Pharmacological treatment of opioid dependence: The basic principles, evidence and practice

What does OST allow?

• stability to allow change to happen

• stops people dying from overdose or getting BBVs

• Stop using illicit drugs

• Support reverse in tolerance

• improves physical and mental health,

• social functioning,

• reduces crime

• helps heal families.

What can people have along side OST?

Psychosocial support helps some people to make changes/stop using drugs

Which patients may benefit from Psychosocial support?

underlying mental ill health benefit

What are the OST principles?

Replace illicit short-acting drugs with longer legal drug

Describe methadone?

Opiate agonist with main activity at mu receptor; antagonist of NDMA

Describe buprenorphine?

Opiate receptor partial agonist mainly at mu receptor at adequate dose; kappa receptor antagonist

OST aims for society

• Reduce drug related crime so improve community safety and reduce fear of crime

• Save money spent within criminal justice system on drug related crime

• Save money on health costs

What is the primary outcome for many studies on OST?

Retention in treatment

more likely to achieve the other related benefits

What does the evidence say about OST?

Opiate substitution treatment has a >85% chance of reducing overall mortality if treatment 12 months
Higher doses keep people
Reduction in illicit drug use and dangerous injecting practices
Criminal activity decreases
Improves employment, housing and families

What is the return?

Every 1 get 4 back

Who is at risk of drug related deaths?

Men
titration phase and post detox
First 2 weeks of OST
Polysubstance
First 2 weeks out of prison/hospital

What is no successful most after detox?

Sustained abstience

Why can buprenorphine not be the right choice?

Does not help to reduce the anxiety and intensity of emotion and trauma

How should dose titrations be done?

done as quickly as is safe to do so.

What is the normal maintenance dose for methadone?

60 to 120 mg per day usually, may need higher

What is the normal maintenance dose for Buprenorphine?

12 to 16mg per day usually, may need up to 32mg

What do high methadone doses require?

>100mg require ECG due to QTc prolongation risk.

What other support may those starting OST need?

Supervised consumption
housing support.

Psychosocial support

psychological interventions

What can reduce barriers to start OST?

• Optimal daily dose (60-120mg usual maybe more)

• Flexibility of take-home doses

• High quality medical and psychosocial services

What other things can help increase treatment retention?

• Orientation towards social rehabilitation

• Sufficient duration of treatment

• Detoxification only of willing, well stabilised patients with established abstinence

• Goal of maintenance as first goal not detox

Why do doses matter?

on <60mg methadone twice as likely to leave treatment as those on 60-80mg and 4x as likely to leave as those on >80mg

What does maintenance dose achieve?

steady state plasma level with no intoxication or withdrawal between doses

How long may it take to stabiles on methadone and buprenorphine?

8 weeks to stabilise on methadone.

Bup is quicker (2-3 days).
Be more cautious in compromised liver function, COPD, CVD, poly CNS depressant drug use

What to check and monitor before initiation?

accurate history taking inc poly drug use, mental health
self reported drug and alcohol use
Urine drug screen (UDS) on the day
BP and pulse
LFTs → only barrier if known problems
Injecting site infections

What to offer before initiation?

• BBV screens

• HBV vaccinations

• course take home naloxone (see later)

What to monitor during OST prescribing?

LFTs Bup/HCV
ECG → methadone
Self reported drug and alcohol use
UDS
Wellbeing
General Health
Social functioning

What are the main drug interactions?

Inducers/inhibitors
QTc prolongation

What are the benefits of supervised consumption?

No to little info

To to little change

Important pharmacy practice rules about OST titration?

Loss of tolerance and the ‘three day’ and ‘five day’ rule.

When in the titration phase do missed doses need to be reported?

report any missed days

When in the maintenance phase do missed doses need to be reported?

three days withhold and discuss; five days re-titrate.

When in the detox phase do missed doses need to be reported?

potential sign of concern.

What are the risks of detox?

Loss of tolerance
Higher death rate in detox
Mortality in maintenance is low

How to ensure detox good practice?

Patient needs to be asses
Planned organised
High risk of relapse and overdoses
Instant treatment is relapse
Support Care plan
Use drug stabilised or can switch to Bup
Written and verbal info on risks and where to get help
Symptomatic relief

What can be used for symptomatic release in detox patients?

lofexidine, mebeverine, ibuprofen, prochlorperazine, diazepam or z-drugs (short term)

How can pharmacists support during titration and maintenance?

• Daily dispensing and supervised consumption

• Monitoring of well being

• Respond to side effects and identify interactions

• General health advice

• Written and verbal information on safe storage, overdose risks, drug interaction and aims of treatment

• report any missed doses

How can pharmacist help monitoring treatment?

• Respond to missed doses & intoxicated patients

• Feedback to prescriber e.g. observations after change in dose/take homes

• Input to treatment decisions

• Contribute to shared care team

• Remember the ‘three day rule’

• Take away doses of methadone in separate daily dose bottles

How can pharmacist help in Harm reduction?

• NSP (or sales) and safer injecting advice

• Hep B vaccination, HCV testing (NSP pilot)

• Supply take home naloxone

• Respond to related and other health issues

• non judgmental non stigmatising environment

Best practice in supervised consumption?

Not in plastic bottles

Privacy
Respect
Sensitive
Body fluid spills
Broken bottles
Clean and confidential bottles
Offer water after meth before bup
Brush teeth after methadone
No food or drink 5 mins after bup

When is it ok to share info?

Okay to share information on a ‘need to know’ basis
Health concerns missed dose, children