MEDICALLY SUPERVISED OPIATE WITHDRAWAL FOR THE DEPENDENT PATIENT. An Outpatient Model

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1 MEDICALLY SUPERVISED OPIATE WITHDRAWAL FOR THE DEPENDENT PATIENT An Outpatient Model

2 OBJECTIVE TO PRESENT A PROTOCOL FOR THE EVALUATION AND TREATMENT OF PATIENTS WHO ARE CHEMICALLY DEPENDENT ON OR SEVERLY ABUSING OPIATES.

3 EVALUATION DEFINE THE CRITERIA WHICH IS USED TO ACCURATELY DIAGNOSE THE CONDITION

4 DSM-IV CRITERIA FOR SUBSTANCE DEPENDENCE DEFINITION: A maladaptive pattern of substance use, leading to clinically significant impairment, as manifested by three of the following within the past three months:

5 1) Increased tolerance of substance 2) Withdrawal Syndrome 3) Preoccupation 4) Reduction in social, occupational and/or recreational activities 5) Continued use, despite consequences

6 INCREASED TOLERANCE INCREASED AMOUNTS OF DRUG NEEDED TO ACHIEVE DESIRED EFFECT DIMINISHED EFFECT WITH CONTINUOUS USE OF THE SAME AMOUNT OF DRUG

7 PATTERN OF USE Substance is used longer and in larger quantities than initially intended. Repeated efforts to quit, control or cutback the use of substance Switching from prescription Opiates to illicit Heroin; a very common scenario in this age group due to affordability. Often begins with single-dose Vicodin/Percocet mixed with alcohol. Progresses to long-acting Oxy product.

8 PREOCCUPATION Once these patients progress to daily HEROIN use, they typically buy it one day at a time. A great deal of time is invested in activities necessary to obtain the drug Other interests and ambitions are neglected (I.e., Education, Sports, Scholarships, friends, self, friendships, relationships, etc) Daily behavior is dictated by withdrawal symptoms from waking up to going to sleep Total focus of the day is PREVENTION OF WITHDRAWAL. Typically, at this point, there is little Eupophoria associated with using.

9 PREOCCUPATION (CONT D) REPEATED EFFORTS TO QUIT, CONTROL OR CUT-BACK THE USE OF SUBSTANCE. SWITCHING FROM PRESCRIPTION OPIATES TO ILLICIT HEROIN; A VERY COMMON SCENARIO IN ADOLESCENT AGE GROUP DUE TO AFFORDABILITY. OFTEN BEGINS WITH SINGLE-DOSE VICODIN/PERCOCET MIXED WITH ALCOHOL

10 LOSS OF CONTROL REPEATED EFFORTS TO QUIT, CONTROL OR CUT BACK THE USE OF SUBSTANCE IS LESS COMMON IN PATIENTS. MOST ADOLESCENTS SETTLE INTO ONE FIXED DOSE 1-2GM HEROIN OR 80MG OXYCONTIN TID. HEROIN IS USUALLY SMOKED OR INJECTED. OXYPRODUCTS ARE GENERALLY CHEWED THEN IT PROGRESSES TO INTRANASAL FOR MORE RAPID EFFECT

11 USE DESPITE ADVERSE CONSEQUENCES SUBSTANCE USE CONTINUES IN THE FACE OF PHYSICAL AND EMOTIONAL BREAK-DOWN DEPRESSION RECURRENT WITHDRAWAL SYMPTOMS, LEGAL COMPLICATIONS COMMON DUE TO POOR IMPULSE CONTROL IN THE FACE OF OBVIOUS RISK

12 WITHDRAWAL Characteristic Opiate Withdrawal Syndrome measured by the COWS Tool Same or related substance is taken to relieve or avoid Withdrawal Syndrome

13 EVALUATION Comprehensive psychosocial history to screen for co-occurring psychopathology Anxiety disorders(ocd,agoraphobia, anorexia/bulemia,gad,social Phobia) ADD/ADHD,ODD,Antisocial Disorders,Sociopathy Bipolar Disorder/Depression Sexual/Physical Abuse history

14 EVALUATION (cont.) Comprehensive Medical History with baseline Urine Drug Screen Chronic pain,trauma history,ibs or IBD Autoimmune disorders,chronic Fatigue Syndrome Sleep Disorders(REM behavioral Disorder-RBD) Parasomnias, Circadian Rhythm Disorder

15 EVALUATION (cont d) Determine Stage of Substance Abuse Disorder Potential for abuse(reduced impulse control with availability of substances and peer pressure Experimentation(learning euphoria, few consequences,minimal behavior change Regular use(seeking euphoria using harder drugs,behavioral changes and some consequences,using along,buying or stealing drugs Regular use-preoccupation and loss of control,multiple consequences and risk taking. Adolescents are often estranged from straight friends Burnout-use of drugs to feel normal, guilt, shame, withdrawal, remorse, depression, suicidal thoughts or attempts

16 PHYSICAL EXAM Routine Medical Examination Clinical Opiate Withdrawal Scale (COWS)

17 COWS Objective measurement of the degree of opiate withdrawal for the purpose of determining the severity of withdrawal as well as when to start Buprenorphine Therapy. This is an 11-category tool.

