Week 6- sbstance misuse

Question 1

what are some full agonists opioids?

Answer 1

Full agonists
▪ -Codeine
▪ -Diamorphine (Heroin)
▪ -Fentanyl
▪ -Methadone
▪ -Morphine
▪ -Pethidine

Question 2

what are some partial agonists?

Answer 2

▪ Buprenorphine

Subutex®

Question 3

what are some antagonists?

Answer 3

Antagonists
▪ Naloxone (Injection) –
Narcan®
▪ Naltrexone (tablets)
▪ Nalmefene- (alcohol)

Question 4

why use methadone or buprenorphine?

Answer 4

-long lasting
-once daily BOTH
formulations not easily inject-able
-historical unpleasant formulation

Question 5

what are the effects of methadone on the CNS?

Answer 5

▪ Euphoria- not as pronounced as heroin
▪ Pleasant, warm feeling in the stomach
▪ Pain relief
▪ Drowsiness- not when tolerant
▪ Nausea/vomiting- stimulation of chemoreceptor trigger zone
▪ Respiratory depression
▪ Cough reflex depression
▪ Arms & legs feel heavy- ?increased blood flow to periphery

Question 6

what are the effects on the peripheral NS?

Answer 6

▪ Dryness of the mouth, eyes, nose- reduction of secretion of
saliva tears & mucous
▪ 53% methadone users report dental problems
(methadone is acidic in nature)
▪ Constipation- opiates are good at slowing passage of food
(patients require high fibre & high fluid)
▪ Constricted pupils- reliable indicator of the level of opiates in
blood stream

Question 7

what are some histaminergic effects of methadone?

Answer 7

▪ Itching
▪ Sweating
▪ Blushing
▪ Flushing
▪ Constricting of the airways

Question 8

what are some other effects of methadone?

Answer 8

▪ Reduced or absent
menstrual cycle- may still
become pregnant
▪ Sexual dysfunction
▪ Hallucinations
▪ Heart pounding transient effect

Question 9

how is methadone metabolised?

Answer 9

• Methadone is soluble in lipids
• Extensive metabolism in the liver
• Binds to albumin
• Slow transfer between tissues
• Half life single dose 15 hours
• At steady state the half life has a
mean of 25 hours (once daily
dosing)
Missed dose: after 25 hours, level
drops to about half the peak level and
after 48 hours drops to 25% peak level

Question 10

what is the tolerance of methadone?

Answer 10

▪ Tolerance to opiates rises more quickly during second &
subsequent exposures to the drug
▪ Tolerance to miosis and constipation develops very slowly and
both are often present years after treatment
▪ Tolerance may go as quickly as it develops
Overdose risk for people
post detoxification and
intermittent users
particularly prisoners
released

Question 11

what is the effectiveness of methadone and buprenorphine?

Answer 11

• Both are effective & used in the
treatment of opioid
dependence & detoxification

Question 12

what is the maintenance of methadone and buprenorphine?

Answer 12

• Methadone is considered the
gold standard 60-120mg
• Buprenorphine 12-32mg

Question 13

what assessment is needed for methadone and buprenorphine?

Answer 13

• Dependence confirmed by
history & examination. Urine or
oral toxicology screening

Question 14

what are some safety consideration of methadone?

Answer 14

• Low opioid tolerance
• Avoid additional drugs which may cause respiratory
depression such as benzodiazepines (be aware of self
med with alcohol)
• Avoid high initial dose (40mg may be fatal in an adult, 10mg in
children)
• Avoid rapid dose increases - methadone slow to clear
• Minimise side effects of constipation and sweating
• Potential interactions QT over 100mg/cardiac risk
• Minimise diversion, accidental ingestion and
overdose errors

Question 15

how is methadone induction occurring dose wise?

