MLSCI 466 - Lec 8 Opioid Use Disorder and Opioid Agonist Treatment

are drug poisoning deaths concerning

yes--it is a major public health concern

relationship between ED visits for opioid OD and mortality rates

mortality hazard was 3.5x greater for admissions related to OD and those who left against medical advice was higher

potential explanations for death following ED visits for opioid OD

• difficult getting pt to complete treatment
• pts use during an admission or leave to use

standard of care for adults with OUD

• OAT
• psychosocial supports
• safer use education
• safer use supplies
• take home naloxone kits

examples of OAT

buprenorphine, methadone, slow-release oral morphine

buprenorphine

• partial agonist for mu-opioid receptor
• less risk for respiratory depression, euphoria like full agonists
• usually use in combo with other meds

why is naloxone combined with buprenorphine in suboxone

naloxone prevents ppl from injecting (meant to be sublingual) because then buprenorphine has no effects intravenously

why do pts on buprenorphine still experience withdrawal

it will kick off existing fentanyl on opioid receptors therefore patients will feel withdrawal if pt currently uses opioids while on medication (classic induction)

induction methods for suboxone

classic, off-label (micro + macro)

classic induction

moderate withdrawal, given 2 mg every hour up to 16 mg on the first day

micro induction

start with 0.5 mg multiple times per day and increase slowly over days --> applicable to many cases and taking this smaller dose therefore less effect than other options

macro induction

8-16 mg once then repeat in one hour, used in the context of corrections because users are in severe withdrawal

buprenorphine extended-release injection

every 28d, injected subcutaneously for pt stabilized on 8-24 mg of sublingual formulation of buprenorphine/naloxone for a min 7 days

methadone

• full agonist opioid
• has some antagonist activity at NMDA receptor
• takes a while to reach steady state

cautions with taking methadone

• multiple drug interactions
• QTc prolongation
• increased risk of death during initiation and titration (first 2-4 weeks)
• narrow therapeutic index
• long elimination half-life

relationship between OAT and mortality

OAT was associated with lower rates of mortality BUT access to OAT remains limited

slow-release oral morphine (Kadian)

• full agonist opioid
• extensive but variable first-pass metabolism
• off-label use
• ingestion witnessed in pharmacy for pt with OUD

is SROM better than methadone

no theyre generally equivalent

injectable opioid agonist treatment

• for treating severe OUD when other OATs hasn't worked
• pts need to be assessed and accepted by a Narcotic Transition Services clinic
• pts required to visit 2-3x a day
• has great success

example of recovery oriented system of care supports

counselling, peer supports, bed-based addiction treatment

examples of safety planning supports

• take home naloxone kit
• safer use education
• new substance use equipment
• supervised consumption services

urine drug testing

part of treatment plan to better understand what drugs pt are user (not punitive!!!)

is pharmacotherapy enough to address OUD

no-- we need to combine it with other interventions such as supervised consumption services

what can we do as healthcare professionals to address OUD

• reducing stigma (self, social, and structural) for users
• improve engagement in care
• providing trauma informed care
• examine and remove structural barriers to care

what can we do as lab techs to address OUD

implement drug checking