opiods abuse

OPIOID USE DISORDERS:

Assessment &Management

Jaison Joseph

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Opioids: Double-edged sword

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Dilemma and Challenge

Opioids• Any drug that acts like opium in the human body

• Opium - prototype opioid which is derived from the poppy plant

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Opiates

Semi-synthetics

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Opioid Receptors

• µ (mu): – Activated by morphine: analgesia– Primary action site of all opioids– Distribution: CNS and GI– Linked to abuse/dependence

• κ (kappa): analgesia, endocrine changes and dysphoria

• δ (delta): for endogenous peptides

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Opioid Classification

Full agonists:•morphine•oxycodone

Partial agonist:•butorphanol

Antagonists:•naloxone•naltrexone

© AMSP 8

Opioids

Mechanism of Action : Opioids

An overview

Withdrawal state

Reward pathway

Pain pathway

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Pharmacodynamics: CNS

Undesirable:• EuphoriaRespiration• Sedation• Endocrine effects

Desirable:• Analgesia• Cough

suppression

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Pharmacodynamics: GI

Undesirable:• Nausea, vomiting • Constipation

Desirable:• Antidiarrheal• Inhibit peristalsis

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Pharmacokinetics

• Absorption: GI tract

• Distribution: protein binding

• Biotransformation: liver

• Excretion: kidney and GI (bile)

• Differs by age, gender

Opioid Abuse

Patterns of abuseHeroin - ‘smack’ or ‘Brown sugar’ – Most

dependence producing derivative

• may be smoked, chased (inhaled) or injected (intramuscular or intravenous)

• Chasing (inhaling the vapors emanating from a heated metallic foil) is the commonest mode of heroin use in India

Opioid abuse : Medical Complications

Investigation

• Naloxone challenge test

• Urinary opioid testing

Acute Intoxication

• Apathy

• Brady cardia, hypotension, subnormal body temperature

• Pin point pupils

• Delayed reflexes, thready pulse, coma- overdose

Acute Intoxication

Treatment

• Inj. Naloxone (I V) 2 mg repeated doses every 2 hours

• Supportive symptomatic management

Withdrawal Syndrome

Occurs within 12- 24hrs

• Lacrimation, Rhinorrhoea, Pupillary dialation

• Nausea , vomitting, Sweating ,diarrhoea, yawning, Muscle cramps

• Tachy cardia, mild hypertension

• Severe anxiety

Non-opioid agents

Clonidine 0.1mg (TDS/QID) ± ketorolac ± hypnotics ± antimotility agents

Opioids :(substitution)

- Methadone (10-20mg/d), (upto 40mg/d)

- Levomethadyl acetate (LAAM)

- Buprenorphine (2mg sublingual)

Relapse Prevention

Counselling: explain patient and family members - need for treatment, course, prognosis

etc.

Detoxification

• Methadone - dose -80-120mg/d (20-60mg/d)Efficacy - 52% abstinence at 6 months

(>60mg/d)• Buprenorphine - dose - 8-12mg/d (sublingual

upto 16-32mg/d)comparable to methadone

• Levomethadyl Actate- Dosage range (25-140mg thrice weekly)- Efficacy - equivalent to methadone

Opioid Antagonists • Naltrexone - 100-150mg thrice weekly (50mg/d)

- 30-40% continued abstinence at 1 year follow up under family supervision.

Opioid Maintenance Therapy

Nicotine use disorders

Do you believe ?

Nicotine

• Legal and popular substance the world• Main active chemical in Tobacco• Generally causes heightened alertness and improved

functioning in continuous repetitive tasks• Variety of ways including smoking, chewing, applying to

gums

How it acts ???

• Inhaled smoke contains Nicotine and Tar • TAR – complex mixture of organic molecules• Nicotinic receptors are found on

dopaminergic cell bodies• Stimulation of nAChR leads to dopamine

release• DOPAMINE – reward neuro transmitter• As the smoking continues endorphin release

also increases

Nicotine – How It Encourages Smoking ???

• It improves concentration and vigilance

• Improves working memory (through enhanced effect of glutamate, acetylcholine and serotonin)

• Moderate consumption of nicotine is associated with pleasure

Nicotine withdrawal

Health Impacts

Health Impacts

Screening

• FAGERSTROM TEST

• WHO ASSIST

FAGERSTROM TEST

• How many cigarettes do you smoke each day/how many times do you smoke tobacco each day ?

» 10 or less cigs / 1 or 2 times ( 0 points)

» 11 – 20 cigs / 3 – 5 times ( 1 point)

» 21 – 30 cigs / 6 – 10 times ( 2 points)

» 31 or more cigs / more than 10 times ( 3 points)

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• How soon after you wake up do you smoke your first cigarette/beedi ?

