Substance Misuse WorkshopSubstance Misuse Workshop

Opioid Substitute Opioid Substitute MedicationMedication

Scottish Specialist Pharmacists in Substance Scottish Specialist Pharmacists in Substance Misuse Misuse

Presentation outlinePresentation outline Scottish StrategyScottish Strategy

Opioid dependence Opioid dependence Patients with drug misuse problemsPatients with drug misuse problems

Opioid dependence interventionsOpioid dependence interventions

Opioid substitute medicationOpioid substitute medication

Instalment dispensing and supervised consumptionInstalment dispensing and supervised consumption

Pharmacists’ roles and responsibilitiesPharmacists’ roles and responsibilities

Case scenariosCase scenarios

The Road to RecoveryThe Road to Recovery

The Road to RecoveryThe Road to RecoveryA New Approach to Tackling Scotland’s Drug A New Approach to Tackling Scotland’s Drug

ProblemProblem

Published by the Scottish Government Published by the Scottish Government in 2008in 2008

New strategy to tackle problem drug New strategy to tackle problem drug use based on the concept of recoveryuse based on the concept of recovery

What is Recovery?What is Recovery? ““A process through which an individual is A process through which an individual is

enabled to move-on from their problem drug enabled to move-on from their problem drug use towards a drug-free life as an active and use towards a drug-free life as an active and contributing member of society.”contributing member of society.”

Each person will have a different recovery Each person will have a different recovery journey, with different goals along the way.journey, with different goals along the way.

““The service users’ needs & aspirations are The service users’ needs & aspirations are placed at the centre of their care and placed at the centre of their care and treatment.”treatment.”

How can pharmacy promote How can pharmacy promote recovery?recovery?

““Pharmacists have the highest number of Pharmacists have the highest number of contacts with people with problem drug use, contacts with people with problem drug use, often seeing them and their families on a often seeing them and their families on a daily basis. As well as providing access to daily basis. As well as providing access to treatment, pharmacists offer a wide range of treatment, pharmacists offer a wide range of other services, such as the treatment of other services, such as the treatment of minor ailments on the NHS, healthy lifestyle minor ailments on the NHS, healthy lifestyle advice and sign-posting other service advice and sign-posting other service providers”providers”

What is opioid What is opioid dependence?dependence?

Opioid dependence (1)Opioid dependence (1)

Most commonly abused opiate “street drug”- HeroinMost commonly abused opiate “street drug”- Heroin Associated with Dopamine release and euphoriaAssociated with Dopamine release and euphoria Injecting increases effectsInjecting increases effects Physical Dependence / opioid withdrawal symptomsPhysical Dependence / opioid withdrawal symptoms Psychological dependence / coping mechanismPsychological dependence / coping mechanism Uncontrolled use, drug-seeking behaviourUncontrolled use, drug-seeking behaviour Chronic relapsing conditionChronic relapsing condition

-

Opioid dependence (2)Opioid dependence (2) Harms – individuals, communities, societyHarms – individuals, communities, society Physical and mental harmsPhysical and mental harms

– Risk of overdose / Drug-related deaths (DRDs)Risk of overdose / Drug-related deaths (DRDs)– Blood-borne viruses (BBVs - HIV, Hepatitis B and C)Blood-borne viruses (BBVs - HIV, Hepatitis B and C)– Poor self-care, malnutrition, sedation, constipationPoor self-care, malnutrition, sedation, constipation– Depression, stress Depression, stress

Social harmsSocial harms– Social exclusion – education, employmentSocial exclusion – education, employment– CrimeCrime– Relationships, families, childrenRelationships, families, children

Patients with drug misuse Patients with drug misuse problemsproblems

• History of abuseHistory of abuse• PovertyPoverty• Parental substance Parental substance

misusemisuse• Parental mental Parental mental

illnessillness• Periods in carePeriods in care• Aggressive behaviour Aggressive behaviour

at schoolat school

• Truancy from schoolTruancy from school• Poor literacy, Poor literacy,

reading/writing skillsreading/writing skills• Episodes of stealingEpisodes of stealing• Episodes of early drug Episodes of early drug

and/or alcohol useand/or alcohol use• ViolenceViolence• Death of carerDeath of carer