Answer 15

-The first dose should not exceed
40mg. If uncertain then 10-20mg
-Where doses need to be increased
the increment should be no more
than 5-10mg in one day
-The total weekly increase should
not usually exceed 30mg above the
starting day’s dose
• Methadone-related deaths during MMT occur during the first
10 days of treatment and are more common with higher
induction doses
• There is no way of directly measuring tolerance to
methadone.
• Estimate of opioid tolerance is based on history and physical,
supported by toxicology tests.

Question 16

what is the buprenorphine induction occurring dose wise?

Answer 16

Dose induction with buprenorphine may be carried out more rapidly
with less risk of overdose
▪ Timing is crucial
Buprenorphine can cause precipitated withdrawals when
transferring from heroin or other opioids.
▪ Start at least 8-12 hours post heroin, 24-36 hours post
methadone, 4mg is a good starting dose then escalate the dose
quickly
▪ Doses above 12mg block the effect of heroin and other opiates
on top

Question 17

what are the advantages of methadone?

Answer 17

▪ Established and familiar
▪ Good evidence base for
Methadone maintenance
treatment
▪ Trusted
▪ Sedating
▪ Cheap
▪ Full agonist
▪ Variety routes/forms
▪ 1
st choice in pregnancyalthough evidence points the other
way??
▪ Easier to supervise

Question 18

what is the advantages of buprenorphine?

Answer 18

▪ More difficult to use on top
(maintenance minimises drug
seeking behaviour, -ve
reinforcement)
▪ Good for clients at risk of
overdosing
▪ Safer in overdose
▪ Less stigmatised
▪ Easier to detox from, easier switch
to naltrexone
▪ Less sedating
▪ Better outcomes of newborns
▪ Can’t be adulterated
▪ Initial titration rapid

Question 19

what is the disadvantages of methadone?

Answer 19

▪ Easy to overdose
▪ Can use heroin on top
▪ Leakage onto the streets
(adulterated, injected)
▪ Stigmatised drug (older users,
deters new clients)
▪ Rots teeth??
▪ Stored in fatty tissue
▪ 3 days to steady state
▪ Long detoxification
▪ Avoids withdrawals but doesn’t
stop craving
▪ Sedating

Question 20

what is the disadvantages of buprenorphine?

Answer 20

▪ Expensive
▪ More difficult to supervise
(concealment)
▪ Poorer evidence base/less
experience
▪ Can be injected
▪ Unpleasant taste (S/L)
▪ Only one dosage form
▪ Less sedating
▪ Precipitated withdrawals

Question 21

what does NICE say?

Answer 21

-Higher fixed doses of methadone
maintenance treatment (MMT) are more
effective than lower fixed doses
-MMT reduces mortality, HIV risky behaviour and
levels of crime c/w no therapy
-Fixed dose MMT has higher levels of
retention in treatment & lower rates of
illicit opioid use c/w placebo or no
treatment

Question 22

what is the role of noradrenaline?

Answer 22

▪ The Locus Coeruleus (LC) is central to the symptoms
of opiate withdrawal. It produces 70% of brain
noradrenaline
▪ LC develops tolerance to opiates, abrupt cessation of
opiates then leads to enhanced LC activity with an
increase in NA release & turnover. This
‘noradrenaline storm’ leads to opiate withdrawals.
These withdrawals can be measured using subjective
and objective opiate withdrawal scales.

Question 23

how to remain free of opioids?

Answer 23

Naltrexone
• Competitive opioid antagonist with high affinity
• Blocks the euphoric and other effects of opioids and thereby
minimising the positive rewards associated with their use
• Is licensed for use as an adjunctive prophylactic treatment for
detoxified formerly opioid-dependent people
• Must be prescribed within a package of support including
relapse prevention
• Clients may be at risk of a fatal overdose caused by
respiratory depression if they relapse while taking
naltrexone.

Question 24

what should be done before using naloxone?

Answer 24

Administration of naltrexone must not be started before a naloxone
challenge test is performed and a negative result obtained.
• Naloxone test
• Subcutaneous: Administer 0.8 mg naloxone subcutaneously.
Observe the patient for 20 minutes for signs and symptoms of
withdrawal
• Confirmation of the test: If there is any doubt that the patient
is opioid-free, treatment with naltrexone should be delayed 24
hours. In this case, the test should be repeated with 1.6 mg
naloxone
• If there is no evidence of a reaction, naltrexone administration
may be initiated with 25 mg by mouth.

