Mary Ann Ferguson,Pharmacist St Josephs Health Care Concurrent Disorders Inpatient Unit

Transcription

1 Mary Ann Ferguson,Pharmacist St Josephs Health Care Concurrent Disorders Inpatient Unit

2 Medication should be considered as part of the treatment plan for addictions/substance use disorders: A- Never B-Rarely C-Sometimes D-Always

3 Identify and address barriers to pharmacotherapy use in addiction Provide general overview of most commonly utilized pharmacotherapies for opioid and alcohol use disorders

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6 Because of the difficulties that many alcoholics have with drugs, some members have taken the position that no one in A.A. should take any medication. While this position has undoubtedly prevented relapses for some, it has meant disaster for others. No A.A. member should play doctor ; all medical advice and treatment should come from a qualified physician

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14 The 4 Cs: o o o Loss of Control of use of the substance Compulsive use or Craving Continued use despite adverse Consequences CSAM Definition: o A primary, chronic disease characterized by impaired control over the use of a psychoactive substance or behaviour. o Clinically the manifestations occur along biological, psychological, social & spiritual dimensions. o Like other chronic diseases, it can be progressive, relapsing & fatal. o Common features are change in mood, relief from negative emotions, provision of pleasure, preoccupation with the use of substances or ritualistic behaviour; & continued use of substances &/or engagement in behaviour despite adverse physical, psychological &/or social consequences.

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16 DSM-IV used the diagnoses substance abuse and substance dependence. This is NOT the same thing as physical dependence Long term use of many drugs can result in tolerance and/or dependence o This can happen with drugs that do not have the potential for addiction o For some drugs, tolerance and dependence will develop in all who use it, but not everyone who becomes tolerant or dependent will become addicted Addiction is characterized by craving for the drug and using it even when it causes harm.

17 Defined by what happens when you STOP taking a drug o Withdrawal signs and symptoms! Core symptom of addiction, but can occur in the absence of addiction What tends to fuel addiction, as once tolerance develops, the euphoria from drugs tends to subside, and use fuelled by avoidance of withdrawal symptoms.

18 Tolerance: o The brain adapts to the constant presence of the drug o It takes more drug to get the euphoria/desired effect o Tolerance to some side effects (ie- respiratory depression with opioids) doesn t develop so quickly-- always risk of death from overdose o Tolerance can be lost if a person stops using (ie- they have been in prison or jail). Returning to previous doses can result in fatal overdoses*

19 Risk of addiction affected by the speed with which the drug enters the brain, the degree of fluctuation vs constancy in drug concentration Route of administration: -Injection and smoking are greatest risk of addiction due to rapid increases of drug, followed by rapid decreases

20 Half Life -Time it take for drug to be eliminated from body -Drugs with shorter half lives tend to be more liable to addiction The more often a drug needs to be taken, the more a behaviour is practiced, and the greater tendency to become habitual

21 Reward Pathways: o Not a smart part of the brain or the part of the brain that has to do with you wallet, or the number of times you go to church o Have less control over it than we think we do (area responsible for holding breath, holding bladder) o Fueled primarily by DOPAMINE!

22 The symptoms of which mental health diagnosis can be explained partly by over activity of dopamine?

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24 Which of the following is NOT a treatment for substance use disorders? A- Opioid replacement therapy B- Substance detox C- 12 Step Programs D- Individual Counselling

25 Which of the following are dangerous in withdrawal? A- Benzodiazepines B- Alcohol C- Crystal Meth D- Opioids E- A and B F- All of the above G- None of the above

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27 Withdrawal o o o o Physical symptoms; flu-like, myalgias, abdominal cramps, diarrhea, nausea, chills Psychological symptoms; anxiety, cravings, insomnia, fatigue, depression Objective signs; lacrimation, rhinitis, yawning, sweating, piloerection, restlessness, uncomfortable, mild tachycardia/hypertension Risks; relapse, overdose, suicide, miscarriage/premature labour Physical symptoms peak at 2-3 days after last use and resolve by 5-10 days---psychological symptoms can last for weeks and months. Symptomatic treatment: clonidine, loperaminde (IMODIUM), antiemetic (GRAVOL), acetaminophen/nsaid s, benzodiazepines

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29 1-Opioid Replacement Therapy 2- Safe injection sites 3- Access to Naloxone (NARCAN)

30 1- Methadone Maintenance Therapy (MMT) 2- Buprenorphine Maintenace Therapy (BMT) Unfortunately, detoxification followed by abstinence has shown little success in reducing illicit opioid use

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32 Evidence clearly shows that MMT has a positive impact on: Retention in treatment Illicit opioid use Evidence is less clear but suggestive that MMT has a positive impact on: Mortality Illicit drug use (nonopioid) Drug-related HIV risk behaviors Criminal activity Evidence suggests that MMT has little impact on: Sex-related HIV risk behaviors Fullerton et al., 2014

33 Evidence clearly shows that BMT has a positive impact compared with placebo on: Retention in treatment Illicit opioid use Evidence is mixed for its impact on: Nonopioid illicit drug use

34 Medications are only part of the puzzle! o Pharmacotherapy assists with physiological symptoms psychosocial therapy helps patients maintain pharmacotherapy pharmacotherapy helps patients maintain psychosocial therapy

35 NIH 1997: The safety and efficacy of narcotic agonist maintenance treatment have been unequivocally established 2008 WHO: Substitution therapies such as methadone remain the most promising method of reducing drug dependence.

