Optimizing Opioid Dependence Treatment A Guideline for Pharmacists

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Katrina Ferguson
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1 Optimizing Opioid Dependence Treatment A Guideline for Pharmacists Module 1: Substance Use Concepts F e b r u a r y

2 Learning Objectives To know and understand the pathophysiology of substance dependence, the principles of addiction and the harm reduction strategies that are encouraged to increase not only the safety of individuals who use, but also the safety of our communities To recognize the signs and symptoms of opioid intoxication, withdrawal and dependence To know how to use methadone and buprenorphine safely and effectively in the treatment of opioid dependence To be able to apply the NLPB Standards of Practice for the Safe and Effective Provision of Medication for the Treatment of Opioid Dependence to ensure optimal patient care delivery

3 Exemption The NLPB Standards for the Safe and Effective Provision of Medications for the Treatment of Opioid Dependence and the Methadone Maintenance Treatment Standards and Guidelines from the College of Physicians and Surgeons of Newfoundland and Labrador do not apply to the use of methadone or buprenorphine specifically for pain management.

4 Outline Module 1: Substance Use Concepts Module 2: Pharmacotherapy of Opioid Dependence Module 3: Optimal Use of Methadone Module 4: Buprenorphine and Opioid Dependence Module 5: Applying the NLPB Standards of Practice for Opioid Dependence Treatment- Methadone Module 6: Applying the NLPB Standards of Practice for Opioid Dependence Treatment- Buprenorphine Module 7: Case Studies

5 Substance Use Concepts Module One

6 Module 1 - Substance Use Concepts 1. Diagnosis 2. Pathophysiology 3. Harm reduction 4. Principles of addictions treatment 5. Referral resources

7 Substance Use Disorders DSM-5 Diagnostic Criteria Use of the following substances can result in a Substance Use Disorder (SUD): Alcohol Cannabis Hallucinogens Inhalants Opioids Sedatives, anxiolytics Stimulants Tobacco Unknown 11 criteria that encompass impaired control, social impairment, risky use and pharmacological adverse effects Disease severity is based upon the number of criteria present Mild: 2-3 symptoms Moderate: 4-5 symptoms Severe: 6 or more

8 SUD Diagnostic Criteria The individual may take the substance in larger amounts or over a longer period than was originally intended The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue use The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects Craving is manifested by an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug was previously obtained or used

9 SUD Diagnostic Criteria Recurrent substance use may result in a failure to fulfill major role obligations at work, school or home The individual may continue substance use despite having persistent or recurrent interpersonal problems caused or exacerbated by the effects of the substance Important social, occupational, or recreational activities may be given up or reduced because of substance use There is risky use of the substance where there is recurrent use in situations in which it is physically hazardous

10 SUD Diagnostic Criteria The individual may continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance Withdrawal is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance Tolerance is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed

11 The Pathophysiology of Substance Dependence

The Dopamine Reward Pathway Drugs are chemicals that tap into the brain s communication system altering the way that neurons normally send, receive and process information Our brains are

12 The Dopamine Reward Pathway Drugs are chemicals that tap into the brain s communication system altering the way that neurons normally send, receive and process information Our brains are wired with a dopamine reward circuit that ensures that we will repeat life-sustaining activities by associating these activities with pleasure and reward VTA dopamine rich: Nucleus Accumbens

The Dopamine Reward Pathway Some drugs such as heroin and marijuana mimic natural neurotransmitters Other drugs including the psychostimulants cause neurons to release abnormal amounts of natural

13 The Dopamine Reward Pathway Some drugs such as heroin and marijuana mimic natural neurotransmitters Other drugs including the psychostimulants cause neurons to release abnormal amounts of natural neurotransmitters or prevent their normal recycling or reuptake Different drugs of abuse alter a variety of neurotransmitter systems Substances of abuse directly or indirectly tap into the dopamine reward pathway

14 The Power of the Dopamine Pathway Activation of the dopamine circuit in the limbic system begins the process through the release of dopamine All drugs of abuse flood this pathway Drugs of abuse can release up to 10 x the amount of dopamine that natural rewards do

15 Contributors to Substance Use Availability Positive and negative reinforcing properties Onset of effect How it is used Orally Mucous membranes Inhaled Injected

16 Classes of Abused Substances CNS depressants Alcohol Opioids: prescribed and illicit such as heroin Benzodiazepines CNS stimulants Cocaine Amphetamines MDMA Ecstasy Crystal meth Methylphenidate Hallucinogens LSD Cannabis THC Psilocybin magic mushrooms Ketamine Solvents Volatile gases and fuels

17 Categories of Substance Use ABST NON- PROB USE AT- RISK USE ABUSE DEP Use Consequences Repetition Loss of control, preoccupation, compulsivity, phys. dep /

Illicit drug use will always happen Minimizing the dangers to

18 Harm Reduction Abstinence from use is the ultimate goal It is NOT the only acceptable outcome Harm reduction philosophy Illicit drug use will always happen Minimizing the dangers to individuals, communities and societies is more realistic than condemning it

19 Harm Reduction Principles A set of practical strategies that reduce negative consequences of drug use Safer use Buddy system Injection clinics Condoms Needle exchange

SWAP Safe Works Access Program A largely volunteer-driven service established in 2005 which operates under the auspices of ACNL A needle distribution service Aims to reduce the incidence of

20 SWAP Safe Works Access Program A largely volunteer-driven service established in 2005 which operates under the auspices of ACNL A needle distribution service Aims to reduce the incidence of drug-related health harms including transmission of infection through needle sharing Facilitates referral to primary health care and addictions/ mental health services and Increases public awareness of harm reduction

21 SWAP Statistics Who is using injection drugs in our province? Survey conducted by SWAP Users are both males and females aged 18 + Of various sexual orientations With or without children With differing levels of education including post-secondary degrees and diplomas Those who are working and not working How many needles do they distribute? 60-fold increase since inception of SWAP in approximately 5600 needles In 2012 a staggering 331,833 distributed throughout NL

SWAP Benefits Increased awareness and understanding of injection drug use and harm reduction Those injecting drugs engage in safer injection

22 SWAP Benefits Increased awareness and understanding of injection drug use and harm reduction Those injecting drugs engage in safer injection practices and connect to treatment options Decrease in transmission of HIV, Hepatitis B & C Safer communities Should not be viewed as condoning drug use

23 SWAP SWAP offices in St. John s and Corner Brook Tree Walsh, Harm Reduction Outreach Worker Tel: or , Business cards available to provide access to patients Volunteers do not necessarily have the time; they just have the heart. - Elizabeth Andrew

24 Harm Reduction Strategies Managed use Time limited Partial abstinence Controlled use Methadone Maintenance Programs

25 Principles of Addictions Treatment No single treatment is appropriate for all individuals Treatment needs to be readily available Effective treatment attends to multiple needs, not simply drug use Remaining in treatment for an adequate period of time is critical Individual and/or group counseling and other behavioral therapies are critical components of effective treatment Medications are an important element of treatment for many individuals especially when combined with counseling and other behavioral therapies Dependent drug-abusing individuals with coexisting mental illness should have both treated in an integrative way

26 Principles of Addictions Treatment Medical detoxification is only the first stage and by itself does little to change long-term drug use Treatment does not have to be voluntary to be effective Possible drug use during treatment must be assessed through regular on-going monitoring Treatment programs should provide for assessment of HIV, AIDS, Hepatitis B & C, TB and other infectious diseases and provide counseling to help individuals modify or change behaviors that place them or others at risk Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment

27 Addictions Treatment is Multi-Faceted Key to Success: Focus on Individual Needs

28 Resources St. John s Adult Central Intake - Tel: ; Fax: Addiction Services (Outpatient), Community Connections, Community Mental Health Counselling (Mt. Pearl, CBC, Ferryland, Shea Heights, Witless Bay, Bell Island, Portugal Cove- St. Phillips, Torbay, Trepassey) LeMarchant House, Strengths Team (case management), Terrace Clinic, Outpatient Psychiatry Adolescent Central Intake - Tel: ; Fax: Concurrent Disorder Services - Tel: ; Fax: Recovery Center - Tel: ; Fax:

