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Opioids

Trainer Notes& Activities

Overview

Although opioids are used by a small proportion of the population relative to other psychoactive drugs, their use entails considerable health, social and legal consequences. GPs can detect early stage use (before dependence develops), to assist patients to reduce harms associated with opioid and injecting drug use, and to support, negotiate, or provide treatment or shared care responses once dependence develops.

KEY POINTS1. GPs can play an important role in identifying and reducing opioid-related harms.

2. Although illicit opioid use is reported by less than 1% of the population, the health and social consequences for the individual and the community can be devastating.

3. The acute risks associated with opioid use relate to acute toxicity.

4. Withdrawal is unpleasant but not life-threatening.

5. Pharmacotherapies for managing opioid dependence, such as methadone, have demonstrated long-term efficacy in improving the health and psychosocial function of opioid-dependent individuals, and in reducing criminal activity.

6. Few physical or psychological harms are related to long-term opioid use, however social relationships, and general functioning may require time for adjustment.

SUGGESTED OBJECTIVESTo enable GPs to: identify the effects and consequences of opioid use and associated harms

apply skills gained in other topics (such as Assessment and Brief Intervention) to assess and respond to the harms associated with opioid use

identify and implement harm reduction strategies relevant to opioid harms

identify, treat and refer patients with problems requiring specific care, such as overdose, local or systemic infections, or pharmacotherapy management.

Resource Kit for GP Trainers on Illicit Drug IssuesPart B4 Drugs: Opioids

4.5: Opioids

Please check that these objectives are relevant for the particular group you are about to train. If not, write down alternatives.

Topic Contents

SLIDESThe slides with slide notes cover: types of opioids commonly used for their psychoactive effect

pharmacology

effects: immediate and long-term, and drug interactions

role of the GP in assessment and examination

treatment options (including withdrawal management and pharmacotherapies).

The slides are on the Resource Kit CDROM under this topic. Trainers are encouraged to select and/or adapt this slide set to meet the focus of the training and information needs of their participants.

ACTIVITIESThe activities, along with those in B3: Clinical Process, provide opportunities for GPs to: identify issues related to the use of opioids within the general practice context

identify relative benefits and harms related to opioid use

plan and implement harm reduction strategies specific to opioid use.

HANDOUTS1. Pharmacological Properties of Opioids

Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, 2nd edn, Custodial Medicine Unit, Victoria Police, Melbourne. pp.1–30.

2. Heroin: GP Supplement No.8Gill, T. 1997, ‘Heroin Addiction’, GP Drug and Alcohol Supplement No.8 Available at: http://www.health.nsw.gov.au/public-health/dpb/supplements/supp8.pdf

3. Pharmaceutical Options for TreatmentPharmaceutical Society of Australia & Pharmacy Guild of Australia 2002, Illicit Drugs: National Training Package for Pharmacy. Pharmacist Facilitator Manual, Commonwealth Department of Health & Ageing, Canberra. p.78.

4. Methadone and Opioid Treatment: GP Supplement No. 2Gill, T. & Evans, M. 1996, Methadone in the treatment of opioid dependence GP Drug and Alcohol Supplement No.2, http://www.health.nsw.gov.au/public-health/dpb/supplements/supp2.pdf

5. Interactions with Methadone


Pharmaceutical Society of Australia & Pharmacy Guild of Australia 2002, Illicit Drugs: National Training Package for Pharmacy, Pharmacist Facilitator Manual, Commonwealth Department of Health & Ageing, Canberra, pp.103–104.

6. Opioid Withdrawal Scales (OOWS & SOWS)DeCrespigny, C., Talmet, J, Modystack, K., Cusack, L., & Watkinson, J. 2003, Alcohol, Tobacco and Other Drugs Guidelines for Nurses and Midwives: Clinical Guidelines, Flinders University and Drug and Alcohol Services Council Adelaide.