» Within 5 mins ( 3 points)

» 5 – 30 mins ( 2 points)

» 31 – 60 mins ( 1 point)

» Aftre 60 mins ( 0 points)

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FAGERSTROM TEST

• Do you smoke or use tobacco product more frequently during the first hour after waking than during the rest of the day

» Yes ( 1 point)

» No ( 0 point)1

FAGERSTROM TEST

• Which cigarette or tobacco use you hate the most to give up / which cigarette or tobacco use do you treasure the most ?

» First one in the morning ( 1 point)

» All others ( 0 point)

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FAGERSTROM TEST

• Do you find it difficult to refrain from smoking or use tobacco in places where it is forbidden?

(Eg: at the mosque, temple, school, bus ?)» Yes ( 1 point)

» No ( 0 point) 1

FAGERSTROM TEST

• Do you still smoke or use smokeless tobacco products when you are so ill that you are in bed most of the day ?

» Yes ( 1 point)

» No ( 0 point)

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FAGERSTROM TEST

SCORING• 7 – 10 points = highly dependent

• 4 – 6 points = moderately dependent

• Less than 4 points = minimally dependent

FAGERSTROM TEST

Pharmacological Treatment

• Nicotine replacement

• Bupropion HCl (bupron XL 150, 300mg)

• Varenicline (CHAMPIX)

Nicotine replacement• NULIFE (elder pharma) – 1mg, 2mg, 4mg chewing gums• Reduces severity of nicotine withdrawal symptoms, urge to

smoke• Dose – smokers of more than 20 cigarettes per day 4mg

chewing gum to start with• Try to reduce to 2mg chewing gum• Chew slowly on parked on gum for 30 mins• Chew it when the urge comes.• Not more than 15 gums per day• Any strength 4 or 2mg• Use for 8 – 12 weeks. Continued beyond this if needed to

prevent a relapse

BUPRON XL

• Significantly reduces the severity of nicotine withdrawal symptoms.

• Reduces the urge to smoke• Makes smoking less pleasurable and rewarding• Start 1- 2 weeks before than planned quit date in the

dose of - 150 mg XL * 6 days

- 300 mg XL from 7th day to 7-9 weeks

VARENICLINE

• Partial agonist binding with high affinity to ß ʠ₄ ₂nAChR receptors

• It also reduces nicotine withdrawal symptoms.• Makes smoking less rewarding.• Dose – day 1-3 - 0.5mg HS. 4-7 - 0.5mg BD.

8 – end of 12 week - 1mg BD.• set a quit date between 8 and 14 days• After 12 week additional course of 12 week can be

considered for a successfully stopped smoker

Nicotine use disorders treatment: Emerging trends

E - cigarette

Substance use disorders treatment: Emerging trends

E cigarette• A battery-powered electronic nicotine delivery device

(ENDD) resembling a cigarette• Efficacy - Conflicting opinions ……(8 articles)

Not a proven nicotine replacement therapy;

No scientific evidence to confirm the product’s safety and efficacy’ (WHO,2008)

Sedative- Hypnotic use disorders

Benzodiazepines

Intoxication & Withdrawal

Pharmacological Treatment• Symptomatic• Gradual tapering• Mild to moderate dependence, an outpatient detoxification by

tapering of the drug, with weekly reduction in doses• Severe dependence, particularly with dependence on short acting

benzodiazepines, indoor detoxification is preferred & can be tapered off at a rate of 10% a day

• Risk of withdrawal seizures in patients dependent on short or intermediately acting benzodiazepine (oxazepam, alprazolam etc) can be dealt with detoxification with equivalent doses of long acting benzodiazepines & tapered off as usual.

• If only insomnia persists, non-benzodiazepine hypnotics like zopiclone alone or with relaxation exercises, should be tried

Cannabis Use Disorders

Cannabis

How cannabis is used ??

Intoxication & Withdrawal

Pharmacological Treatment

• Symptomatic

• No medicine for craving

• Treatment of psychiatric disorders

Volatile solvents use disorders

Inhalants

Mode of use

Intoxication

Death can occur due to cardiac arrhythmias, respiratory depression or asphyxia

Complications

Pharmacological Treatment

• No specific treatment

• Symptomatic management

A. Individual Psychotherapy

1. Brief psychotherapies

2. Cognitive & cognitive behavior therapies

(i) Cognitive therapy

- Reduction in drug used by identifying & modifying

maladaptive thinking patterns.

(ii) Relapse prevention model (Marlatt & Gordon)

- Cognitive behavioral approach to help patients develop

greater self control in order to avoid relapse.

Non-Pharmacological Management

(iii) Motivational interviewing

- Motivating patient by cognitive approach to his

problem and its solutions.

(iv) Operant behaviour therapy

- Involve operant rewarding or punishing of patients

for desirable or undesirable behaviours.

(v) Contingency management

- A kind of operant behavioural therapy based on use

of predetermined positive and negative

consequences to reward abstinence or punish drug

related behaviours.

(vi) Cue exposure treatment

- Based on Pavlovian extinction paradigm.