29 Resources St. John s, cont d Opioid Treatment Center - Tel: ; Fax: Outreach and Promotion (youth and adult) - Tel: ; Fax: Rowan Center (Youth Addictions Services) - Tel: ; Fax: Carters Hill Youth Services - Tel: ; Fax: Paradise Wellness - Tel: ; Fax: Methadone Prescriber - Tel: ; Fax:

30 Resources Avalon and Burin Peninsula Mental Health and Addictions Community Counsellors Bay Roberts - Tel: ; Fax: Bonavista - Tel: ; Fax: Marystown - Tel: ; Fax: Clarenville - Tel: ; Fax: Harbour Grace - Tel: ; Fax: Holyrood - Tel: ; Fax: Placentia - Tel: ; Fax: Whitbourne - Tel: ; Fax:

31 Resources Central Mental Health and Addictions Offices Gander - Tel: ; Fax: Badgers Quay - Tel: ; Fax: Grand Falls-Windsor - Tel: ; Fax: Methadone Prescriber - Tel: Methadone Prescriber - Tel: ; Fax:

32 Resources Western Mental Health and Addictions Counsellors Corner Brook - Tel: ; Fax: Burgeo - Tel: ; Fax: Norris Point - Tel: ( x 266); Fax: Springdale - Tel: ; Fax: Port Saunders - Tel: ; Fax: Stephenville - Tel: ; Fax: Deer Lake - Tel: ; Fax: Port Aux Basques - Tel: ; Fax:

33 Resources Western Methadone Prescriber - Tel: ; Fax: Humberwood Treatment Center (referral only) - Tel: ; Fax: Blomidon Place (youth services) - Tel: Labrador Grenfell Health St. Anthony - Tel: ; Fax: Happy Valley-Goose Bay - Tel: ; Fax: Labrador City - Tel: /7413; Fax: Port Hope Simpson - Tel: (x 230) or

34 References Standards for the Safe and Effective Provision for the Treatment of Opioid Dependence. Newfoundland and Labrador Pharmacy Board 2015 Methadone Maintenance Treatment. Standards and Guidelines. College of Physician s and Surgeons of Newfoundland and Labrador 2013 Addiction Treatment Standards. Clinical Guidelines and Standards of Practice in Newfoundland and Labrador. Department of Health and Community Services 2013 Trebault J, Fiellin. Current and Potential Pharmacological Treatment Options for Maintenance Therapy in Opioid-Dependent Individuals. Drugs 2012; 72(2): Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence. WHO 2009 Mattick RP, Kimber J, Breen C, Davioli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews 2008 Faggiano F, Vigna-Taglianti F, Versino E, Lemma P. Methadone maintenance at different dosages for opioid dependence. Cochrane Database of Systematic Reviews 2008 ACOG Committee Opinion No. 524: Opioid abuse, dependence and addiction in pregnancy. Obstet Gynecol 2012 May; 119(5): Jones H, Finnegan L, Kaltenback K. Methadone and Buprenorphine for the Management of Opioid Dependence in Pregnancy. Drugs April 2012, Vol 72, Issue 6 pp Farrell M, WodakA, Gowing L. Maintenance drugs to treat opioid dependence. BMJ 2012;344:e2823 doi: 10;1136/bmj.e2823 (published May 2012) Orser S, Elkader A. An Update on the Treatment of Opioid Dependence. Pharmacy Practice June 2011 Safe Methadone Practices ISMP Canada

35 Questions? Contact NLPB: Contact Program Developer:

Optimizing Opioid Dependence Treatment A Guideline for Pharmacists

Optimizing Opioid Dependence Treatment A Guideline for Pharmacists Module 3: Optimal Use of Methadone F e b r u a r y 2 0 1 5 Learning Objectives To know and understand the pathophysiology of substance