadone
Buprenorphine
Methadone hydrochloride is initiated at least ___________ after the last heroin dose
8 hours; provided that there is objective evidence of withdrawal symptoms
Because of the ________________ of methadone, a dose that was tolerated on the first day of treatment may become a toxic dose on the third day as cumulative toxicity develops
Long half-life; plasma concentrations progressively rise during initial treatment even if the patient remains on the same daily dose (it takes 3–10 days for plasma concentrations to reach steady-state in patients on a stable dose)
Acute withdrawal of opioids should be avoided in pregnancy because it can cause ___________.
fetal death
_____________ is recommended during pregnancy because it carries a lower risk to the fetus than continued use of heroin or other illicit drugs
Opioid substitution therapy
If a woman who is stabilised on methadone hydrochloride or buprenorphine for treatment of opioid dependence becomes pregnant, what is the recommended management?
Therapy should be continued [buprenorphine is not licensed for use in pregnancy]
Many pregnant patients choose a withdrawal regimen but withdrawal during the first trimester should be avoided because it is associated with an increased risk of ______________
spontaneous miscarriage
Many pregnant patients choose a withdrawal regimen but withdrawal during the _____________ should be avoided because it is associated with an increased risk of spontaneous miscarriage
first trimester
Withdrawal of methadone hydrochloride or buprenorphine should be undertaken gradually during the _____________ trimester, with dose reductions made every _________
second
3-5 days
If illicit drug use occurs in a pregnant woman undertaking an opioid withdrawal regimen in the second trimester of pregnancy, what is the recommended management?
The patient should be re-stabilised at the optimal maintenance dose and consideration should be given to stopping the withdrawal regimen
Further withdrawal of methadone hydrochloride or buprenorphine in the third trimester _____ (is/is not) not recommended
Is NOT; maternal withdrawal, even if mild, is associated with fetal distress, stillbirth, and risk of neonatal mortality
Further withdrawal of methadone hydrochloride or buprenorphine in the third trimester is not recommended because maternal withdrawal, even if mild, is associated with ___________, ___________, and the risk of ____________.
fetal distress
stillbirth
neonatal mortality
Drug metabolism can be ____________ (increased/decreased) in the third trimester; it may be necessary to either __________ (increase/decrease) the dose of methadone hydrochloride or change to twice-daily consumption (or a combination of both strategies) to prevent withdrawal symptoms from developing.
Increased
Increase
Drug metabolism can be increased in the third trimester; it may be necessary to either increase the dose of methadone hydrochloride or change to twice-daily consumption (or a combination of both strategies) to prevent ____________ symptoms from developing.
withdrawal
The neonate should be monitored for ____________ and signs of __________ if the mother is prescribed high doses of opioid substitue.
Respiratory depression
Withdrawal
Signs of neonatal withdrawal from opioids usually develop ____________ after delivery but symptoms may be delayed for up to ________, so monitoring may be required for several weeks.
24–72 hours
14 days
Symptoms of neonatal withdrawal from opioids include…? (6)
- high-pitched cry
- rapid breathing
- hungry but ineffective suckling
- excessive wakefulness
severe, but rare symptoms include:
- hypertonicity
- convulsions
Can breastfeeding be continued while on opioid substitution therapy?
Yes, but doses of methadone and buprenorphine should be kept as low as possible
________________, _______________, or __________ in breast-fed babies of mothers taking opioid substitutes should be reported urgently to a healthcare professional.
Increased sleepiness
breathing difficulties
limpness
In the adjunctive treatment of opioid withdrawal, loperamide may be used for ___________
Control of diarrhea
In the adjunctive treatment of opioid withdrawal, _____________ may be used for the control of diarrhea
Loperamide
In the adjunctive treatment of opioid withdrawal, mebeverine may be used for ___________
Controlling stomach cramps
In the adjunctive treatment of opioid withdrawal, ____________ may be used for controlling stomach cramps
Mebeverine
In the adjunctive treatment of opioid withdrawal, paracetamol and NSAIDs may be used for ______________ and __________
Muscular pains
headaches
In the adjunctive treatment of opioid withdrawal, ______________ and ____________ may be used for muscle pain and headaches
Paracetamol
NSAIDs
In the adjunctive treatment of opioid withdrawal, metoclopramide or prochlrperazine may be used for ___________ or ___________
Nausea
Vomiting
In the adjunctive treatment of opioid withdrawal, ______________ or _____________ may be used for nausea or vomiting
Metoclopramide
Prochlorperazine
Topical ____________ can be helpful for relieving muscle pain associated with methadone hydrochloride withdrawal
rubefacients
If a patient is suffering from insomnia associated with opioid withdrawal, short-acting _____________ or ____________ may be prescribed, but because of the potential for abuse, prescriptions should be limited to a short course of a few days only.
