Transcript September 23, 2004

Opioid Dependence
Anne Kalvik
Pearl Isaac
Learning Objectives
1. To develop an understanding of opioid
dependence issues including tolerance, abuse,
toxicity, overdose and withdrawal
2. To become familiar with various treatment
strategies for the management of opioid
dependence and develop an understanding of
the advantages and disadvantages of each
approach
3. To consider options available to pharmacists
that can impact patient outcome in opioid
dependence in its various stages. Students will
be encouraged to examine their own attitudes
to this issue
Opioid Dependence
and
Pharmacy Practice
Medical Uses for Opioids
• PAIN
• Cough
• Diarrhea
Undesirable Effects of Opioids
• Nausea and vomiting
• Sedation
• Some people don’t like effects, e.g.,
itching
• Physical and psychological
dependence
• Respiratory depression
• DEATH
Why are Opioids Abused?
Some Examples of Opioids
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Codeine
Oxycodone
Hydromorphone
Morphine
Meperidine
Hydrocodone
Heroin
Methadone
Street Value of Selected Rx Narcotic Drugs in
Vancouver’s Downtown Eastside
Sajan et al, CMAJ July 28, 1998; 159 (2)
Addiction
• Compulsive drug use
• Consequences: use despite harm
• Inability to Cut down
• Cravings
DSM-IV Criteria for
Substance Dependence
At least 3 of the following in 12-month
period:
• Tolerance
• Withdrawal
• Taking larger amounts than
intended
• Unsuccessful efforts to reduce
drug use
DSM-IV
• Great deal of time spent acquiring
and using the drug
• Reduction of important activities
because of the drug
• Continued use despite knowledge
of drug-related physical or
psychological problems
Tolerance
• Neurobehavioural adaptation
• Rapid tolerance to psychoactive
effects
• Tolerance to analgesic effects
develops slowly
• Tolerance disappears within days
Heroin Dependence
• Short acting drug
• Cycles of intoxication and withdrawal
• Injection drug use
– HIV, hepatitis, other medical issues
– Contaminants
• Crime, unemployment, domestic
problems
• Prostitution, unsafe sex
Effects of Heroin
• Physical effects on user
– direct
– indirect
• Physical effects on others
• Psychosocial effects on user
• Psychosocial effects on others
Bob
• 37-year old man buying 10
Oxycontin® per day off the street
• Currently lives alone, unemployed
Opioid Withdrawal
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(objective)
Nausea and vomiting
Diarrhea
Runny nose, sneezing
Lacrimation
Dilated pupils
Gooseflesh
Tremor
Feelings of hot and cold
Yawning
Tachycardia
Blood pressure elevation
Opioid Withdrawal
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(subjective)
Anxiety
Restlessness
Abdominal pain and cramps
Muscle aches
Bone pain
Anorexia
Craving
Insomnia
Opioid Intoxication/Overdose
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Euphoria
Dysphoria
Motor retardation
Sedation
Slurred speech
Pinpoint pupils
Respiratory depression
Circulatory collapse
Cardiac arrest
DEATH
Medical Detoxification
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Clonidine
Loperamide
Dimenhydrinate
NSAIDs
(Benzodiazepines)
(Naltrexone)
UROD
Why not detoxify?
• Opioid withdrawal not life-threatening
BUT
• Alternative for many is return to drug use
and not staying ‘clean’
• Often a chronic and relapsing disorder
• Some cannot see themselves as able to
function without opioids
Harm Reduction
Why Methadone?
• Most effective pharmacological
treatment for heroin dependence
• Well accepted
• Effective HIV/AIDS and Hepatitis
prevention
• Reduces or eliminates heroin use
(cont’d)
Why Methadone?
• Reduces criminal behaviour
• Improved employment rates
• Improved psychological status
• Decreased mortality
• Cost effective
• Availability
How does Methadone Work?
• Opioid (substitute for heroin)
• Orally effective
• Little or no euphoria / ‘high’
• Long acting (at least 24 hours)
• Prevents withdrawal
• Reduces craving
• Blocks effects of other opioids
• Permits normal functioning: stability
Sick
Normal High
A Day on
Methadone vs. Heroin
0
6
12
Time (hrs)
18
24
Comparative Profiles of
Heroin and Methadone
Heroin
Methadone
Route of
Administration
Injected
Smoked, snorted
Consumed
orally
Onset of Action
Immediate
30 minutes
Short-Acting
(3-6 hours)
Common
Long-Lasting
(24-36 hours)
Rare
3-4 hours after
last use
24 hours after
last use
Duration of
Action
Euphoria
Withdrawal
Symptoms
Is Methadone ‘Safe’?
• Well tolerated
• Not associated with organ damage
• Some side effects (e.g.,
constipation and sweating)
• Correct dose is essential
Methadone Treatment
• Medication
but also:
• Counselling
– coping skills
– nutrition
– housing, job, child care, etc.
• Medical care
• Come to pharmacy often on daily basis
Methadone and Pregnancy
• Fluctuating levels not good for
mother or baby
• Lifestyle
• Medical, psychosocial, nutritional
care
• Methadone does pass to baby,
but…
Other Treatments for
Opioid Dependence
• Naltrexone
• (LAAM)
• Buprenorphine
• Heroin
Changing Patterns of
Methadone Maintenance
Treatment
• In Ontario, major thrust to get treatment
into community settings
• Trend away from large centres like ARF
• Number of prescribers has increased
• Number of clients has increased
• Number of clients going to community
pharmacies has increased
Stages of Change
Lapse/Relapse
Maintenance
Action
Pre-Contemplation
Contemplation
Preparation