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Opiate substance misuse
- 3. The Road to Recovery
- 7. What is opioid dependence?
- 16. Methadone - Single Dose
- 17. Methadone - Titrating Dose (3 days)
- 18. Methadone - Steady State
- 19. Methadone - Missed Dose
- 27. What is the role of the community pharmacist?
Notes de l'éditeur
- Welcome This is one of three workshops provided by the SSPiSM Group
- Eg. Goal may to be to have access to children,to re-build relationships, to secure a tenancy, to gain weight, to attend college, to be abstinent from drugs. Multidisciplinary with social intervention.
- Heroin like most psychoactive substances (cocaine, alcohol) exerts its effects by increasing dopamine levels in the pleasure centre of the mid-brain. This generates pleasurable, rewarding and euphoric feelings. The extent of euphoria experienced depends on the rate of dopamine release – which is affected by the route of administration – so injecting produces greater effects than other routes. With repeated heroin use - the brain chemistry is altered - so that if you stop using heroin you get withdrawal symptoms and you keep needing to use more and more to get the same effects i.e. you become tolerant and dependence develops. There are 2 types of dependence Physical – occurs after prolonged, chronic exposure to substances. Stopping heroin - quickly induces withdrawal symptoms like severe flu – shaking, sweating, bone pain, stomach cramps, vomiting, anxiety. Therefore user develops constant need for heroin– in increasing amounts as tolerance develops. Psychological – occurs when ‘learnt rewards’ from repeated use become relied upon as a coping mechanism or for the user to feel psychologically normal. As dependence becomes more severe, the frequency of drug use and quantities used can escalate out of control. The individual’s need to obtain and use heroin often becomes more important than normal activities and functions. As drug-seeking activity becomes a priority, this leads to many of the stereotypical behaviours associated with heroin dependence, such as stealing. Drug users will balance the apparent benefits of use against actual or potential harm. Therefore a significant life event or near-death experience can motivate change in drug-taking behaviour. The ‘cycle of change’ theory (smoking cessation) suggests that dependence is a chronic relapsing condition – with periods of abstinence and controlled use.
- Substance dependence can lead to physical, mental and social harms for the individual with knock-on effects for their families, the wider community and society. Physical harms associated with heroin dependence : Risk of overdose and DRDs Becoming infected with BBVs, through injecting/sharing needles Mental harms include depression Social exclusion of drug misusers can reduce the likelihood of them engaging with health and social care services, education and employment Crime - Home Office figures show that each year in the UK around £15.4bn in criminal justice and healthcare costs can be attributed to class A drug use. It is estimated that a third to a half of acquisitive crime is drug related. Many heroin users have done a spell or 2 in prison. Living like this doesn’t bode well for social or family relationships – where drug misusers may be borrowing or stealing money from those close to them. As we know the welfare of children living in families with parental substance misuse is a priority.
- The reasons why people end up addicted to heroin - can be complex and multiple It has been found that this patient group tend to have at least one of these problems
- The drug misuse and dependence UK guidelines on clinical management. Last updated in 2007. It is intended for all clinicians, especially those providing pharmacological interventions for drug misusers. They are based on current evidence and consensus on how to provide drug treatment for the majority of patients. Forms the basis of the majority of local guidelines.
- Effective management of substance dependence involves a range of pharmacological and psychosocial interventions – and pharmacists are involved in the delivery of a number of these. Treatment is underpinned by a focus on harm reduction which is a term which covers a wide range of interventions to reduce harm of drug use – interventions used depend on patients’ needs and their goals – which may or may not be abstinence – Goals are agreed and reviewed with the patient regularly. Goals can seem to be small to others but significant to the drug user. Achieving the goals will help the drug user achieve progress to their aim and improve their confidence and ensure engagement with services. There are different pathways / journeys to recovery – and this ethos reflected is Scottish Government Drug Misuse Policy - Road to Recovery 2008 Development of the Scottish Drugs Recovery Consortium Within the package of care there is usually a prescription of substitute medication – which offers a legal supply of a medicine that replaces the illicit drug on which they are dependent Opioid substitution medication is considered a harm reduction intervention Methadone and buprenorphine are the main drugs used to treat opioid dependence, as maintenance replacement therapy, or part of a structured detoxification regimen Maintenance treatment provides stability for patients to look at other areas of their lives and engage in non-pharmacological interventions such as psychotherapies Allows drug misusers to reintegrate and engage with other agencies – such as social work etc – and prescribing services work in partnership with these other agencies
- There is strong evidence that opioid substitute medication Reduces illicit drug use risk of overdose injecting activity BBV transmission crime Brings about improvements in mental and physical health Cost effective intervention – just in terms of healthcare costs alone. Problem drug users who were not in treatment cost more in health care than those in treatment. In fact the cost per PDU is more than doubled when comparing those not in treatment with those in treatment for more than a year. http://www.scotland.gov.uk/Resource/Doc/287490/0087669.pdf And allows the patient to engage in structured, long term treatment including counselling and management of other issues
- Both methadone and buprenorphine are approved for use as opioid substitute therapy NICE recommends that if both drugs are equally suitable, methadone should be prescribed as the first choice. Explain later when to use – buprenorphine Methadone is – bullet points Euphoric effects of methadone are not nearly as pronounced as those of heroin Used since the 1960s in treating opiate addiction as delivered by Nyswander and Dole, who used a dose of 80ml as a “narcotic blockade” for patients using opiate drugs. Now nearly 50 years of an evidence base and treatment.
