opioid dependence anne kalvik pearl isaac. learning objectives 1.to develop an understanding of...
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Opioid Dependence
Anne KalvikPearl Isaac
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Learning Objectives1. 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
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Opioid Dependence and
Pharmacy Practice
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Medical Uses for Opioids
• PAIN• Cough• Diarrhea
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Undesirable Effects of Opioids
• Nausea and vomiting• Sedation• Some people don’t like effects, e.g.,
itching• Physical and psychological
dependence• Respiratory depression• DEATH
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Why are Opioids Abused?
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Some Examples of Opioids
• Codeine• Oxycodone• Hydromorphone• Morphine• Meperidine• Hydrocodone• Heroin• Methadone
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Street Value of Selected Rx Narcotic Drugs inVancouver’s Downtown Eastside
Sajan et al, CMAJ July 28, 1998; 159 (2)
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Addiction
• Compulsive drug use
• Consequences: use despite harm
• Inability to Cut down• Cravings
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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
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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
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Tolerance
• Neurobehavioural adaptation• Rapid tolerance to psychoactive
effects• Tolerance to analgesic effects
develops slowly• Tolerance disappears within days
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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
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Effects of Heroin
• Physical effects on user– direct– indirect
• Physical effects on others• Psychosocial effects on user• Psychosocial effects on others
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Bob
• 37-year old man buying 10 Oxycontin® per day off the street
• Currently lives alone, unemployed
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Opioid Withdrawal (objective)
• Nausea and vomiting• Diarrhea• Runny nose, sneezing• Lacrimation• Dilated pupils• Gooseflesh• Tremor• Feelings of hot and cold• Yawning• Tachycardia• Blood pressure elevation
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Opioid Withdrawal (subjective)
• Anxiety• Restlessness• Abdominal pain and cramps• Muscle aches• Bone pain• Anorexia• Craving• Insomnia
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Opioid Intoxication/Overdose• Euphoria• Dysphoria• Motor retardation• Sedation• Slurred speech• Pinpoint pupils• Respiratory depression• Circulatory collapse• Cardiac arrest• DEATH
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Medical Detoxification
• Clonidine• Loperamide• Dimenhydrinate• NSAIDs• (Benzodiazepines)• (Naltrexone)• UROD
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Why not detoxify?
• Opioid withdrawal not life-threateningBUT
• 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
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Why Methadone?
• Most effective pharmacological treatment for heroin dependence
• Well accepted• Effective HIV/AIDS and Hepatitis
prevention• Reduces or eliminates heroin use
(cont’d)
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Why Methadone?
• Reduces criminal behaviour• Improved employment rates• Improved psychological status• Decreased mortality• Cost effective• Availability
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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
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A Day on Methadone vs. Heroin
0 6 12 18 24Time (hrs)
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Comparative Profiles of Heroin and Methadone
Heroin Methadone
Route of Administration
InjectedSmoked, snorted
Consumed orally
Onset of Action Immediate 30 minutes
Duration of Action
Short-Acting(3-6 hours)
Long-Lasting(24-36 hours)
Euphoria Common Rare
Withdrawal Symptoms
3-4 hours after last use
24 hours after last use
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Is Methadone ‘Safe’?
• Well tolerated• Not associated with organ damage• Some side effects (e.g.,
constipation and sweating)• Correct dose is essential
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Methadone Treatment
• Medicationbut also:
• Counselling– coping skills– nutrition– housing, job, child care, etc.
• Medical care• Come to pharmacy often on daily basis
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Methadone and Pregnancy
• Fluctuating levels not good for mother or baby
• Lifestyle• Medical, psychosocial, nutritional
care• Methadone does pass to baby,
but…
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Other Treatments for Opioid Dependence
• Naltrexone• (LAAM)• Buprenorphine• Heroin
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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
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Stages of Change
Pre-Contemplation
Contemplation
PreparationAction
Maintenance
Lapse/Relapse