Optimizing Opioid Dependence Treatment A Guideline for Pharmacists Module 1: Substance Use Concepts F e b r u a r y 2 0 1 5
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
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.
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
Substance Use Concepts Module One
Module 1 - Substance Use Concepts 1. Diagnosis 2. Pathophysiology 3. Harm reduction 4. Principles of addictions treatment 5. Referral resources
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
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
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
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
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 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 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
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
Contributors to Substance Use Availability Positive and negative reinforcing properties Onset of effect How it is used Orally Mucous membranes Inhaled Injected
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
Categories of Substance Use ABST NON- PROB USE AT- RISK USE ABUSE DEP Use Consequences Repetition - - - Loss of control, preoccupation, compulsivity, phys. dep. + - - + -/+ - + + + + ++ + + 3
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
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 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
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 2005 2005 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 practices and connect to treatment options Decrease in transmission of HIV, Hepatitis B & C Safer communities Should not be viewed as condoning drug use
SWAP SWAP offices in St. John s and Corner Brook Tree Walsh, Harm Reduction Outreach Worker Tel: 579-8656 or 757 7927, 1-800-563-1575 Business cards available to provide access to patients Volunteers do not necessarily have the time; they just have the heart. - Elizabeth Andrew
Harm Reduction Strategies Managed use Time limited Partial abstinence Controlled use Methadone Maintenance Programs
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
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
Addictions Treatment is Multi-Faceted Key to Success: Focus on Individual Needs
Resources St. John s Adult Central Intake - Tel: 752-8888; Fax: 752-6852 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: 777-2200; Fax: 777-2211 Concurrent Disorder Services - Tel: 777-3330; Fax: 777-3912 Recovery Center - Tel: 752-4980; Fax: 752-4985
Resources St. John s, cont d Opioid Treatment Center - Tel: 752-4478; Fax: 752-4012 Outreach and Promotion (youth and adult) - Tel: 777-5074; Fax: 777-5170 Rowan Center (Youth Addictions Services) - Tel: 752-4452; Fax: 752-4119 Carters Hill Youth Services - Tel: 729-4412; Fax: 729-4628 Paradise Wellness - Tel: 752-4123; Fax: 782-4120 Methadone Prescriber - Tel: 726-0701; Fax: 726-0734
Resources Avalon and Burin Peninsula Mental Health and Addictions Community Counsellors Bay Roberts - Tel: 786-5224; Fax: 786-5221 Bonavista - Tel: 468-5318; Fax: 468-7690 Marystown - Tel: 279-7952; Fax: 279-7933 Clarenville - Tel: 466-5723; Fax: 466-5718 Harbour Grace - Tel: 945-6512; Fax: 945-6514 Holyrood - Tel: 229-1551; Fax: 229-1591 Placentia - Tel: 227-1624; Fax: 227-3749 Whitbourne - Tel: 759-3862; Fax: 759-3360
Resources Central Mental Health and Addictions Offices Gander - Tel: 256-2813; Fax: 256-5667 Badgers Quay - Tel: 536-1135; Fax: 536-2433 Grand Falls-Windsor - Tel: 489-8180; Fax: 489-8182 Methadone Prescriber - Tel: 256-5423 Methadone Prescriber - Tel: 257-2999; Fax: 257-4687
Resources Western Mental Health and Addictions Counsellors Corner Brook - Tel: 634-4506; Fax: 634-0160 Burgeo - Tel: 886-2185; Fax: 886-2301 Norris Point - Tel: 458-2381( x 266); Fax: 458-2943 Springdale - Tel: 673-4973; Fax: 673-4970 Port Saunders - Tel: 861-9125; Fax: 861-3762 Stephenville - Tel: 643-8720; Fax: 643-9054 Deer Lake - Tel: 635-4286; Fax: 635-5211 Port Aux Basques - Tel: 695-4650; Fax: 695-7990
Resources Western Methadone Prescriber - Tel: 634-4506; Fax: 634-0160 Humberwood Treatment Center (referral only) - Tel: 634-4506; Fax: 634-0160 Blomidon Place (youth services) - Tel: 643-4171 Labrador Grenfell Health St. Anthony - Tel: 454-0262; Fax: 454-2131 Happy Valley-Goose Bay - Tel: 896-2343; Fax: 896-4900 Labrador City - Tel: 938-7056/7413; Fax: 938-7235 Port Hope Simpson - Tel: 960-0271 (x 230) or 960-0461
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): 217-228 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): 1070-6 Jones H, Finnegan L, Kaltenback K. Methadone and Buprenorphine for the Management of Opioid Dependence in Pregnancy. Drugs April 2012, Vol 72, Issue 6 pp747-757 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 www.ismp-canada.org
Questions? Contact NLPB: inforx@nlpb.ca 709-753-5877 Contact Program Developer: