doughnutsdoughnuts. opioid agonist therapy the skinny on methadone et al
TRANSCRIPT
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DOUGHNUTS
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Opioid Agonist Therapy
The Skinny on Methadone et al.
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Christopher Levesque
– Physician• 20 years ER TMH• 15 years correctional medicine
– Dorchester Institution• 9 years community addictions
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Christopher Levesque
• Lawyer – retired– UNB Law School 1975 (LL.B.)– London School of Economics (1976)
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Doughnuts (Adaptive behavior)
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PLEASURE
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Pleasure
• Brain reward system
• Dopamine
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Brain Reward Pathway
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Maladaptive Behavior
(Substance Use Disorders/Addiction)
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Brain Reward Pathway
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• Maladaptive behavior – Drugs
• Continued use despite significant use related problems
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• SUDS or Addiction
– Change in brain circuitry– Persists
• Relapses• Drug cravings
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• Substance Use Disorders, DSM – V
– 10 separate classes of drugs:• Alcohol• Caffeine• Cannabis• Hallucinogens
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• Inhalants• Opioids• Sedatives• Hypnotics• Anxiolytics • Stimulants (amphetamine-type
substances, cocaine, and other stimulants)
• Tobacco
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• Common drugs in Moncton
– Prescription opioids• Dilaudid, hydromorphone, oxycontin,• Morphine, … fentanyl
– Cocaine, crack cocaine– Speed - crystal methamphetamine– Benzopiazapines
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Diagnosis SUDs
• Criterion:• Impaired control
• Social impairment
• Risky use
• Pharmacological criteria
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• Impaired control
– Longer than intended, larger amounts
– Unsuccessful efforts to stop– Excessive time pre-occupation
• Finding, using, recovering– Craving
• Could think of nothing else
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• Social Impairment
– Neglect work, school, home– Interpersonal relationships – withdraws
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• Risky use
– Continued use despite knowledge of physical or psychological problem
– Failure to abstain despite recognition of risk
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• Pharmacological criteria
– Tolerance• Dose
– Respiratory depression– Sedation– Motor coordination
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• Pharmacological Criteria
– Withdrawal
– (N.B., not now a requisite to dx SUDs)
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Opioid Agonist Therapy (Substitution Therapy)
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Abstinence
Harm reduction
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• Y substitution
– Intense withdrawal (physical)– Cravings
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• Methadone
• Suboxone (buprenorphine + naloxone)
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• Methadone
– U Agonist– Long half-life (8-100hrs)
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• Suboxone (Subutex)• Combination drug
– Buprenorphine– Naloxone
• Unique characteristics
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• Analgesic properties
– Both
– Rarely utilized in management of acute pain
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So what about your practice !
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• Peri-operatively
– Take their usual dose same time~
• Methadone as clear undiluted liquid• Buprenorphine sublingual dissolution
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• Post-operatively
– Entitled to appropriate pain management• With mutually agreed careful monitoring
– No magic formula• Combination of short acting morphine
and long acting depending on the expected duration of pain.
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• Post-operative pain control
– Manage acute post-op pain• Same approach as with non-substitution
patients• Recognize there may be a requirement
for increases doses• Avoid the “drug seeking” badge
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• Post-operative pain control
• Fixed schedule….preferable to PRN
• Do Not Use Agonist-Antagonists
– Talwin (act at non-u receptors)– Stadol
» Antagonist action on u receptors
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• Simple Approach !!!
– Prescribe adequate doses of opioids– Maintain maintenance methadone
dose
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Couple of issues
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• Missed doses
– They will always be “ok” in the face of missed doses
– Better that they receive or take their dose around the same time of day
– For my purposes, 3 missed doses results in a 50% reduction in their dose and a re-titration.
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Pregnancy
slowed gastrointestinal absorptionexpanded fluid load/body fatHepatic enzyme activity (CYP3A4)increased glomerular filtration
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• Again
– Patients in substitution programs for opiate addiction…..• Are people…talk to them about pain
control• Must be accorded the same access to
appropriate management under any circumstance
• Will most likely require higher doses to manage pain (tolerance/cross tolerance)