7. Opioid SDSGossop, M., Darke, S., Griffiths, P., Hando, J., Powis, B., Hall, W. & Strang, J. 1995, ‘The Severity of Dependence Scale (SDS): Psychometric Properties of the SDS in English and Australian Samples of Heroin, Cocaine and Amphetamine Users’, Addiction, vol. 90, pp. 607–614.Dawe, S., Loxton, N., Hides, L., Kavanagh, D., & Mattick, R. 2002, Review of diagnostic screening instruments for alcohol and other drug use and other psychiatric disorders 2nd Edition Commonwealth Department of Health and Ageing, Canberra.

8. Common Presentations of Drug UseSource: Population Health Education Curriculum (PHEC): Alcohol and Other Drugs Training Module (1998) Available within training curriculum from Rural and Remote Medical Education Online (RRMEO) at http://prodsg.rrmeo.comNCETA 2004, Alcohol and Other Drugs: A Handbook for Health Professionals Australian Government Department of Health and Ageing.

Please refer to the Resource Kit CDROM for a copy of handouts (in PDF and Word).


4.5: Opioids

Slides, Activities & Handouts from other topics may be useful. Please refer to Part A3 for: Examples of Potential Links to Other Slides, and for a Listing of Activities and Handouts.

Additional Sources of Information

PATIENT RESOURCESDunlop, A., Thornton, D. Lintzeris, N., Muhleisen, P., Khoo, K. & Lew, R. 1996, Coming Off Methadone Fitzroy, Victoria: Turning Point Alcohol and Drug Centre Inc.

Lintzeris, N., Dunlop, A., & Thornton, D. 1996, Getting Through Heroin Withdrawal Fitzroy, Victoria: Turning Point Alcohol and Drug Centre Inc.

NDARC (National Drug and Alcohol Research Centre) no date, What You Need to Know About Methadone, National Drug and Alcohol Research Centre, Sydney.

NDARC (National Drug and Alcohol Research Centre) no date b, Heroin, National Drug and Alcohol Research Centre, Sydney.

O’Brien, S. 2004, Treatment Options for Heroin and Other Opioid Dependence: A Guide for Users, Australian Government Department of Health and Ageing, Canberra http://www.nationaldrugstrategy.gov.au/publications/illicit.htm

O’Brien, S. 2004, Treatment Options for Heroin and Other Opioid Dependence: A Guide for Families and Carers, Australian Government Department of Health and Ageing, Canberra http://www.nationaldrugstrategy.gov.au/publications/illicit.htm

A number of fact sheets for patients/carers are available from the ADF website at http://www.adf.org.au/index.htm and ABC online Health Matters at http://www.abc.net.au/health/default.htm

State and Territory Health websites also provide patient orientated information and contact information.


Patient resources are a valuable tool in the clinical setting. They can be obtained through ADIS or the publisher – free or at nominal cost.

http://www.nationaldrugstrategy.gov.au/publications/illicit.htm


KEY READINGSAlliance of NSW Divisions GP Liaison Project, Tip Sheet Series. Available from: www.answd.com.au

Narcotic drugs: a general information guide Heroin – Effects Heroin – overdose, pregnancy and driving Detoxification from heroin in General Practice Detoxification from heroin using clonidine in the General Practice setting Buprenorphine: a general information guide for the General Practice setting Commencing Buprenorphine in the General Practice setting Buprenorphine detoxification in the General Practice setting Relapse prevention strategies for heroin in General Practice Buprenorphine maintenance in the General Practice setting Methadone programs Methadone: a general information guide for the General Practice setting Methadone: pregnancy and take-away doses Methadone – Effects Treatment matching for alcohol and other drugs in General Practice Treatment matching after detoxification in General Practice

Bell, J., Kimber, J., Lintzeris, N., White, J., Monheit, B., Henry-Edwards, S., Mattick, R., Ali, R., Ritter, A. & Quigley, A. 2003, Clinical Guidelines and Procedures for the Use of Naltrexone in the Maintenance Treatment of Opioid Dependence, Australian Government Department of Health and Ageing, Canberra. http://www.nationaldrugstrategy.gov.au/publications/illicit.htm

DeCrespigny, C., Talmet, J, Modystack, K., Cusack, L., & Watkinson, J. 2003, Alcohol, Tobacco and Other Drugs Guidelines for Nurses and Midwives: Clinical Guidelines, Flinders University and Drug and Alcohol Services Council Adelaide.