Question 25

what is naloxone?

Answer 25

• Naloxone is the emergency antidote for overdoses caused
by heroin and other opiates or opioids (such as methadone,
morphine and fentanyl).
• The main life-threatening effect of heroin and other opiates is
to slow down and stop breathing. Naloxone blocks this effect and
reverses the breathing difficulties.
• Naloxone is a prescription-only medicine, so pharmacies
cannot sell it over the counter. But drug services can supply it
without a prescription. And anyone can use it to save a life in an
emergency.

Question 26

what mental health issues can occur from alcohol misuse?

Answer 26

Depression
• There is a close link between alcohol misuse and
depression. Between 15-25% of all suicides in England &
Wales are associated with alcohol misuse
Anxiety
• Alcohol is used as a means of coping with social and other
anxieties
Personality disorder
• Alcohol misuse may produce a pattern of behaviour which
mimics that found in long term personality disorder
Amnesia
• Alcoholic amnesias are experienced by a quarter of young
men and 10% young women

Question 27

what is cognitive impairment due to alcohol and mental health?

Answer 27

Cognitive impairment
• Alcohol is neurotoxic and when taken to excess causes
cognitive impairment – alcohol dementia & long term
neuropathy
• There may be evidence of cerebral atrophy

Question 28

what are the effects on the CNS of alcohol and mental health?

Answer 28

Wernicke-Korsakoff syndrome
• A neuropsychiatric disorder of acute onset associated with
thiamine deficiency.
• Encephalopathy is characterised by confusion, apathy,
disorientation and disturbed memory
• Post mortem analysis has demonstrated that Wernickes may occur
in as many as 12.5% of chronic alcohol misusers
• Encephalopathy resolves but reversal of psychosis less predictable

Question 29

what can Chronic alcohol consumption can result in?

Answer 29

thiamine deficiency
• Decreased absorption of thiamine from the
gastrointestinal tract, and impaired thiamine utilisation
in the cells
• Poor dietary intake/nutrition
• Low vitamin content in alcoholic drinks
• Impaired storage in the liver
• Increased requirement due to alcohol metabolism

Question 30

what thiamine supplementation can be given ?

Answer 30

• Oral thiamine
• 100mg three times daily but poor absorption orally is poor
• Pabrinex
• One pair of ampoules I/M daily
• for 3-5 days

Question 31

why should structured reduction of alcohol occur?

Answer 31

• Prolonged heavy drinkers should not stop abruptly, as may cause
alcohol withdrawal seizures. Compensatory adaptation of
GABAA
receptors to prolonged ethanol exposure plays a critical
role in alcohol dependence
• Do NOT suggest structured reduction if history is complicated (e.g.
seizures, hallucinations)
• Use an alcohol diary
• Stick to same type and strength of alcohol
• Gradual monitored reduction as tolerated

Question 32

what can occur due to using canabis when driving and to memory?

Answer 32

• Loss of co-ordination
• Driving under the influence of
cannabis almost doubles the risk of
a fatal road crash
• Legal limit for driving is so low that
labs have difficulty detecting it to
that level

• Problems with memory and
learning
• Distorted perception
• Difficulty in thinking and
problem solving

Question 33

what is the ink between cannabis and schizophrenia?

Answer 33

• If you start smoking cannabis before 15, (especially heavy
consumption) you are 4 times more likely to develop a psychotic
illness. Early positive response to cannabis can predict later
dependence
• The more cannabis you use, the more likely you are to
develop psychosis, especially in people predisposed or with a
genetic vulnerability to psychosis
• It isn’t clear why cannabis use in adolescence seems to have
such an effect, but it may be because the brain is still developing
• Can make relapse more likely
• However, no increase in schizophrenia despite increase in
cannabis use?