Opioid Dependence

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Opioid Dependence

• Anne Kalvik
• Pearl Isaac

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Learning Objectives

1. To develop an understanding of opioid dependence
   issues including tolerance, abuse, toxicity,
   overdose and withdrawal

• To become familiar with various treatment
  strategies for the management of opioid
  dependence and develop an understanding of the
  advantages and disadvantages of each approach

3. To consider options available to pharmacists
that can impact patient outcome in opioid
dependence in its various stages. Students will
be encouraged to examine their own attitudes to
this issue
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Opioid Dependence andPharmacy Practice
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Medical Uses for Opioids

• PAIN
• Cough
• Diarrhea

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Undesirable Effects of Opioids

• Nausea and vomiting
• Sedation
• Some people dont like effects, e.g., itching
• Physical and psychological dependence
• Respiratory depression
• DEATH

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Why are Opioids Abused?
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Some Examples of Opioids

• Codeine
• Oxycodone
• Hydromorphone
• Morphine
• Meperidine
• Hydrocodone
• Heroin
• Methadone

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Street Value of Selected Rx Narcotic Drugs
in Vancouvers Downtown Eastside
Sajan et al, CMAJ July 28, 1998 159 (2)
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Addiction

• Compulsive drug use
• Consequences use despite harm
• Inability to Cut down
• Cravings

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DSM-IV Criteria for Substance Dependence

• At least 3 of the following in 12-month period
• Tolerance
• Withdrawal
• Taking larger amounts than intended
• Unsuccessful efforts to reduce drug use

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DSM-IV

• Great deal of time spent acquiring and using the
  drug
• Reduction of important activities because of the
  drug
• Continued use despite knowledge of drug-related
  physical or psychological problems

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Tolerance

• Neurobehavioural adaptation
• Rapid tolerance to psychoactive effects
• Tolerance to analgesic effects develops slowly
• Tolerance disappears within days

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Heroin Dependence

• Short acting drug
• Cycles of intoxication and withdrawal
• Injection drug use
• HIV, hepatitis, other medical issues
• Contaminants
• Crime, unemployment, domestic problems
• Prostitution, unsafe sex

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Effects of Heroin

• Physical effects on user
• direct
• indirect
• Physical effects on others
• Psychosocial effects on user
• Psychosocial effects on others

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Bob

• 37-year old man buying 10 Oxycontin per day off
  the street
• Currently lives alone, unemployed

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Opioid Withdrawal (objective)

• Nausea and vomiting
• Diarrhea
• Runny nose, sneezing
• Lacrimation
• Dilated pupils
• Gooseflesh
• Tremor
• Feelings of hot and cold
• Yawning
• Tachycardia
• Blood pressure elevation

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Opioid Withdrawal (subjective)

• Anxiety
• Restlessness
• Abdominal pain and cramps
• Muscle aches
• Bone pain
• Anorexia
• Craving
• Insomnia

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Opioid Intoxication/Overdose

• Euphoria
• Dysphoria
• Motor retardation
• Sedation
• Slurred speech
• Pinpoint pupils
• Respiratory depression
• Circulatory collapse
• Cardiac arrest
• DEATH

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Medical Detoxification

• Clonidine
• Loperamide
• Dimenhydrinate
• NSAIDs
• (Benzodiazepines)
• (Naltrexone)
• UROD

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Why not detoxify?

• Opioid withdrawal not life-threatening
• BUT
• Alternative for many is return to drug use and
  not staying clean
• Often a chronic and relapsing disorder
• Some cannot see themselves as able to function
  without opioids
• Harm Reduction

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Why Methadone?

• Most effective pharmacological treatment for
  heroin dependence
• Well accepted
• Effective HIV/AIDS and Hepatitis prevention
• Reduces or eliminates heroin use
• (contd)

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Why Methadone?

• Reduces criminal behaviour
• Improved employment rates
• Improved psychological status
• Decreased mortality
• Cost effective
• Availability

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How does Methadone Work?

• Opioid (substitute for heroin)
• Orally effective
• Little or no euphoria / high
• Long acting (at least 24 hours)
• Prevents withdrawal
• Reduces craving
• Blocks effects of other opioids
• Permits normal functioning stability

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A Day on Methadone vs. Heroin
High
Normal
Sick
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Comparative Profiles of Heroin and Methadone
Heroin Methadone
Route of Administration Injected Smoked, snorted Consumed orally
Onset of Action Immediate 30 minutes
Duration of Action Short-Acting (3-6 hours) Long-Lasting (24-36 hours)
Euphoria Common Rare
Withdrawal Symptoms 3-4 hours after last use 24 hours after last use
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Is Methadone Safe?

• Well tolerated
• Not associated with organ damage
• Some side effects (e.g., constipation and
  sweating)
• Correct dose is essential

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Methadone Treatment

• Medication
• but also
• Counselling
• coping skills
• nutrition
• housing, job, child care, etc.
• Medical care
• Come to pharmacy often on daily basis

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Methadone and Pregnancy

• Fluctuating levels not good for mother or baby
• Lifestyle
• Medical, psychosocial, nutritional care
• Methadone does pass to baby, but

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Other Treatments for Opioid Dependence

• Naltrexone
• (LAAM)
• Buprenorphine
• Heroin

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Changing Patterns of Methadone Maintenance
Treatment

• In Ontario, major thrust to get treatment into
  community settings
• Trend away from large centres like ARF
• Number of prescribers has increased
• Number of clients has increased
• Number of clients going to community pharmacies
  has increased

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Stages of Change
Pre-Contemplation
Lapse/Relapse
Contemplation
Maintenance
Preparation
Action