- Start low and go slow – cannot predict what dose a patient will need/be tolerant to (street drugs vary considerably in quality) - allow time to reach steady state Dose is titrated according to individual’s needs. Usual daily dose is 60 – 120mg Vary dependent on the quantity of heroin used and tolerance Doses out with this range may be required dependent on patient’s tolerance Can take a period of time to reach a good clinically effective dose for the patient.
- This is plasma concentration against time. This is for one dose only where the starting point is 0. It takes about 4 hours to reach a peak and the average half life is 15 hours.
- What happens over the first 3 days of methadone consumption is that the reservoirs in the lungs/kidneys/liver/fat stores all gradually fill up. The second dose doesn’t start from 0 so the peak is higher each day until steady state is reached. This is why you have to be cautious about increasing the dose too quickly in the early stages. The half life is now around 25 hours.
- Once all the reservoirs are filled you can see that the blood concentrations don’t vary very much. This is why once daily dosing is adequate.
- This is a good illustration of why, when the patient has reached a steady state, missing one dose is not a huge problem. The methadone from the stores will continue to leach out slowly. Missing one dose isn’t the great panic that people sometimes think. Occasionally patients genuinely forget because they feel fine. We encourage pharmacists to phone and check with the doctor if they have missed two consecutive days. After 3 missed days the doctor will generally reduce the dose.
- Constipation- almost a universal problem and patients do not develop tolerance to it Nausea and vomiting – particularly at the start of treatment All opiates reduce the secretion of saliva and when you couple that with the acidity of methadone then you can see why the dental problems are significant Constricted pupils- again don’t develop tolerance and is a reliable external indicator of the level of opiate in the blood stream Rashes Sweating is mediated by histamine release. Histamine is the main part of an allergic response but it is not the methadone causing an allergic reaction. Basically the methadone enters the mast cells and displaces the histamine causing the reaction. Respiratory Depression – particularly if the dose is too high or patient is not tolerant – this is how opiates tend to cause death in drug overdoses. http://www.medicines.org.uk/EMC/medicine/10721/SPC/Methadone+Hydrochloride+DTF+1mg+1ml+Oral+Solution+(Rosemont+Pharmaceuticals+Ltd)/#UNDESIRABLE_EFFECTS
- Most areas use Suboxone now- Subutex useful for detox because of availability of tablet 400 micrograms Evidence base is growing – but not as good as methadone – as not been in use as long (1990s)
- Advantages- Has ceiling effect with regards to respiratory depression Due to high affinity for receptor sites there is less on top use but can be fatal with other drugs. Reportedly drug users find it easier to reduce and detox using buprenorphine Clearer head is very useful for clients who want to get on with their life, return to work or education DISADVANTAGES Solubility is clearly a problem as it makes it easily injectable and only needs water added. Buprenorphine was previously available as temgesic – a sublingual opiate pain killer, which was widely abused and GPs took a voluntary prescribing ban of due to the problems arising. NB Suboxone – combination of buprenorphine and naloxone, if not taken correctly and either injected or snorted, the naloxone component exerts its effect and higher receptor affinity displacing all the opiates on the receptors and causing precipitated withdrawal. – not fatal but severely unpleasant Initiation of buprenorphine is carefully planned as patient must be in a state of withdrawal before commencing treatment Clearer head can also be a disadvantage as if the patient has underlying problems such as abuse then they may want to block out past experiences and they may find it difficult to cope with a clear head. Supervision is more difficult as it is not a case of swallowing a liquid. Expense especially in these times of economic restraints.
