Buprenorphine/Naloxone Training Workshop for Medical Practitioners

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1 Buprenorphine/Naloxone Training Workshop for Medical Practitioners Program developed by Dr Nicholas Lintzeris MBBS, PhD, FAChAM (RACP) Turning Point Alcohol and Drug Centre, Melbourne, Australia Federation of Private Medical Practitioners Associations, Malaysia Ministry of Health Malaysia

2 Workshop Overview Module 1 Working with heroin users» Drugs, dependence and harms» Overview of services» Clinical assessment of drug users Module 2 Treatment with Suboxone (Buprenorphine-naloxone)» Clinical Pharmacology» Therapeutic guidelines Module 3 Addressing co-morbidity» BPN abuse» Polydrug use» Psychiatric comorbidity» Medical comorbidity 2

3 Module 1 Working with Heroin Users Heroin, dependence and harms Overview of services Clinical assessment of drug users Drugs, dependence and harms Overview of services Clinical assessment of drug users Federation of Private Medical Practitioners Associations, Malaysia Ministry of Health Malaysia

4 Learning Objectives 1. To understand opiate pharmacology, and the concepts of withdrawal, tolerance and dependence. 2. To recognise the potential biological, psychological and social harms associated with heroin use. 3. To be familiar with the general principles and effectiveness of different treatment services available for dependent heroin users. 4. To be able to conduct a clinical assessment of a patient and develop a suitable treatment plan. 4

5 Classification of Opioids 100 Full Agonists: Heroin, morphine, methadone, codeine Size of Opiate Agonist Effect. 0 Threshold for respiratory depression Drug Dose Partial Agonists: Buprenorphine Antagonists: Naltrexone, naloxone 5

6 Exercise 1: Heroin Effects List common acute effects of heroin or morphine use 6

7 Effects of Heroine / Morphine Nervous Analgesia, euphoria, sedation, drowsiness Suppression of cough reflex Pupillary constriction Gastro-Intestinal Nausea and vomiting, constipation Cardio-respiratory Orthostatic hypotension, bradycardia, Respiratory depression Endocrine Women: menstrual changes; galactorrhoea ( prolactin; FSH, LH) Men: Reduced libido, gynaecomastia ( testosterone) Skin Itching, sweating, flushed skin from histaminic reaction; dry mouth, skin and eyes Inhibits urinary reflex - difficulty passing urine7

8 Physical Dependence Body adapts to repeated use of a drug Tolerance Withdrawal Also known as neuroadaptation 8

9 Exercise 2: Opiate Withdrawal List common features of heroin withdrawal. What is the time course of withdrawal? 9

10 Heroin Withdrawal Acute (onset hrs, peak days 2-4) Dilated pupils, yawning, runny nose, tachycardia, BP Diarrhoea, nausea & vomiting, urinary frequency Piloerection, sweating, shivers ( cold turkey ) Arthralgia, muscle tension pain, abdo cramps Cravings, anxiety, dysphoria, irritability, insomnia Protracted (lasting weeks to months) Fluctuating cravings, anxiety, dysphoria, poor sleep Greater sensitivity to pain 10

11 Opioid Dependence (DSM IV-R) MORE THAN 3 occurring at any time in the same 12 month period: 1. Tolerance 2. Withdrawal 3. Opioids taken in larger amounts or longer than intended. 4. Persistent desire or unsuccessful attempts to cut down or control opioid use. 5. A great deal of time is spent in activities necessary to obtain opioids, use opioids, or recover from their effects. 6. Important social, occupational, or recreational activities are given up or reduced because of opioid use. 7. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids. 11

12 Natural history of heroin dependence Chronic, relapsing remitting condition Usually starts several years after 1 st heroin use 2 5 % remission rate per annum 1 2 % mortality rate per annum 10 year outcomes (US treatment seekers): 40 50% still using / imprisoned 30 40% abstinent 10 20% dead Most stop heroin use by mid 30 s to 40 s 12

13 Characteristics of heroin dependence Short-acting drug Often need to use several times / day to avoid withdrawal Day revolves around getting / using heroin Heroin is expensive Injecting a common mode of use Better value for money Illegal and stigmatised behaviour Polydrug use is common 13

14 Exercise 3: Heroin related harms List potential harms associated with heroin use 14

15 Heroin Related Harms Biological Overdoses & other opioid effects Local / systemic infections from injecting HIV / HBV / HCV Psychological Anxiety, depression, suicide Impaired cognition Social Impact upon employment, education, parenting Personal & family relationships & stigma Crime, violence, sex work 15

16 Overview of treatment options for heroin dependent users

17 Harm Minimisation Aims to reduce drug related harm to the individual and the community Common paradigm for medicine Hierarchy of goals: cure (abstinence) is ideal reducing levels of drug use changing high-risk behaviours 17