Henry-Edwards, S., Gowing, L., White, J., Ali, R., Bell, J., Brough, R., Lintzeris, N., Ritter, A. & Quigley, A. 2003, Clinical Guidelines and Procedures for the Use of Methadone in the Maintenance Treatment of Opioid Dependence, Australian Government Department of Health and Ageing, Canberra. http://www.nationaldrugstrategy.gov.au/publications/illicit.htm

Intergovernmental Committee on Drugs, National Pharmacotherapy Policy for People Dependent on Opioids. 2004, Australian Government Department of Health and Ageing, Canberra. http://www.nationaldrugstrategy.gov.au/publications/illicit.htm

Lintzeris, N., Clark, N., Muhleisen, P., Ritter, A., Bell, J., Gowing, L., Hawkin, L., Henry-Edwards, S., Mattick, R., Monheit, B., Newton, I., Quigley, A., Whicker, S., & White, J. 2001, National Clinical Guidelines and Procedures for the Use of Buprenorphine in the Treatment of Heroin Dependence, Australian Government Department of Health and Ageing, Canberra. http://www.nationaldrugstrategy.gov.au/publications/illicit.htm

Mattick, R., Digiusto, E., Doran, C., O’Brien, S., Shanahan, S., Kimber, J., Henderson, N., Breen, C., Shearer, J., Gates, J., Shakeshaft, A., & NEPOD Trial Investigators, (2001), National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD): Report of Results and Recommendations, Australian Government Department of Health and Ageing, Canberra. http://www.nationaldrugstrategy.gov.au/publications/illicit.htm


4.5: Opioids






O’Brien, S. 2004, Treatment Options for Heroin and Other Opioid Dependence, A Guide for Front Line Workers, Australian Government Department of Health and Ageing, Canberra. http://www.nationaldrugstrategy.gov.au/publications/illicit.htm

Palmer, B. 2001, Alcohol and Drug Withdrawal: A Practical Approach. A manual for Doctors to Assist in the Treatment of Patients Withdrawing from Alcohol and Other Drugs, Next Step Specialist Drug and Alcohol Services, Mt Lawley, Perth, Western Australia.

Sim, M., Hulse, G., Martin, J., Liew, D., Ferguson, J., & Conigrave, K. 2004, ‘Opioids’ in Hulse, G. (ed.) 2004, Alcohol and Drug Problems: A Case Studies Workbook, ch. 1, Oxford University Press, South Melbourne, pp.1–34.

Todd, F. 2002, ‘Coexisting Alcohol and Drug Use and Mental Health Disorders’ in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 20, Oxford University Press, South Melbourne, pp.359–373.

Young, R., Saunders, J., Hulse, G., McLean, S., Martin, J. & Robinson, G. 2001, Opioids (Eds) Hulse, G., White, J. & Cape, G. 2002, Management of Alcohol and Drug Problems, ch. 6, Oxford University Press, South Melbourne, pp.79–123.



ADDITIONAL RESOURCESCDHA (Commonwealth Department of Health and Ageing) 2002, Illicit Drug Training for Pharmacists, CDHA, Canberra, pp.104–5.

Dale, A. & Marsh, A. 2000, A Summary of the Evidence Based Practice Indicators for Alcohol and Other Drug Interventions, Best Practice in Alcohol and Other Drug Interventions Working Group, Perth, Western Australia.

Dawe, S., Loxton, N., Hides, L., Kavanagh, D. & Mattick, R. 2002, Review of Diagnostic screening instruments for alcohol and other drug use and Other Psychiatric Disorders, 2nd edn., Commonwealth Department of Health and Ageing (CDHA), Canberra.

Gossop, M., Darke, S., Griffiths, P., Hando, J., Powis, B., Hall, W. & Strang, J. 1995, ‘The Severity of Dependence Scale (SDS): Psychometric Properties of the SDS in English and Australian Samples of Heroin, Cocaine and Amphetamine Users’, Addiction, vol. 90, pp. 607–614.