benzodiazepines
zopiclone
Lofexidine hydrochloride may alleviate some of the physical symptoms of opioid withdrawal by attenuating the increase in _______________ that occurs during opioid withdrawal
adrenergic neurotransmission
__________________ may alleviate some of the physical symptoms of opioid withdrawal by attenuating the increase in adrenergic neurotransmission that occurs during opioid withdrawal
Lofexidine hydrochloride
______________ can be prescribed as an adjuvant to opioid substitution therapy, initiated either at the same time as the opioid substitute or during withdrawal of the opioid substitute
Lofexidine hydrochloride
_____________ may be prescribed instead of an opioid substitute in patients who have mild or uncertain dependence (including young people), and those with a short history of illicit drug use
Lofexidine hydrochloride
Can also be used as an adjuvant to opioid substitution therapy
Lofexidine hydrochloride may be prescribed instead of an opioid substitute in patients who have ____________ or ___________ dependence (including young people), and those with a _________ history of illicit drug use
mild
uncertain
short
What is the mechanism of action of naloxone?
Opioid antagonist; reverses the effects of opioids including respiratory depression, sedation, and hypotension
Can be given to patients in the case of accidental overdose
What is the mechanism of action of naltrexone?
Mu-opioid receptor antagonist; blocks opioid effects and precipitates withdrawal symptoms in opioid-dependent subjects
Prescribed as an aid to prevent relapse
What is the role of naloxone in opioid cessation?
Can be given to patient to be used in case of accidental overdose
What is the role of naltrexone in opioid cessation?
Can be given to formerly opioid-dependent patients to block opioid effect in the case of relapse
Why is opioid substitution therapy usually inappropriate in younger patients (under 18 yo)?
Drug misuse is more often related to acute intoxication than to dependence; maintenance treatment with opioid substitution therapy is therefore controversial in young people
However, it may be useful for older adolescents who have a history of opioid use to undergo a period of stabilisation with buprenorphine or methadone before starting a withdrawal regimen
For opioid substitution therapy, in patients taking methadone who want to switch to buprenorphine, the dose of methadone should be reduced to a maximum of ________ daily before starting buprenorphine treatment
30 mg
For sublingual tablets of buprenorphine, if the dose of methadone is over 10 mg daily, buprenorphine can be started at a dose of ________ daily and titrated according to requirements
4 mg
For sublingual tablets, if the dose of methadone is below 10 mg daily, buprenorphine can be started at a dose of _______ daily
2 mg
The MHRA reminds healthcare professionals that opioids co-prescribed with benzodiazepines and benzodiazepine-like drugs can produce additive CNS depressant effects, thereby increasing the risk of ___________, ___________,
__________, and _________.
sedation
respiratory depression
coma
death
The MHRA reminds healthcare professionals that opioids co-prescribed with ___________ and ___________-like drugs can produce additive CNS depressant effects, thereby increasing the risk of sedation, respiratory depression, coma, and death.