- Exposure to craving inducing cues and prevention of drugs use response leads to extinction of dependence.

B. Group therapies

C. Family therapy

Other Approach

- Self help approach - Narcotic Anonymous (NA)

- Social correctional approach

-Moralistic religious approach

Substance Use Disorders

Substance Use Disorders: Role of Nurse

Where are WE ????

• Substance abuse : Is it treatable ?????

• Is there any role of nurse ????????

Goals & phases of Treatment

• Immediate goals (Initial phase) 2- 4 weeks

Completion of detoxification, psychosocial and medical crisis interventions

• Short-term goals (middle phase) 3- 6 months

management of medical and psychiatric co-morbidity and re-integration with family

Goals & phases of Treatment

• Long-term goals (Late phase) > 6 months

Prevention of relapse

Re-integration into the society

Occupational rehabilitation

Improvement in overall quality of life

Substance abuse disorders: Role of Nurse

Why to intervene ?

Where to intervene ?

What to intervene ?

Nurses in Substance abuse disorders: Why to intervene?

Nurses in Substance abuse disorders: Where to intervene?

Nurses in Substance abuse disorders: What to intervene?

The story of Mr. XYZ………Role of nurse : Why ? Where ? What?

• A 45 yr old/5th std/farmer/small town/wife & 3 children

Dependence

Abuse

Use

1992 1999 2010 2012 2013

1 ½ bottle /day 1 bottle / day

½ bottle /day

2-3 quarter /week

large peg / occasional or party

24 yrs *bottle- MC Dowells 245 rs

AbsenteeismquarrelsViolent

behaviors

Wife admitted in hospital due

to head injury

Role of Nurse ???

• Feedback (scale assessment)

• Responsibility• Advice• Menu of options• Empathy• Self efficacy

The story of XYZ………Role of nurse : Why ? Where ? What?

Brief intervention or counseling

“ I am asking for a change in your 5- 8 years habit .…. Cut down your drinking habit first….am sure you can also do it because many people

have done it …..”

Motivation Enhancement therapy(Stages of Treanstheoretical model of change ; Prochaska & DiClemente, 1983)

The story of Venketesh…….Role of nurse : Why ? Where ? What?

• A 27 yr old, IT professional, Urban background, unmarried

• Diagnosis F 11.20 (Cap.Spasmoproxyvyn & Syp. Corex)• Treatment: T. Naltrexone 50 mg/day (Non compliant)• During follow up meets OPD nurse with bombarding

arguments ????

Why IV Naloxone to me now??

No effect at all ???

Am taking still capsules & syrup

The story of Venketesh…….Role of nurse : Why ? Where ? What?

Client Education

Why IV Naloxone to me now??

• IV/ SC 0.4-0.8 mg (opiate free period)

No effect at all ??? Am taking still capsules & syrup !!!!

• Very high doses of opioids to overcome the blockade of receptors

First visit

Subsequent visit

Now am taking alcohol but stopped opioids…any problem??

• Naltrexone in F10.20 & “ High use alcohol Vs No effect” and dose regulation

How long I should take …..very costly !!!!

• No general rules; 6 months -1 year

Nurses in substance abuse treatment:Emerging trends

VERY Less attention by nurses as independent practice

Nurses in substance abuse treatment:Emerging trends

• Undergraduate nurses in Brazil are not adequately prepared in the care and management of substance misuse problems

• Specific support in teaching and research to nurse teachers…….

Nurses in substance abuse treatment:Emerging trends

• Large body of research on brief intervention by nurses (Emergency unit, OPD clinics, OBG unit, workplace settings, primary care area)

• Strong recommendation by WHO (varied results & modest effect)

• Brief intervention @ PGIMER, Chandigarh experience….

SLNo:

Change in ASSIST scores n %

1 Reduced ASSIST Score 24 77 %

2 No change 05 16%

3 Increased ASSIST Score 02 7%

Substance use disorders treatment: Current trends

NO FDA-approved medications to treat cocaine, marijuana, or methamphetamine SUDs.

Treatment modalities

Treatment Modalities- 1Medicines (Agonist, Antagonist, Deterrents&

Others)

• Reversal of acute effects• overdose & toxicity• Detoxification• Decline of craving• Prevent relapse• Restoration of health damage

Treatment modalities

Treatment Modalities- 2Psychological & Social Therapy

• Brief Counselling• Motivation enhancement therapy• Cognitive behavioural therapy• Relapse prevention counselling• Network therapy• Family and Marital Therapy • Therapeutic alliance

Treatment decision tree

ConclusionManagement of Substance Use Disorder

• Well-planned , comprehensive and co-ordinated strategy • The treatment goal could either be abstinence or harm

reduction• Chronic relapsing disorder: frequent relapse- up to 80%

within three months

• Therapist-patient relationship

• Improvement of treatment compliance by supervised and contractual pharmacotherapy

Thank You

For kind attention