18 Changing Human Behaviour: Stages of Change Model Pre-contemplation: People do not have major concerns regarding their drug use and are not interested in changing behaviour Contemplation: People aware that there are both benefits & problems arising from their drug use, & are weighing up whether or not to make changes - or what those changes should be Action: People are implementing strategies in order to change Maintenance: Holding onto the behaviour changes Relapse: Can be volitional, or triggered by physical, emotional, social factors 18

19 Working with Drug Users Confidentiality Empathy Non-judgemental approach Accept patient s autonomy to make decisions (both good & bad ones) Work with the patient to achieve outcomes how can you help the patient achieve their goals 19

20 Treatment Pathways Dependent Heroin User Detox Substitution Maintenance Treatment Detox from maintenance treatment Post Detox Treatment Options 20

21 Objectives of Detoxification Detox is not a cure for heroin dependence Most heroin users relapse after withdrawal Need long-term treatment to achieve long-term changes Short-term intervention that aims to: Interrupt a pattern of heavy & regular drug use Alleviate withdrawal discomfort Prevent complications of withdrawal Facilitate post-withdrawal treatment linkages 21

22 Components of Detox Program Supportive care safe environment (inpatient / outpatient) patient information supportive counselling regular monitoring Medication Buprenorphine is preferred medication Avoid benzodiazepines in outpatient settings Post-withdrawal linkages 22

23 but beware of limitations of detox 23

24 RCT BPN Maintenance vs Detox Kakko et al Lancet subjects randomised to 1 week detox / 1 yr maintenance all provided counselling for 1 year Heroin use Detox = all relapsed Maintenance=75% Opiate (-)ve UDS Mortality (p=0.015) Detox 4/20 (20%) Maintenance 0/20 24

25 Post-withdrawal Interventions Counselling various models (supportive, behavioural, dynamic) Residential rehabilitation Self help (Narcotics Anonymous) Naltrexone opioid antagonist that blocks effects of additional heroin use (and reduces cravings in some) effective for those who take it, but high drop out rate (<20% retention at 6 months) 25

26 Overview of Substitution Maintenance Treatment Provision of a long acting opioid (e.g. methadone, buprenorphine) enables patient to cease / reduce their heroin use and related behaviours Long term treatment approach: provides opportunity for patients to distance themselves from drug-using lifestyle Combines medication with psychosocial services 26

27 Rationale for Substitution Treatment 27

28 Objectives of Substitution Maintenance Treatment To reduce heroin and other drug use To reduce mortality To reduce transmission of BBVs To improve the patient s general health and well being (psycho-social functioning) To reduce drug-related crime Long-term medical intervention for chronic illness 28

29 Principles of Effective Maintenance Treatment Duration of treatment (generally > 1-2 years) Dose of medication Quality of therapeutic relationship Regular review, supervision & monitoring Psychosocial supports for the patient voluntary participation in counselling environment, family, friends, employment Bio-psycho-social model for chronic condition 29

30 Does Substitution Treatment Work? Heroin use Despite considerable variation between programs, almost all patients reduce heroin use ~ 1/2 of patients stop using heroin ~ 1/3 of patients use heroin infrequently ~ 1/6 of patients continue to use heroin frequently 30

31 Does Substitution Treatment Work? Mortality rates Heroin users not in treatment = 1-2% per annum (p.a.) Methadone maintenance treatment = 0.5 to 0.75 % p.a. HIV transmission lower risk practices than users not in treatment (placebo or wait list controls); lower rates of HIV transmission. 31

32 Selecting treatment modalities: Evidence-based medicine Patient circumstances Patient goals & expectations of treatment Past history of what has worked before Available resources Treatment services available Cost of different treatment approaches Evidence regarding safety & effectiveness 32

33 Comparing Treatment Outcomes Heroin use & retention Mortality Detox 5 10% long term abstinence? Increase / no change Suboxone Maintenance Residential rehab 50% yr 25% no heroin 1yr Few remain in Rx unless legal / external pressure Naltrexone 10 20% retention 6/12 Most drop outs relapse 3 4 fold reduction??increase / no change 33

34 Assessing Patients

35 Role of Assessment Assessment serves two key functions: to ascertain valid information in order to identify the most suitable management plan; to engage the patient in the treatment process establishing rapport with the patient facilitating treatment plans 35

36 Key Features of the Assessment Presenting problem & motivation Drug use (include all drug classes) Quantity frequency route of administration Duration of use Severity of dependence & neuroadaptation Medical, psychiatric & social circumstances Past treatment attempts Patient goals / expectancy 36

37 Conducting Assessments (1) History Examination Features of intoxication / withdrawal Evidence of drug use (e.g. injecting sites) Evidence of drug-related harm (infection, liver) Investigations Urine drug screens Viral serology & LFTs Collateral information 37

38 Conducting Assessments (2) Do not take short cuts. If rushed: Identify key features in assessment Reassure patient that treatment process has commenced Provide literature and instructions as appropriate Re-schedule another appointment to complete process Do not attempt to assess an intoxicated patient Seek specialist advice or refer if complex presentation or any concerns 38