benzodiazepines
benzodiazepine
Healthcare professionals are advised to discuss with patients that prolonged use of opioids, even at therapeutic doses, may lead to __________ and __________
dependence
addiction
Healthcare professionals are advised to agree on a treatment strategy and plan for __________ with the patient before starting opioids
end of treatment
Healthcare professionals are advised to counsel patients and their carers on the risks of _________ and potentially fatal ____________, as well as signs and symptoms of overdose when taking opioids (eg buprenorphine, methadone)
tolerance
unintentional overdose
Regarding the use of buprenorphine and methadone, healthcare professionals are advised to provide regular monitoring and support to patients at increased risk, such as those with current or history of ___________ or ____________
substance use disorder (including alcohol misuse)
mental health disorders
Healthcare professionals are advised to consider _____________ in patients on long-term opioid treatment who present with increased pain sensitivity
hyperalgesia
Do not confuse the formulations of buprenorphine______________ which are available in 72-hourly, 96-hourly and 7-day forms
transdermal patches
What are the contraindications to prescribing buprenorphine, methadone, and all opioids? (5)
- Acute respiratory depression
- Comatose patients
- Head injury (interfere with pupillary responses vital for neurological assessment)
- Raised ICP ( “ “ )
- Risk of paralytic ileus
Prolonged use of opioid analgesics may lead to drug dependence and addiction, even at therapeutic doses. There is an increased risk in individuals with current or history of _______________ or ____________
substance use disorder
mental health disorders
Opioids cause a dose-dependent increased risk of _____________, consider total opioid dose reduction
central sleep apnoea
In the control of pain in terminal illness, the cautions listed _____________ (should/should not) be a deterrent to the use of opioid analgesics
Should not
In elderly adults, buprenorphine should not be prescribed without concomitant __________
Laxatives
What are the common or very common side effects of buprenorphine?
- Anxiety
- Decreased appetite
- Depression
- Diarrhea
- Dyspnea
- Syncope
- Tremor
Many more….
Arthralgia (in adults); asthenia (in adults); asthma (in adults); behaviour abnormal (in adults); chest pain (in adults); chills (in adults); cough (in adults); dysmenorrhoea (in adults); eye disorders (in adults); fever (in adults); gastrointestinal discomfort (in adults); gastrointestinal disorders (in adults); hypersensitivity; hypotension; increased risk of infection (in adults); insomnia (in adults); lymphadenopathy (in adults); malaise (in adults); migraine (in adults); muscle complaints (in adults); muscle tone increased (in adults); pain (in adults); paraesthesia (in adults); peripheral oedema (in adults); speech disorder (in adults); thinking abnormal (in adults); vasodilation (in adults); withdrawal syndrome neonatal; yawning (in adults); asthenia (in adults); gastrointestinal discomfort (in adults); muscle weakness (in adults); oedema (in adults); sleep disorders (in adults)
Neonates breastfed by mothers taking buprenorphine should be monitored for ____________, ____________, and _____________
Drowsiness
Adequate weight gain
Developmental milestones
Can buprenorphine be prescribed in patients with hepatic and/or renal impairment?
Avoid in severe hepatic impairment; dose reduction in mild to moderate impairment
Caution and dose reduction in severe renal impairment
Documentation of ___________ status is recommended before commencing therapy for opioid dependence.
viral hepatitis
What monitoring is required for patients taking buprenorphine as opioid substitution therapy?
Liver function (baseline before commencing therapy AND regular LFTs throughout treatment)
Many preparations of Methadone oral solution are licensed for opioid drug addiction only but some are also licensed for ____________ in _____________.
Analgesia
severe pain
In addition to contraindications associated with opioid use, what is the main contraindication specific to methadone?
Phaeochromocytoma
Methadone should be prescribed with caution in patients with _______________ or risk factors for it
QT interval prolongation
In addition to preventing opioid relapse, naltrexone is also used in patients with _________-dependence
Alcohol
What are the common or very common side effects of naltrexone? (9)
- Abdominal pain, diarrhea, constipation, vomiting
- Arthralgia
- Asthenia
- Eye disorders
- Altered mood, anxiety
- Sexual dysfunction
- Palpitations, tachycardia, chest pain
- Sleep disorders, headache
- Skin reactions, hyperhydrosis
Is naltrexone safe to use in breastfeeding?
Avoid due to potential toxicity
Is naltrexone safe to use in hepatic and/or renal impairment?
Caution in mild to moderate hepatic impairment (adjust dose); avoid if severe or acute impairment
Caution in mild to moderate renal impairment (adjust dose)avoid in severe impairment
What pre-treatment screening is required before starting naltrexone?
Test for opioid dependence with naloxone before treatment.
What are the monitoring requirements for patients taking naltrexone?
LFTs before and during treatment
Patients and carers should be given what additional advice regarding opioid blocking drugs like naltrexone?
Attempts to overcome blockade of opioid receptors by overdosing could result in acute opioid intoxication
