Substance misuse

Question 1

What assessments are required of someone presenting to services wanting to detox off heroin?

Answer 1

Hx - medical, psycho, social, drug
Physical examination
Urine drug screen - to confirm the drugs that are being taken
Assessment of needs in terms of support

May also need:
Bloods tests - HIV, Hep B + C
Immunisation - against Hep A + B + tetanus; partner + children immunisation
Advice on dangers of injections + harm reduction strategies

Question 2

What drug treatments can be used when coming off heroin?

Answer 2

Methadone:

• μ-opioid receptor agonist
• Used for detoxification from heroin/opioids or as a maintenance medication in those that would otherwise take heroin
• Taken PO, OD, usually in front of dispensing staff
• Detox can take between 1-6 months; if people want/are able to come clean
• Same side effects/overdose features as opioids; also analgesic
• Higher risk of OD if taking heroin concurrently

Naltrexone:

• For opioid maintenance after detox
• PO daily or IM monthly
• Not a restricted medication (unlike methadone)
• Can also be used for alcohol abstinence maintenance

Buprenorphine:
- As above, can also be given in combo with naloxone (suboxone) to discourage misuse by injection

Question 3

What are the signs of opioid overdose?

Answer 3

Respiratory depression 
Pinpoint pupils 
Dry mouth 
Low blood pressure 
Spasms 
Disorientation 
Delirium  
Coma 

Evidence of injection sites, paraphernalia

Signs of malnutrition

Question 4

How do you acutely manage opioid overdose?

Answer 4

Naloxone - IV, IM, Intranasal
(can give subdermal implants)

Competitive opioid antagonist, trade name narcan, half life much shorter than heroin - need to stop the overdose but not make them too awake too quickly else they may run away, the OD will continue and they may die; upon waking from OD patients can be angry (as you’ve effectively wasted their money/ + ruined their high

Start with 50-100mcg, gauge response and repeat, can give up to 2mg total - by not waking people up quickly, they will hate you less for ruining their high

Support airway and let heroin work itself out of system

Question 5

What other support might be important following recovery from an OD?

Answer 5

Asking whether OD was intentional or an accident - may desire more formal psych followup

Referrals to drugs services, social work followup etc

Question 6

How does opioid withdrawal present?

Answer 6

For short-acting opioids (eg, heroin, morphine immediate-release, oxycodone immediate-release), acute withdrawal
symptoms:
- Usually begin 6 to 12 hours after the last dose
- Peak in 24 to 48 hours
- Diminish over the next 3 to 5 days

For longer-acting opioids (eg, methadone) or opioid formulations (eg, oxycodone extended-release, morphine extendedrelease), acute symptoms:

• Occur within 30 to 72 hours after last dose (although anxiety may occur before this)
• Resolve over the next 10 days or so

Antagonist-precipitated withdrawal can begin within 1 minute of an IV-administered dose of naloxone and last from 30 to 60 minutes

Its highly uncomfortable, but not life-threatening for most patients

Features:
- Myalgia and arthralgia
– Hyperalgesia
– Gastrointestinal distress (eg, stomach cramping, nausea, loose stools)
- Anxiety
– Moodiness
– Dysphoria
– Irritability
– Insomnia
– Hot or cold flashes
– Poor concentration
– Increased drug craving 
- Tachycardia
– Hypertension
– Diaphoresis
– Rhinorrhea
– Yawning
– Increased lacrimation
– Muscle twitching
– Restlessness
– Vomiting
- Diarrhea 
– Piloerection (ie, gooseflesh)
- Tremor 
– Mydriasis

Signs and symptoms can be measured on the Clinical Opioid Withdrawal Scale

Question 7

What are some key prescription medications associated with abuse and dependency? And some key over the counter medications?

Answer 7

Prescribed:
Opioids (rates increasing) 
Benzodiazepines - for anxiety and sleep (rates decreasing)
Z-drugs 
SSRIs 
GABAergics 

OTC:
Analgesic codeine +/- paracetamol or ibuprofen
Opiate cough medicines e.g. codeine lunctus
Sedative antihistamines e.g. chlorphenamine
Laxatives
Nicotine replacement therapy
Stimulant decongestant stimulants e.g. pseudoephedrine

Question 8

Who is affected by medication abuse?

Answer 8

Not a clear picture

• Possibly older females for OTC
• Genetics, FHx
• Personal biopsychoscial profile
• high dose opioids, use of short acting opioids, high pain level, multiple pain complaints, self-reported craving, concurrent use of tobacco/alcohol/benzos

Question 9

How can we manage OTC abuse?

Answer 9

• Hide products, refuse sales, record sales
• Harm-reduction schemes?
• Pack warnings
• Change the indications e.g. severe pain only
• Training/raising awareness