18 COWS Pulse, Sweating, Restlessness, Pupil Size, Bone or Joint Aches, Runny nose or tearing, GI upset, Tremor, Yawning, anxiety or Irritability, Gooseflesh. Each numbered 1-5 then totaled 5-12=mild,13-24=moderate,25-36=moderately severe, >36=Severe

19 COWS Once a patient reaches a level of 15 or higher, it is safe to start Buprenorphine Therapy with Subutex(not Suboxone due to Naloxone component) 8-10% of Naloxone absorbed subliqually vs. 50% of Buprenorphine 4:1 Combination ideal ratio to discourage diversion yet be effective(8/2 and 2/.5)

20 BUPRENORPHINE Pharmacokinetics/Pharmacodynamics 3 key aspects of this medication 1.High Affinity for Mu Receptor 2.Long duration of action 3.Slow dissociation Partial agonist= partial stimulation at mu receptor and an Antagonist at Kappa which results in a decreased opiate effect the higher the dose.

21 BUPRENORPHINE Important to spend time educating the patient (and caregiver) about the nature of this medication which will improve compliance and reduce relapse Many misconceptions about it s effects Describe the 3 phases of treatment Induction /Stabilization/ Maintenance

22 INDUCTION Patients are divided into 2 catagories prior to Induction 1.Short-Acting Opioids(Heroin,Oxycodone, Hydro-codone, etc 2.Long-Acting Opioids(Methadone, Oxy contin,ms contin,opana ER) (This is more problematic due to having to wait longer to go into withdrawal)

23 INDUCTION Instruct Patient on how to take a subliqual tablet Administer patient s first dose(usually 4mg) and wait Onset usually minutes(anxiety and restlessness are the first to go) Observe for 2 hours and re-dose 2-4mg as needed

24 INDUCTION Key is to dose patient and have them wait first for relief then for withdrawal symptoms to return, then re-dose 2-4mg. Maximum dose for first day should be 8-12mg On Day #2, Total what the patient needed on day one and administer in 4mg increments throughout the day waiting after each dose to see how long it lasts Maximum dose for Day #2 should be 16mg

25 INDUCTION Day #3- Total the dose given on day 2 and dose in 4-8mg increments again waiting after each dose to determine how long it works. If patient is coming off Long-acting Opioids, must wait longer to induce and may need adjuctive meds

26 STABILIZATION Once the total daily dose is determined, start pre-empting the return of withdrawal symptoms so as not to reinforce pain/drug relief EXAMPLE: 8mg at 8am then normally symptoms return at 4pm, then start taking second dose at 3pm. Repeat this protocol for 3-4 days so patient never physically feels the need to take meds

27 STABILIZATION Very important not to reward patient with the drug following effective Induction and early Stablization. With adolescent and adult population, administration and responsibility of securing the medication should be that of the adult or caregiver Random drug testing begins(can differentiate general opiates from oxycodone and buprenorphine

28 STABILIZATION Minimal time for stablization should be three months to create a homeostasis at the mu receptor in order to allow the pschosocial and nutritional/health components of recovery to have a chance to be effective-otherwise poor prognosis Without a NeuroBiological Stablization the chance for a meaningful recovery is bleak

29 MAINTENANCE This phase of therapy should not apply to adolescent patients since there is no reason complete abstinance from opiates should not be the goal, unlike some adults

30 BUPRENORPHINE TAPER Ideal rate of weaning should be 1-2mg every 2 weeks(suboxone should be used during stablization and return to subutex for taper Cognitive Behavioral Therapy plays an important role Must identify and address the reason patient chose opiates as their drug of choice

31 CONCLUSION The epidemic of adolescent and adult opiate addiction can be effectively and safely treated on an outpatient basis if there is sufficient expertise of prescribing,development of a trusting doctor/patient relationship and a supportive caregiver role model. Drug testing is also a key factor if it is presented as a therapeutic tool and not a punishment It is also important to reward compliance with more independence

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