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PHA333 > substance misuse - opioids > Flashcards

substance misuse - opioids Flashcards

1
Q

What opioid has the greatest dependence potential?

A

diamorphine (heroin)

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2
Q

What is an opioid/opiate?

A

natrual derivative of opium or a synthetic substance with agonist, partial agonist or mixed agonist and antagonist activity at opioid receptors

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3
Q

When does dependence develop?

A

after a period of regular use of opioids

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4
Q

What leads to opioid dependence?

A

social, psychological and biological consequences and changes in the brain

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5
Q

How soon can physical/psychological dependence develop?

A

short period of continuous use 2-10 days

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6
Q

complications of opioid dependence

A

overdose
infections eg. HIV
hepetitis
social problems - homelessness, crime

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7
Q

key elements of opioid dependence

A
  • strong desire to take opioids
  • difficulty controlling use
  • physiological wd state after reducing/stopping
  • evidence of tolerance
  • neglect of other interests
  • persistence with use despite consequences
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8
Q

What is OST (opioid substitution therapy)?

A
  • buprenorphine and methadone
    aim:
  • improve QoL of pts
  • reduce potential harm of using drugs for individual/those affected (children/family)
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9
Q

What type of drug is methadone?

A
  • mu agonist
  • weak NMDA antagonist
  • 5-HT reuptake inhibition
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10
Q

initiation and maintenance dose of methadone

A

initiation 10-30 mg/day

maintenance 60-120 mg/day

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11
Q

adverse effect of methadone > 100mg/day

A

risk of QT prolongation

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12
Q

What is the QT interval?

A

begins at onset of QRS complex and ends at end of T wave

  • time from start of ventricular depolarisation and end of ventricular repolarisation
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13
Q

ranges for QT interval

A

normal < 440ms
borderline - 440-500ms
prolonged - >500ms

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14
Q

monitoring for methadone for QT interval prolongation

A 
BP
pulse
LFTs
U&E
ECG
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15
Q

signs of QT prolongation

A

palpitations
syncope (fainting)
dizziness
light headedness

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16
Q

risk factors for QT prolongation

A

> 100mg mathadone/day

QT prolonging drugs

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17
Q

What type of drug is buprenorphine?

A

partial opioid agonist at the mu receptor

antagonist at kappa receptors

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18
Q

usual and max dose of buprenorphine

A

usual 12-16mg

max 32mg

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19
Q

formulations of buprenorphine

A

sublingual tablet (temgesic unlicenced for opioid misuse)

injection

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20
Q

benefit of buprenorphine compared to methadone

A

buprenorphine less sedating than methadone

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21
Q

complications of drug misuse/presentations

A 
overdose
infection (injecting)
HIV
hepatitis B/C
DVT
poor nutrition
poor dental care
psychological problems
death
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22
Q

clinical features of opioid intoxification

A 
constriction of pupils
itching/scratching
sedation (slurred speech)
low BP
slower pulse
hypoventlation
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23
Q

symptoms of acute withdrawal of opioid

A 
watering eyes
rhinorrhoea
yawning
sneezing
sold/clammy skin
dilated pupils
cough
abdominal cramps
N&V
diarrhoea
tremor
sleep disorder
restlessness
anxiety
ittirability
hypertension
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24
Q

What is included in a drug assessment?

A

History taking

  • degree of dependence
  • medical Hx
  • psychiatric Hx
  • family Hx
  • social problems

