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Transcript
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? • • • • How much ? How often? How using? 5 day history • Past drug history • • • • When did using start? Previous treatments? Overdoses? Injecting history? Optimising OST - Assessment • Other history • • • • • 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 • • • • • • 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 100 90 80 70 60 50 40 30 20 10 0 %Heroin use 0 10 20 30 40 Methadone dose (mg) 50 60 70 80 90 100 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 • • • • • • • • • • 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 • 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 • Reducing barriers to entry • Optimal daily dose • High quality medical and psychosocial services • Treatment retention • Orientation towards social rehabilitation • Sufficient duration of treatment • 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