- The key difference between buprenorphine and methadone is the precipitated withdrawal that can occur in the early stages with Buprenorphine. The key to understanding this is the high affinity and lower intrinsic activity of Buprenorphine on the opiate receptors. Basically if the receptors are filled up with heroin or methadone and a dose of buprenorphine is administered then it knocks off the heroin or methadone from the receptors because it has a higher infinity and binds more strongly. So what’s happening is that the drug with the higher euphoric effect is being replaced by a drug which has a lower effect. This is why the patient should be in a state of withdrawal before buprenorphine is administered. This high affinity and receptor occupation, and tight binding is why the effects of “topping up” with street drugs is much less common as it is difficult to dislodge the Buprenorphine from the receptors which is why the safety profile is much better. Titration of buprenorphine dose can be done very rapidly. Patient transfers from methadone to buprenorphine have to be carefully planned and are generally recommended at methadone doses of less than 30mg, but some health boards are conducting the transfers at doses much higher (excess of 80mg) with no problems arising. The very long half life and strong binding affinity may allow the ability to dose patients every 2-3 days is useful to clients who perhaps would want to return to work or education. http://www.medicines.org.uk/EMC/medicine/19265/SPC/Suboxone+Tablets+2mg+%26+8mg/
- These side effects are all similar to the other opiates.
- Rationale for instalment dispensing and supervised consumption Supervised consumption ensures…. Reduces diversion to users not accessing treatment Improved retention in treatment Pharmacist / pharmacy staff are a key therapeutic relationship for the patient Policy on supervision varies between NHS boards, but the Orange Guide recommendation is for 3 months of daily supervision when starting treatment. After this dispensing arrangements may be relaxed should all other considerations be met e.g. on a stable dose, not using on top, perhaps started work/education. If patients are not on supervision then its worth remembering that also their monitoring is reduced and problems can then go un-noticed for longer. For some boards the policy of increased supervision exists if a patient is prescribed or continues to use other substances, such as diazepam (or other benzodiazepines) this is to minimise potentially serious interactions.
- Preparation in advance where possible is always recommended (with the exception of pharmacies using the automated measuring devices) Always check names, address and date of birth of the patient and if you are not satisfied do not give the medication There should be written down pharmacy specific Standard Operating Procedures. These should be followed at all times. Some health boards may occasionally request that suboxone (or subutex) be crushed for some patients, this is generally to prevent potential diversion of the buprenorphine.
- Stigma can be a real concern for patients on opiate substitution, these are common and frequent examples It is important the patients are treated in the same manner as all other patients UKDPC – undertook programme of research to investigate the extent and nature of stigma towards people with a history of drug problems and their families in the UK. The reports also looked at stigma within the media and amongst the general population. There were reports of stigmatisation by a wide range of healthcare professionals including pharmacists. Supported by the Scottish Drug Recovery Consortium.
- In a recent survey of patients receiving substitution therapy from community pharmacies in Glasgow, patients were asked “What changes or ideas would you suggest to improve the service?” Staff attitudes and services are important This patient is particular is accessing a full range of pharmacy services. The UKDPC also commented in it’s study that there were examples of positive practice.
- Lead by example in your pharmacy by supporting the patients & addressing the needs, as with any other patient group. It is not a methadone “contract” but an agreement between the patient, prescriber, addiction worker and pharmacist to everyone’s rights and responsibilities. Gives CONSENT to share information and concerns between professionals. Pharmacy staff can monitor patient. Any concerns e.g. change in mood, behaviour, appearance can be noted. Are there any concerns for children? Has the patient missed doses? Is the patient doing really well? These can all be fed back to the prescriber or team working with the patient.
- MAS – important for patient and family to be able to access advice and medicines for common complaints. Helps to address inequalities in health. Patients prescribed substitute medication should be able to access all services.
- Benzodiazepines, methadone, heroin and alcohol are all examples of depressant drugs. This is especially dangerous when drugs are taken in combination or are taken when tolerance is low Poly drug taking is fairly common with patients who misuse drugs. Respiratory depression occurs and breathing can stop and heart rate is reduced. Loss of tolerance occurs when doses of methadone are missed. If a patient misses more than three consecutive doses then the dose may have to be reduced when restarted. This is why it is important to inform the prescriber about missed doses. Other high risk times are: Relapse Leaving prison Holiday periods e.g. Xmas – no access to services, take home medication. Difficult life events e.g. bereavement Opiate naïve patients are at a exceptional risk especially children, therefore safe storage is very important and should be discussed and reminded to patients regularly A new national scheme is being rolled out to train patients how to administer Naloxone (reverses the actions of opiates for a short period of time) and administer basic life support to help save lives. Sugar Free methadone also has no benefits to the teeth as it is the methadone molecule that is acidic and which can cause damage. This is why we recommend that patients drink water (which also lets us know that they have swallowed it) and chewing of gum after the dose.