Orange GuidelinesOrange Guidelines

Opioid dependence interventionsOpioid dependence interventions Pharmacological & psychosocial interventionsPharmacological & psychosocial interventions Harm Reduction, including a goal of abstinenceHarm Reduction, including a goal of abstinence Road to Recovery (Scottish Government 2008)Road to Recovery (Scottish Government 2008) Opioid substitution medication Opioid substitution medication Methadone, buprenorphineMethadone, buprenorphine

– Maintenance replacement therapyMaintenance replacement therapy– Structured detoxificationStructured detoxification

Stability for patientsStability for patients ReintegrationReintegration Prescribing services work in partnership with Prescribing services work in partnership with

other agencies e.g. social work, housing other agencies e.g. social work, housing support, trainingsupport, training

Substitute medication Substitute medication for opioid dependencefor opioid dependence

• Strong evidence base Strong evidence base • ↓↓ illicit drug use illicit drug use • ↓ ↓ mortalitymortality• ↓↓ risk of overdose risk of overdose • ↓↓ injecting activityinjecting activity• ↓↓ transmission of BBVs transmission of BBVs • ↓↓ crimecrime• Improved mental and Improved mental and

physical healthphysical health

• Cost effective Cost effective interventionintervention

• Re-employment, return Re-employment, return to educationto education

• Social rehabilitationSocial rehabilitation• Need to stay in Need to stay in

treatment to achieve treatment to achieve best outcomesbest outcomes

• Benefits to the Benefits to the communitycommunity

MethadoneMethadone

Long acting synthetic opioid – Long acting synthetic opioid – administered once dailyadministered once daily

Occupies opioid receptors and reduces Occupies opioid receptors and reduces the effects of heroin and other opioids the effects of heroin and other opioids

Used to reduce and replace heroin useUsed to reduce and replace heroin use Alleviates opioid withdrawal symptomsAlleviates opioid withdrawal symptoms ReducesReduces cravingscravings Recommended preparation: 1mg/ml Recommended preparation: 1mg/ml

(green)(green)

Methadone initiation Methadone initiation and maintenance treatmentand maintenance treatment

Starting dose 10-40mg (prescriber’s assessment)Starting dose 10-40mg (prescriber’s assessment) Dose increase no more than 10mg on one day Dose increase no more than 10mg on one day

and 30mg in one week and 30mg in one week Allow a few days between each dose increaseAllow a few days between each dose increase Time to reach steady state (3-10 days)Time to reach steady state (3-10 days) Titrate methadone dose until patient Titrate methadone dose until patient

experiencing neither withdrawals or intoxicationexperiencing neither withdrawals or intoxication Usual daily dose 60-120mg Usual daily dose 60-120mg May take several weeks to reach desired doseMay take several weeks to reach desired dose

Methadone - Methadone - Single DoseSingle Dose

Methadone - Titrating Dose (3 Methadone - Titrating Dose (3 days)days)

Methadone - Steady StateMethadone - Steady State

Methadone - Missed DoseMethadone - Missed Dose

Methadone side effectsMethadone side effects

ConstipationConstipation Nausea, vomiting (start of treatment)Nausea, vomiting (start of treatment) Dry mouth, eyes and noseDry mouth, eyes and nose Constricted pupilsConstricted pupils RashesRashes SweatingSweating Respiratory depression (overdose)Respiratory depression (overdose) QTc prolongation – other risk factors, dose QTc prolongation – other risk factors, dose

>100mg/day>100mg/day

BuprenorphineBuprenorphine Solo preparation SubutexSolo preparation Subutex® (Buprenorphine)® (Buprenorphine) Combined preparation Suboxone Combined preparation Suboxone ®® (Buprenorphine with (Buprenorphine with

naloxone) naloxone) Both forms are sublingual tabletsBoth forms are sublingual tablets Partial opioid agonistPartial opioid agonist Treatment option – Patient criteria- differs between heath Treatment option – Patient criteria- differs between heath

board policyboard policy Current hazardous alcohol and / or benzodiazepine useCurrent hazardous alcohol and / or benzodiazepine use High risk of opioid overdoseHigh risk of opioid overdose Previously failed with or been intolerant to methadonePreviously failed with or been intolerant to methadone Risk of QTc interval prolongationRisk of QTc interval prolongation Patient choice Patient choice Short history of opioid dependence Short history of opioid dependence Motivated for detoxification (some board use for maintenance)Motivated for detoxification (some board use for maintenance)