Gowing, L., Ali, R. & White, J. 2000, ‘The Management of Opioid Withdrawal’, Drug and Alcohol Review vol. 19, pp. 309–318.

Gossop, M 1990, ‘The Development of a Short Opiate Withdrawal Scale (SOWS)’ Addictive Behaviours vol. 15, issue 5, pp. 487–490.

Lorimer N. et al. 1991, ‘Comparison Between Observer Assessment and Self-rating of Withdrawal Distress During Opiate Detoxification’, Drug and Alcohol Dependence vol. 18, issue 3, pp. 265–268.

For up-to-date information regarding drug use trends seek out the range of publications from the ‘Illicit Drug Reporting System’ (IDRS). These can be obtained from NDARC at http://ndarc.med.unsw.edu.au/ndarc.nsf


4.5: Opioids

OpioidsActivities

Activity 1: Opioids and Harm Reduction in General Practice

PURPOSETo develop strategies to reduce opioid and injection related harms.

PROCESS 1.1 Divide participants into small groups

1.2 Provide the Case Georgia below or consider other sources

1.3 Instruct each group to identify key clinical issues describe harm reduction strategies

1.4 Each group presents their response to the wider group for open discussion

1.5 Facilitate discussion about common findings and approaches that are appropriate.


Case vignettes can be:drawn from the examples given belowsupplied by the trainer and/ordeveloped by GPs based on their recent experience.

CASE: GEORGIA Georgia is a 26 year-old woman who has been using heroin for most of the previous 7 years. She is a sex worker and has presented for a sexual health screening and for you to assist her with an arm abscess.

She often uses a ‘drug cocktail’ that includes alcohol, cannabis and benzodiazepines. She has heard bad press about methadone, but is expressing some interest in going on buprenorphine. She is currently squatting until housing trust accommodation becomes available.

Key issues that may arise from discussion: Blood-borne viruses

current needle use practices

polydrug use interactions

what she wants and how her needs can be met

appropriateness of longer-term interventions (e.g., pharmacotherapies)

likelihood of a response to GP prescribed methadone (in contrast to a clinic based program)

housing and nutritional needs

support of family/friends and existing social supports

role of social services where she is already known.


4.5: Opioids

Activity 2: Opioids, Comorbidity and Relapse

PURPOSETo identify and respond to issues related to comorbidity and relapse.

PROCESS2.1 Divide participants into small groups

2.2 Ask each group to consider the Case Rory (below) and discuss/describe salient assessment considerations brainstorm and list the range of potential interventions you could offer this

patient

2.3 From this list, select one of the possible interventions and work through the case in detail, describing immediate issues and a treatment plan In your responses, anticipate how Rory will react to each of these

suggestions, and make a contingency plan should he not agree to your suggestions

2.4 Each group presents their case intervention to the wider group for open discussion

2.5 Facilitate discussion about common findings and approaches that are appropriate


CASE: RORYRory, 32, a diagnosed severe paranoid schizophrenic, presents with severe depression. He has recommenced using heroin over the last few weeks after a long period of abstinence. He had contacted the 'mental health hotline' who referred him back to you, as his local GP. He was reluctant to present as he felt you would be disappointed in him. Due to his current use he was asked to leave his current accommodation, but thinks he can return when he has straightened out. His schizophrenia is relatively stable at present, and managed by a psychiatrist who has prescribed tricyclic antidepressants.

Source: adapted from Case Number 5 from the Primary Mental Health Care Australian Resource Centre, http://som.flinders.edu.au/FUSA/PARC/CASE5.HTM

The above page reference provides case studies that address opioid issues related to young people; injection-related harms; harm reduction, dependence, withdrawal and associated management; women; comorbidity.

Full citation: Sim, M., Hulse, G., Martin, J., Liew, D., Ferguson, J., & Conigrave, K. 2004, ‘Opioids’ in Hulse. G. (ed.), Alcohol and Drug Problems: A Case Studies Workbook, Oxford University Press, South Melbourne, pp.1–34.


4.5: Opioids

Additional case studies are in Hulse, G. 2004, ‘Opioids’, Alcohol and Drug Problems: A Case Studies Workbook, ch. 1, pp. 1–34.

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