- Familiarise yourself with your local addiction teams, NEXs, substance misuse pharmacist. SOPs – ensure support staff aware. Locums – check them, they can differ between shops Individual Bottles? – can a patient safely measure 68mls for a daily dose from a three day supply in one container? CD wording – do your prescriptions comply with regulations? Is home office approved wording used to allow supply when pharmacy is closed or if a patient misses a dose? Communicate with the prescriber or addiction team as required.
- The start date may not be the date that the prescription has been signed by the prescriber. If it is started early then patient may have had a dose elsewhere that day. The written start date if on the prescription is the date the supply starts, and the date the 28 day validity period starts from. The PC70 as well as the controlled drug register entry should be completed in order to demonstrate that the patient has received the dose. Separating completed prescriptions should ensure that the patient should not receive any extra doses. You can ask the patient to state a combination of name, address, DOB, daily dose to ensure you have the correct patient in front of you. It is important to have a procedure to alert the prescriber to missed doses but also to highlight to other staff members and locums in the pharmacy especially if you have a day off!!
- Prescriptions are not read correctly. If there is any doubt, check it out with the prescriber / addiction team Use communication books and notes to ensure information is shared within the pharmacy
- There were 485 drug related deaths in Scotland in 2010. A slight decrease on 2009. There is a medication that can reverse opiate overdoses, Naloxone. Naloxoe temporarily reverses the effects of an opiate overdose. In 2005, naloxone was added to Section 7 of the Medicines Act, which allowed naloxone to be administered by anyone for the purposes of saving a life. Therefore, although supply must be to a named patient by a prescription or PGD, in the event of a suspected opiate overdose anyone can administer that named patient’s supply of naloxone to anyone in order to save a life. This change to the Medicines Act allowed a training and supply programme to be developed. Following successful programmes in Glasgow, Lanarkshire and the Highlands in August 2010, the Scottish Government announced the rollout of a National Naloxone Programme.
- Example of national material ‘what to do if someone has overdosed.’ There is a naloxone lead within each health board area and the lead can advise on where and how patients/clients can access training and supplies.
- Identify your local naloxone lead. if you do not have information, contact your local drug services to gather the information Display the National Naloxone Programme materials distributed by the Scottish Government. Provide information about overdose prevention. signpost to a local training session. Observations and clinical impressions are important. Monitor service users, especially those who are titrating, detoxing or recently released from hospital or prison. Patients who may present under the influence of drugs and/or alcohol because of polydrug use are at a greater risk of drug overdose. Establishing a good therapeutic relationship with your patients can allow you to discuss overdose awareness at an appropriate time. Important to remember that the pharmacist may be the only contact with a healthcare professional that the client has. Especially for those pharmacists providing IEP services.
- SNIPS – special needs in pregnancy services Co-Morbidity – mental health problems and substance misuse
- It is important the hospital confirms the dose of medication the patient is on and also when the last dose was taken, as a precaution community pharmacies should be contacted to inform when the last dose was given and the prescribed dose, as they see the patient more frequently, also if the patient is receiving a take-away prescription you will need to make sure they haven't sent anyone else into collect it and then possibly risk double dosing or the patient being able to stock up a supply on top of what they receive while admitted procedures will ensure that the prescription is cancelled on admission and a new prescription started on discharge. Again communication between services is important for the safety and treatment of the patient Individual Health Boards may have withdrawal guidelines, particularly for the treatment of drug users not on a substitute prescription Individual Health Boards may have guidelines for pain management for patients on Methadone or Buprenorphine, although opiate medication they are not necessarily good analgesics and additional analgesia is often required. Addiction liaison nurses may be available Patients not currently in a treatment programme may be signposted to local drug treatment services.
- The period immediately following discharge from hospital may be a particularly ‘high risk’ time for this patient group. Research evidence shows that the first 90 days post-hospital discharge is a particularly high drug related death risk period for opiate dependent patients, and there is an increased risk of drug-related deaths during the first 2 weeks after release from prison, and that the risk remains elevated to at least the fourth week.
- Different roles – depends on the Health Board Some examples of roles – Health Board roles vary – some cover alcohol, drugs and harm reduction or varying combinations of these All contributing to develop the role of pharmacies, pharmacy staff and develop services to continue to improve the pharmaceutical care of patients with substance misuse problems Some are prescribers and have clinical caseloads