physical examination
- urine drug screening

investigations

  • ECG
  • LFTs, U&Es, FBC
  • screen for HIV, hepatitis B&C
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25
when to do urine drug screenings
before OST at least every 3mths
26
How long does heroin/methadone/buprenorphine last in urine?
heroin up to 48hrs methadone metabolites 7-9 days buprenorphine 1-2 weeks
27
oral fluid (mouth swab) analysis
if tampering wth urine samples suspected drugs present in lower concs and shorter detection window
28
2 main treatment options for addiction
1. maintenance OST | 2. detoxification
29
What is maintenance OST?
used for patients who are not ready to come off opioids completely aim - reduce/stop illicit drug use, harm reduction and stabilise lifestyle supervised consumption for at least 3mths is maintenance decided
30
What is detoxification therapy?
for patients who want to become drug free aim - safe and effective discontinuation of opioids and minimal withdrawal symptoms usually takes 28 days as inpatient, 12 weeks in community initiated once patient stabilised on OST
31
What patient use detoxification programme?
patients who want to stop taking opiates
32
first line for detoxicifation
methadone or buprenorphine
33
reduction of methadone for detoxification
reduced at a rate that will result in 0 in around 12 weeks reduce by 5mg ever 1-2 weeks
34
reduction of buprenorphine for detoxification
reduced by 2mg every 2 weeks final reductions around 400mcg
35
symptomatic treatment to manage withdrawal s/e
``` diarrhoea - loperamide N&V - metoclopramide stomach pain - mebeverine aches/pains - paracetamol/ibuprofen agitation/anxiety - diazepam/zopiclone ```
36
drug used for relapse prevention
naltrexone
37
first line opiate treatment
methadone
37
What to consider for treatment choice?
- preference for either drug - previous benefit from either - safety concerns - need for strong opioids other than buprenorphine for pain - drug interactions - pregnancy (both can be used) - risk of diversion (inc with buprenorphine) - severity of dependence
38
risk factors for overdose in methadone induction
- low opioid tolerance - use of CNS depressant drugs (BDZs, alcohol) - drug interactions - too high initial dose - too rapid dose increase - slow methadone clearance (hepatic impairment)
39
initiation of methadone maintenance
week 1 - initial dose 10-30mg/day - 20mg if low/uncertain tolerance/other sedative drugs - up to 40mg us heavily dependent - no more than 5-10mg inc in 1 day - no more than 30mg inc over 1 week -> dose inc until confortable (60-120mg/day usually)
40
When is risk for methadone overdose greatest?
greatest in first few weeks
41
What can precipitate withdrawal syndromes with buprenorphine?
its partial agonist properties
42
When is 1st dose of buprenorphine given?
when patient is exhibiting objective signs of withdrawal ideally within 6-12hrs after last use of heroin 24-48hrs after last dose of low-dose methadone
43
mild/moderate signs of withdrawal
anxiety abdominal/joint pain dilated pupils sweating
44
dose titration for buprenorophine day 1
day 1 - starting dose of 4-8mg - withdrawal symptom dependent: mild/mod 4mg, mod/severe 8mg - 4mg if unknown level of dependence/high risk use of alcohol/BDZs
45
initiating buprenorphine day 2
- rapidy titrate dose - by 2/4/8mg according to response over next few days - aim to achieve dose that provides stable effects for 24hrs and is clinically effective - typical maintenance dose 12-24mg - max 32mg
46
example of dose titration for buprenorphine
day 1 - up to 8mg day 2 - up to 16mg day 3 - up to 24mg
47
Why is buprenorphine titrated qicker than methadone?
it is safer to initiate less risk of over sedation respirarory depression and overdose
48
Which drug has higher risk of opiate overdose?
methadone
49
When does OD occur with methadone?
around day 3/4 of induction
50
OD signs/symptoms
``` PINPOINT PUPILS (miosis) RESPIRATORY DEPRESSION UNRESPONSIVENESS/REDUCED CONSCIOUSNESS dizziness sedation bradycardia nausea slurred speach hypotension coma pale clammy skin ```
51
How to manage opioid toxicity?
naloxone
52
When to use buprenorphine over methadone?
- safer in OD - adverse effects with methadone - pt dependent on codeine/dihydrocodeine - pts who want to stop heroin completely - less affected by interactions with enzyme inducers/inhibitors - better clear head/clarity of thought - less sedating
53
When to use methadone over buprenorphine?
- easier to supervise - better for pts using high levels of heroin - better in pts who continue to use - pts who use large amounts of heroin - if sedation required - if other opioid meds Rx - less supervision requiremnents
54
Suboxone
combined sublingual tablet of buprenorphine and naloxone | 4:1
55
2 strenghts of Suboxone
2mg bup and 0.5mg naloxone 8mg bup and 2mg naloxone
56
Why is sublingual Suboxone beneficial?
sublingually - naloxone has low bioavailability (and minimal effects) and doesn't alter therapeutic effect of bupernorphine, reduces misuse injected - high bioavailability which precipitates withdrawal
57
When is Suboxone useful?
concern about pt reverting to injecting
58
supervision vs take home consumption
supervised - diversion concerns - 1st 3 mths min - after treatment break - after significant dose inc - other drugs/alcohol take home - stable dose - treatment progressing - no other drugs/alcohol - no diversion concerns - no mental health issues
59
missed doses
if missed 3 days Rx treatment pt may have lost tolerance to the drug might restart the patient with an initiation dose

PHA333 (27 decks)

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