Opiate misuse

1
Opiate misuse

• Agenda
• Prevalence
• Consequences
• Treatment goals
• Recommendations in current guidelines
• Substitution prescribing
• Summary

2
Illicit drug use in England Wales (2006/07
data) UK drug situation Annual report to the
EMCDDA. 2007

• In the general adult population (1659 years)
• lifetime prevalence is over a third
• 10 of adults have used drugs in the last year
• In young adults (1624 years)
• lifetime prevalence is 45
• 24 have used drugs in the last year
• Males are significantly more likely to use than
  females
• lifetime prevalence 42 versus 29 in 1659 year
  olds
• Cannabis was the most commonly used drug
• lifetime prevalence 30 in 1659 year olds
• 1 of the population aged 1564 years are
  estimated to be using drugs in a chronic,
  potentially damaging way
• two thirds of those seeking treatment use opiates
  as their main drug

3
Consequences of drug misuseUK drug situation
Annual report to the EMCDDA. 2007

• 1,827 drug-related deaths in the UK in 2005
• Mainly relating to opiate use
• Mortality risk of people dependent on illicit
  diamorphine is estimated to be around 12 times
  that of the general population
• Risk of blood-borne diseases
• HIV
• Hepatitis B and C
• Psychiatric co-morbidity is commonly reported
• Depression, anxiety, personality and psychotic
  disorders
• There is evidence of the link between drug use
  and acquisitive crime
• Around 75 of the users of heroin and crack
  cocaine admit to committing crime to support
  their habit
• The economic and social costs of Class A drug use
  in England are estimated to have been around
  22.3 billion in 2003/04
• This equates to 63,940 per year per problematic
  drug user

4
Treatment goals Drug Misuse Dependence UK
Guidelines on Clinical Management (2007)

• Hierarchy of goals
• Reducing health, social, crime and other problems
  related to drug misuse.
• Reducing health, social or other problems not
  directly attributable to drug misuse.
• Reducing harmful or risky behaviours associated
  with the misuse of drugs (e.g. sharing injecting
  equipment).
• Attaining controlled, non-dependent or
  non-problematic drug use.
• Abstinence from main problem drugs.
• Abstinence from all drugs.

5
Orange book principles of treatmentDrug
Misuse DependenceUK Guidelines on Clinical
Management (2007)

• Healthcare professionals have a duty of care to
  drug misusers.
• A multidisciplinary approach is generally
  essential.
• All drug misusers should have a care plan which
  is regularly reviewed.
• Treatment should involve a psychosocial
  component.
• A prescription for substitute medication should
  only be considered if there is convincing
  evidence of current dependence.
• Coerced detoxification against a patients will
  is likely to lead to relapse and increased risks
  of harms e.g. overdose and blood-borne viruses.
• Most patients require the support of prescribed
  medicines for longer than just a few months.
• Supervised consumption should be available for
  all patients for a length of time appropriate to
  their needs and risks.

6
NICE guidance principles of treatment NICE
TA114 TA115, Jan 2007 NICE CG 51 CG52, July
2007

• The decision whether to use methadone or
  buprenorphine should be made on a case by case
  basis but if both drugs are equally suitable,
  methadone should be the first choice option.
• Detoxification should be an available treatment
  option for those people who have expressed an
  informed choice to become abstinent.
• Naltrexone can be used in detoxified formerly
  opioid-dependent people who are highly motivated
  to remain in an abstinence programme.
• Offer opportunistic brief interventions focused
  on motivation to people in limited contact with
  drug services.
• Routinely provide people who misuse drugs with
  information about self-help groups.
• Contingency management programmes should be
  introduced to reduce illicit drug use and/or
  promote engagement with services.

7
Substitution prescribing of opiates

• Although tapered doses of methadone appear to be
  effective in the treatment of heroin
  detoxification, the majority of patients relapse
  to heroin use (Amato L, et al. Cochrane
  Review 2005)
• 60100mg methadone daily is more effective than
  lower doses at retaining patients in treatment
  and reducing use of heroin or cocaine
  (Faggiano F, et al. Cochrane Review 2003)
• Methadone maintenance therapy is significantly
  more effective than buprenorphine maintenance
  therapy at retaining patients in treatment
  however there is no good clinical evidence to
  support claims that it is easier to withdraw
  patients from buprenorphine than MMT
• (Mattick RP, et al. Cochrane Review 2008 Gowing
  L, et al. Cochrane Review 2006)
• If both drugs are equally suitable, methadone
  (60100mg) should be the first choice treatment
  (NICE TA 114. Jan 2007)
• Methadone can prolong the QT interval and carries
  a risk of overdose during induction the initial
  daily dose will be in the range of 1030mg
  (Current Problems in Pharmacovigilance. Vol
  31, 2006 Orange book 2007)

8
Summary

• Methadone maintenance therapy and harm reduction
  is preferred for most patients
• since the majority of patients will relapse to
  heroin use following detoxification
• MMT plus psychosocial support first-line, unless
  there is good reason not to
• 60 to 100mg methadone daily is most effective at
  retaining patients in treatment and reducing use
  of heroin or cocaine
• Buprenorphine is less effective than high-dose
  MMT but is an alternative where this cannot be
  used
• Consider detoxification only when the patient is
  motivated and circumstances are suitable
• These interventions are worthwhile because they
  increase abstinence from illicit drug usage,
  improve health and reduce crime