Transcript Optimising Opioid Substitution Therapy

Optimising Opioid Substitution
Therapy- clinical assessment,
maintenance & detox
Dr Matthew Young
GP and Speciality Doctor
Regional lead for London RCGP Substance Misuse Unit
Optimising Opioid Substitution Therapy
• UK has among the highest rates of illegal drug misuse in the western
world
• Increasing availability
• Mortality 14 x higher than for age matched individuals but good
outcomes for many if kept alive: Harm Reduction Philosophy
• Often a chronic relapsing condition – similar to many others treated
in primary care (depression, diabetes, arthritis)
Optimising OST - Dependency
Addiction (ICD 10) :
► craving
► tolerance
► compulsive drug-seeking behaviour
► physiological withdrawal state
Physically addictive or psychologically addictive?
When do you need a substitute?
Optimising OST - Assessment
• What drugs?
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How much ?
How often?
How using?
5 day history
• Past drug history
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When did using start?
Previous treatments?
Overdoses?
Injecting history?
Optimising OST - Assessment
• Other history
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Past medical history
Past psychiatric history
Drugs
Allergies
Social history
• Work
• Families
• Legal history
• Mental state
Optimising OST - Assessment
• Examination
• Injecting sites
• What organs can be affected by drug and alcohol misuse?
Optimising OST - Assessment
• Investigations
• Drug screen – oral fluid or urine
• Near v. far testing
• How often
• BBV
• Other tests
Optimising OST – Purpose of Treatment
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To reduce harm to user, family, community and society
To improve health and prevent death
To stabilise physically and psychologically
To improve quality of life and social functioning
To address all issues and reduce harm associated with substance misuse
To reduce crime
Substitute prescribing by doctors and non-medical prescribers is only one
part of treatment and can only succeed in conjunction with adequate key
worker and psychosocial support during and after an individual being on
substitute medication
Optimising OST - Treatments
• Methadone
• Buprenorphine
• Lofexidine
• If you don’t have morphine or methadone in you drug screen – don’t
prescribe.
Optimising OST - Methadone
Graph showing deaths,
comparing
untreated patients with those
in
Methadone maintenance
treatment
in the Sweden
(Gronbladh L Ohland M,
Gunne L. Mortality in heroin
addiction: impact of
methadone treatment. Acta
Psychiatr Scand 1990; 82:
874-79.)
Optimising OST - Methadone
• Starting dose 30mgs or less
• Increase by 30mgs per week
• Half life
• Optimal dose?
Optimising OST - Methadone
• Good evidence-base and recommended option for maintenance therapy in the management of
Opioid dependence
• Long acting, can be taken orally
• Addictive, develop tolerance & dependency
• Difficult to withdraw from
• Useful for maintenance – long half life, steady blood levels
• Need to start low and titrate up against signs of withdrawal
• Need to balance between achieving right dose and preventing overdose or diversion
• Common side effects include constipation, dizziness, drowsiness
• Needs care during titration (risk of OD) and in conjunction with other substances (alcohol,
benzodiazepines, antidepressants)
• Be aware of risk of pronged QT interval (especially at doses over 100mg per day) and subsequent
risk of cardiac arrhythmias
Optimising OST - Methadone
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%Heroin use
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Methadone dose (mg)
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Ball J, Ross A. The effectiveness pf
methadone maintenance treatment:
patients, programs, services and
outcome. New York: Springer-Verlag,
1991.
Optimising OST - Methadone
• Sub-optimal dosages tend to be less effective
• Many patients will need 60-120mg Methadone to be comfortable, some may
need more or less
• Dosages should be tailored to clinical response
• Patients can determine their dose levels within limits
• Patients will not automatically push for the highest possible dosages
• Flexible dosing contributes to retaining patients successfully in treatment
Optimising OST - Buprenorphine
• Partial agonist
• Starting dose
• Starting time
Optimising OST - Buprenorphine
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A useful alternative to Methadone
0.4mg, 2mg, 8mg tablets – dissolve sublingually
Some advocate crushing the tablets, though this is an unlicensed approach
Used for maintenance and detoxification
Partial agonist, also has antagonist activity so may initially cause withdrawal from other opioids if started too
early
Blockade effect on other opioids during treatment- if dose sufficient
Maintenance dose between 12-32mg [blockade at 16mg]
LFTs should be carried out before or early in treatment, especially if any suspicion of liver problems, but
should not delay starting treatment
Good safety profile but only when used alone
Side effects include constipation, drowsiness, headaches
Optimising OST - Buprenorphine
Advantages:
1. Less dangerous in overdose
2. Between 16-32mgs use ‘on top’ markedly reduced
3. Useful in maintenance and detoxification
4. Clearer head
Disadvantages:
1. Highly soluble leading to potential for injection
2. Can precipitate acute opiate withdrawal if induction incorrect
3. Less ‘Opiate-like’ or ‘clouding’ effect
4. Sublingual: slower to supervise
Optimising OST - Buprenorphine
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An increasing body of evidence for the effectiveness of
Buprenorphine in maintenance and recommended option for
maintenance therapy in the management of Opioid dependence
• Flexible Methadone Maintenance regimes appear to have better
retention at the start of treatment than flexible Buprenorphine
Maintenance regimes
• If both Methadone and Buprenorphine are equally suitable,
Methadone should be prescribed as the first choice
Optimising OST - Buprenorphine
• ‘Suboxone’ is a combination of Buprenorphine [8mg or 2mg] and
Naloxone [2mg or 0.5mg]
• Naloxone is inactive when taken sublingually or orally but is activated
if used intravenously or absorbed through a mucus membrane-such
as the nasal passages
• ‘Suboxone’ may have a role in discouraging injection or ‘snorting’ of
Buprenorphine or other Opioids due to causing precipitate
withdrawal
Optimising OST - Lofexidine
• Non-opiate
• Alpha2-adrenergic agonist
• Related to clonidine and antihypertensive
• Oral
• Only used to detoxification when on low doses of methadone or coming off (smoked) heroin
• Side effects are low BP and drowsiness
• Only helps symptoms of withdrawal and not cravings
• Other symptomatic medication may be used, including:
• Musculoskeletal pains: NSAIDs (avoid Codeine containing drugs)
• Gastro-intestinal symptoms: Loperamide, Kaolin, Buscopan, Mebeverine
• Nausea/vomiting: Prochlorperazine, ‘Buccastem’, Metoclopramid
• Anxiety, agitation, insomnia: Avoid diazepam – sleep hygiene and reassurance
Optimising OST
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Reducing barriers to entry
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Optimal daily dose
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High quality medical and psychosocial services
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Treatment retention
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Orientation towards social rehabilitation
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Sufficient duration of treatment
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Detoxification only of willing, well stabilised patients with established abstinence
Programme variables far more significant than patient variables
- the therapeutic relationship is key
Optimising OST – further reading
• Orange book – DoH (2007). Drug Misuse and Dependence: UK
Guidelines on Clinical Management. London: DoH.
• Available online at www.dh.gov.uk/publications
• RCGP (2011). Guidance for the use of substitute prescribing in the
treatment of opioid dependence in primary care. London: RCGP.
• Available on line at www.smmmgp.org.uk
• NICE technology appraisal guidance 114 (2007). Methadone and
Buprenorphine for the management of opioid dependence. London:
NICE.
• Available on line at www.nice.org.uk