36 President Barack Obama tackled the opioid epidemic on Wednesday by telling health care providers across the country that access to medication-assisted treatment must be expanded. For decades, those treating opioid addiction ignored the scientific consensus that the best approach involved medications approved by the Food and Drug Administration, coupled with counseling. Instead, the treatment industry insisted on a model known as "abstinence," in which any prescription medication aimed at addressing a patient's opioid use disorder was forbidden. He released an order giving federal agencies with health care responsibilities 90 days to identify barriers to MAT and to come up with ways to remove them.

37 Full mu opioid agonist with long half-life Does not induce euphoria in dependent patients and reduced euphoric effects of exogenous opioids. Goal is to reach a stable dose where withdrawal and cravings are supressed for 24 hours Will not treat acute pain Also an NMDA antagonist may help prevent or reverse opioid tolerance and hyperalgesia so patient can be maintained on stable dose.

38 Only needs to be taken once daily. Slow peak (at hours) o No quick rush, or sudden crash leading to withdrawal. o Long time to get to steady-state dose Patients are at very high risk of overdose during induction phase (can take 2-8 weeks to stabilize patients) Mixed with Tang (to prevent injection) Can only be prescribed by authorized methadone prescriber. Stable dose for most patients between mg Any carries must be safely stored

39 Partial Agonist at mu opioid receptor and antagonist at kappa* opioid receptor High affinity for mu receptor o o Can displace full agonist opioids such as heroin Dissociates slowly from the receptors No formal certificate required to prescribe (unlike methadone) Preferred for: o o o o o o Pts who are at higher risk of methadone toxicity (elderly, BZD pt) Adolescents/young adults Short history of use Patients in communities where methadone treatment is unavailable Patients where pharmacy not open weekends. Patient preferences

40 Impacts: 1- Safety 2- Induction 3- Efficacy?

41 Ceiling effect makes respiratory depression less likely o CAN occur with excessive use of EtOH, benzodiazepines or other CNS depressants.

42 Because is partial agonist, will blunt response of any full agonist opioids present, and induce a sudden withdrawal. For this reason, started after patient has started entered moderate withdrawal (and will then be experienced as relieving, not causing, withdrawal.)

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45 Advantages of buprenorphine over methadone: Less side effects, including QTc prolongation Less risk of overdose Can be prescribed by primary care physicians. Faster titration/stabilization period Longer duration of action can mean more flexible dosing In theory, less withdrawal when tapering (?in practice) Disadvantages of buprenorphine over methadone: COST $$$ (only covered by ODB by LU Code) Have to be in withdrawal to initiate Ceiling effect **It is far easier to transition from buprenorphine to methadone, than from methadone to buprenorphine PROGRAM CHARACTERISTICS MORE IMPORTANT THAN DRUG USED

46 Naloxone is an opioid antagonist Not well absorbed under the tongue, so does not interfere with the actions of the buprenorphine However, if tablets crushed and injected, naloxone will block effects of opioids and cause withdrawal for those with opioids in the system.

47 Free Naloxone Kits for persons using or who have used opioids Call x 7475 to arrange for in-home overdose training and naloxone kits Also available at Street Health Clinic (Wesley Centre and Urban Core) and the AIDS Network.

48 The VAN (905) Elizabeth Fry Society Wesley Health Clinic The AIDS Network Hamilton Urban Core Community Health Centre East End Sdexual Health Clinic Mountain Sexual Health Clinic Dundas Sexual Health Clinic Waterdown Sexual Health Clinic ADGS

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51 Block opioid receptor (antagonist) and reduces euphoric effect from drinking Reduces heavy drinking and helps patients achieve and maintain abstinence Do not need to abstain from alcohol prior to starting Only covered by EAP criteria: in psychosocial treatment Side effects- nausea, elevated liver enzymes Contra-indications o On opioids o Liver dysfunction o Elevated liver enzymes- AST ALT (>3x normal) o Pregnancy

52 Antagonizes glutamate receptors (excitatory neurotransmitter) Does not reduce heavy drinking Helps patients maintain abstinence Only effective if patients have been abstinent for at least several days Covered by EAP Criteria: in psychosocial treatment/program, abstinent for at least 4 days, contraindication or side effect from naltrexone. Side effects: nausea, agitation Contraindications: o Significant kidney disease o Pregnancy

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54 Blocks conversion of acetaldehyde to acetate and causes buildup of acetaldehyde, leading to a very unpleasant reaction if alcohol ingested.? Effective when taken under supervision o No longer first line recommendation! Side effects:- Hepatitis, neuropathy, depression, psychosis Contra indications: elderly, cardiac disease, liver dysfunction, psychosis, cognitive dysfunction, pregnancy MUST be abstinent for at least 2 days prior to initiation Reaction can happen up to 7 days after stopping medication NOT available commmercially. Must be compounded at specialty pharmacies.

55 Topiramate (TOPAMAX) Ondansetron (ZOFRAN) Baclofen Gabapentin

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