39 Case Vignette: Selecting Treatment (1) Mohammed, 25, regular heroin use for 4 years. Now injecting 3 times / day. Three prior failed attempts at outpatient withdrawal. Lives with other heroin users. Wants help to become abstinent, requesting outpatient detox, and asks for some Suboxone and midazolam. What are your concerns & how do you advise MO? 39

40 Case Vignette: Selecting Treatment (1) Concerns: Failed previous attempts at outpatient detox & living with other heroin users Why will this attempt be any different tp previous attempts? Concerns about medication safety (overdose, abuse, diversion) Suggest: Stabilise on Suboxone, stop heroin use, and then review treatment plan No benzodiazepines & supervised Suboxone dosing Suggest longer term period of treatment when Mo has distanced himself from heroin use and other users. 40

41 Case Vignette 2 Alice, a 26 year old presents to your practice for the first time. She says her friend, who you also treat, speaks highly of you. It is 4.45 on a Thursday (the practice closes at 5.00) and she presents wanting to start Suboxone today. She appears slightly anxious, with large pupils (4mm) and frequently yawning. How do you proceed? 41

42 Case Vignette 2 Reassure that treatment process has commenced Identify need for assessment discussion of treatment options (provide client literature) registration of patient Make another appointment (tomorrow if possible) to: Complete paperwork & clinical assessment Commence dosing: patient to present in opiate withdrawal Do not prescribe other drugs (e.g. BZDs) as a means of holding her until the following day 42

43 Self Assessment of Learning Module 1

44 1. Which of the following are uncommon features of opiate withdrawal? A. Low mood for weeks B. Joint pains and backache C. Rhinorrhoea, lacrimation and sweating D. Nausea and/or vomiting E. Auditory hallucinations 44

45 2. Which of the following statements regarding heroin dependence is / are TRUE? A. Most people who use heroin become dependent B. Dependence is defined as: the experience of biological, psychological or social harms related to heroin use. C. Dependence is usually a chronic, relapsing condition spanning years D. Dependence to heroin is defined as: the experience of tolerance to the effects of heroin and withdrawal on the cessation of heroin use. E. Identifying the underlying cause of dependence is essential in order for treatment to be effective. 45

46 3. Which of the following statements are TRUE? A. The main objective of detox is to achieve long-term abstinence B. Key goals of detox include the alleviation of withdrawal discomfort and linking the patient to ongoing treatment. C. All the features of heroin withdrawal have resolved by 5 to 7 days. D. Maintenance substitution treatment has been consistently shown to reduce mortality rates. E. Patients should only enter maintenance substitution treatment after having failed multiple attempts at detox or therapeutic communities 46

47 4. In conducting an assessment of a heroine User, which of the following is/are TRUE? A. Self-report of drug and alcohol use by patients is almost always unreliable B. It is important to ask about use of other drugs, including alcohol, tobacco, other opiates, cannabis, benzodiazepines and stimulants. C. You must always confirm the patient s history of drug use with relatives or friends before starting treatment. D. It is usually too intrusive and inappropriate to examine injection sites during the initial assessment. E. The emphasis during the first interview should be to establish the patient s drug use and start treatment a medical and psychiatric assessment can be deferred until after commencing treatment 47

48 48

49 1. Which of the following are uncommon features of opiate withdrawal? A. Low mood for weeks B. Joint pains and backache C. Rhinorrhoea, lacrimation and sweating D. Nausea and/or vomiting E. Auditory hallucinations 49

50 2. Which of the following statements regarding heroin dependence is / are TRUE? A. Most people who use heroin become dependent B. Dependence is defined as: the experience of biological, psychological or social harms related to heroin use. C. Dependence is usually a chronic, relapsing condition spanning years D. Dependence to heroin is defined as: the experience of tolerance to the effects of heroin and withdrawal on the cessation of heroin use. E. Identifying the underlying cause of dependence is essential in order for treatment to be effective. 50

51 3. Which of the following statements are TRUE? A. The main objective of detox is to achieve long-term abstinence B. Key goals of detox include the alleviation of withdrawal discomfort and linking the patient to ongoing treatment. C. All the features of heroin withdrawal have resolved by 5 to 7 days. D. Maintenance substitution treatment has been consistently shown to reduce mortality rates. E. Patients should only enter maintenance substitution treatment after having failed multiple attempts at detox or therapeutic communities 51

52 4. In conducting an assessment of a heroine User, which of the following is/are TRUE? A. Self-report of drug and alcohol use by patients is almost always unreliable B. It is important to ask about use of other drugs, including alcohol, tobacco, other opiates, cannabis, benzodiazepines and stimulants. C. You must always confirm the patient s history of drug use with relatives or friends before starting treatment. D. It is usually too intrusive and inappropriate to examine injection sites during the initial assessment. E. The emphasis during the first interview should be to establish the patient s drug use and start treatment a medical and psychiatric assessment can be deferred until after commencing treatment 52

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