PSYC: SUD [Opioid Use Disorder]

Buprenorphine / Naloxone

1) MOA

2) Route of administration (2)

3) What is the naloxone for 

4) Suboxone has fewer + milder side effects when compared to methadone. Why is this?

5) Why can it be administered just once daily

6) Does it have a relatively slow or fast titration regimen compared to methadone / SROM

7) What’s one side effect you have to be worried about + monitor carefully when starting a patient on this + one caveat

8) Induction / starting buprenorphine… When should you use a traditional dose to initiate therapy + what would that dose be

9) Induction / starting buprenorphine… When should you use a micro dose to initiate therapy + what would that dose be

10) In a person doing a slow induction with the help of a full agonist, when should you discontinue the full agonist 

11) After how many days missed WITHOUT opioid use do you need to dose titrate buprenorphine/naloxone

12) After how many days missed WITH opioid use do you need to dose titrate buprenorphine/naloxone

13) DDIs (2) 

14) CI in what population (1) 

1) MOA:

• Buprenorphine = Partial agonist at Mu receptor

• Naloxone = Antagonist of Mu receptor

2) Sublingual or buccal 

3) Reduces abuse potential (if not taken SL, naloxone makes it so that drug can’t bind to opioid receptor and produce a high)

4) VERY High affinity for Mu receptor; competes w/ and displaces other opioids with lower affinities; therefore blocking the effects of them

5) Slow dissociation from receptors —> long duration of effect

6) Faster than methadone / SROM

7) Precipitated withdrawal (can feel worse than natural withdrawal)

8) Patient has already DC’d opioids and is in active moderate-severe withdrawal (16mg starting —> 24-32mg)

9) Patient is still on opioids or is on a full opioid agonist and we want to titrate up gradually (2-4mg starting)

10) Once they’re at 16 mg daily

11) 6 or more days

12) 5 or more days (if 4; weigh risks vs benefit)

13) CYP3A4; CNS depressants 

14) Hepatic impairment 

Is it easier to switch from suboxone → methadone or the other way around and why

Suboxone → Methadone

• Opposite can cause precipitated withdrawal 

Methadone

1) MOA (2)

2) What does the agonism lead to

3) What does the antagonism lead to

4) ___ onset of action and ___/___ half life

5) Treatment initiation: Can you start immediately?

6) Is titration fast or slow?

7) When is risk of overdose highest when on methadone

8) DDI (3)

9) ADR unique (3) 

10) After how many days can you resume dose with no dose adjustment 

11) After how many days of missing dose do you have to reduce dose by 50% or to 30-40mg 

12) After how many missed doses do you have to re-titrate

1) MOA:

• Full Mu agonist

• NMDA receptor antagonism

2) Full CNS depressant

3) Complex pain management

4) Slow onset of action; long/variable half life

5) Can start immediately even if they’re still on opioids. Titration is SLOW

6) SLOW

7) During initiation or titration

8) CYP3A4, CNS depressants, QTc prolonging meds

9) QTc prolongation, sedation, hormonal dysfunction 

10) 3 or less

11) 4 consecutive missed daily doses

12) 5 or more consecutive missed daily doses

Does methadone or buprenorphine/naloxone have better retention rates

Methadone has better retention rates

OAT: SROM

1) Name an example of a medication

2) MOA

3) Short acting or long acting

4) Contraindicated in what 

5) DDI

6) How long does it take to go into withdrawal from this from missed doses

7) Benefits of this medication (2) 

8) What’s an ADR. It’s due to ___ of ___ ___. This makes it bad for ___

9) Faster titration compared to ___, slower titration compared to __

10) Why should you NEVER crush or chew this 

11) Why do you need to take it at the same time every day 

12) Missed dose titration?

1) Kadian

2) Full mu receptor agonist

3) Longer acting

4) Renal impairment

5) CNS depressant

6) FASTEST to go into withdrawal

7) Don’t hafta worry about QTc or CYP

8) Neurotoxic (COMA), due to accumulation of active metabolite, bad for CKD

9) Faster = Methadone; Slower = Buprenorphine 

10) It will remove prolonged release; it’ll turn into immediate release morphine

11) B/c short ½ life leads to faster withdrawal 

12) Same as methadone (3 for resume dose, 4 for reduce dose, 5 for re-titrate)

OAT: Rank Buprenorphine, Methadone, SROM

1) Retention

2) Induction (Fastest to slowest)

3) Titration (Fastest to slowest)

4) ADRs (Most to least)

5) Renal Impairment

6) Hepatic impairment

7) Take-home dose (no witness required)

8) Switching OATs (which is the hardest to switch to and why)

9) Tapering off: Which is easiest

10) Which is the best for pain management 

Retention

Methadone = SROM > Buprenorphine

Induction

Buprenorphine > SROM > Methadone

Titration

Buprenorphine> SROM > Methadone

ADRs:

Methadone > SROM > Buprenorphine

Renal Impairment

SROM

Hepatic Impairment

Methadone = SROM > Buprenorphine

Take Home Dose

Buprenorphine

Switching OATs

Switching to buprenorphine is the hardest

Tapering Off

Buprenorphine is used because of the slow dissociation

Pain management

All can be used equally 

What are the medications given for opioid WITHDRAWAL management (6)

What’s the only one that requires a Rx

Should you just treat withdrawal symptoms without opioid agonist treatment (OAT)

Acetaminophen/Ibuprofen

Loperamide

Dimenhydrinate

Ondasetron

Clonidine

Clonidine requires Rx (sweating, tremors, chills, anxiety)

NO!!!!! NOT RECOMMENDED

What are the most common ADRs of opioids (7)

What happens BEFORE resp depression

• CNS depression

• RESP depression

• Constipation

• Hyperalgesia (increase pain sensitivity, doesn’t feel pain as easily)

• Sedation

• Cognitive slowing

• Androgen deficiency (decrease testosterone)

Sedation occurs before resp depression

COWS

1) What is it for

2) What’s the range for no active withdrawal

3) What’s the range for moderate withdrawal

4) What’s the range for moderate-severe withdrawal

5) What is SOWS

1) Clinical Opioid Withdrawal Scale

2) <5

3) 13-24

4) 24-35

5) Subjective; modified for patients to complete on their own

Buprenorphine Monthly Injection (LAI)

1) What must be done prior to initiating (trial)

2) Can it be dispensed to a patient

3) Why does it have to be administered by a health care professional

1) Trial of transmucosal suboxone for 1-7 days to ensure no allergy

2) No

3) Can cause tissue damage + thromboembolism; solidifies in vein

iOAT (Injectable IAT)

1) Which meds

2) Who injects

3) What else does the patient usually need to have to prevent withdrawal symptoms between doses (overnight)

1) IV Hydromorphone or Diacetylmorphine (Rx heroin)

2) Patient self-injects under supervision of a nurse

3) SROM or methadone

Fentanyl Patch

1) Good evidence?

2) MOA

3) What’s one downside adherence / comfortability wise

4) Metabolism

5) How often is it dosed and why

1) Not really

2) Full Mu receptor agonist

3) You may need multiple patches to achieve dose

4) CYP 3A4

5) Q2-3 days because it’s very long acting