Buprenorphine ‘v’ methadoneBuprenorphine ‘v’ methadone Advantages compared to methadoneAdvantages compared to methadone

- Less dangerous in overdose- Less dangerous in overdose - “On top” use reduced- “On top” use reduced - Reportedly easier withdrawal- Reportedly easier withdrawal - Clearer head, less “opiate like” or “clouding effect”- Clearer head, less “opiate like” or “clouding effect”

DisadvantagesDisadvantages - Highly soluble, potential for injection (NB. - Highly soluble, potential for injection (NB.

Suboxone)Suboxone) - Precipitated withdrawal if used incorrectly- Precipitated withdrawal if used incorrectly - “clearer head!”- “clearer head!” - Supervision is more difficult- Supervision is more difficult - More expensive- More expensive

Buprenorphine initiation Buprenorphine initiation and maintenance treatmentand maintenance treatment

Risk of precipitated withdrawal – inform patientsRisk of precipitated withdrawal – inform patients Delay first dose until patient experiencing Delay first dose until patient experiencing

withdrawalswithdrawals Starting dose 4-8mg Starting dose 4-8mg Daily dose increases 2-8mgDaily dose increases 2-8mg Usual daily dose 12-16mg Usual daily dose 12-16mg Maximum dose 32mg (Subutex) and 24mg Maximum dose 32mg (Subutex) and 24mg

(Suboxone)(Suboxone) Longer half-life therefore allows Longer half-life therefore allows

for alternate day dosing at higher dosesfor alternate day dosing at higher doses

Buprenorphine side effectsBuprenorphine side effects

InsomniaInsomnia

ConstipationConstipation NauseaNausea Sweating Sweating HeadacheHeadache

Respiratory depression (less)Respiratory depression (less)

Instalment dispensing & supervised Instalment dispensing & supervised

consumption consumption • Reduce diversionReduce diversion• Improve retention in treatmentImprove retention in treatment• Relationship with pharmacistRelationship with pharmacist• Medico-legal protection for prescriber Medico-legal protection for prescriber

and pharmacistand pharmacist• Regular monitoringRegular monitoring• Helps checks dose correctHelps checks dose correct• Initially supervised for 3 monthsInitially supervised for 3 months• Intoxication- drugs or alcohol-risk of Intoxication- drugs or alcohol-risk of

overdoseoverdose

Supervised consumptionSupervised consumption procedures procedures

• Privacy, prepare in advance if possiblePrivacy, prepare in advance if possible• Check patient’s identityCheck patient’s identity• Methadone Methadone

– Measure dose – plastic cup, strawMeasure dose – plastic cup, straw– Ensure the dose has been swallowed – drink of Ensure the dose has been swallowed – drink of water afterwards, talk with the patientwater afterwards, talk with the patient– Soft drink cans / ‘spit methadone’Soft drink cans / ‘spit methadone’

• BuprenorphineBuprenorphine– Drink water before not immediately afterDrink water before not immediately after– Put in container – not in patient’s hand ‘palming’Put in container – not in patient’s hand ‘palming’– Ensure patient puts tablets under their tongue Ensure patient puts tablets under their tongue – Ensure tablets have dissolvedEnsure tablets have dissolved– Crushing tabletsCrushing tablets

What is the role of What is the role of the community the community

pharmacist?pharmacist?

Role of Community PharmacistRole of Community Pharmacist

““Pharmacists are the most accessible healthcare Pharmacists are the most accessible healthcare professionals & see the greatest number of professionals & see the greatest number of patients without an appointment on a daily basis. patients without an appointment on a daily basis. Pharmacists, located in almost every local Pharmacists, located in almost every local community, are ideally placed to promote public community, are ideally placed to promote public health & facilitate a reduction in health health & facilitate a reduction in health inequalities”inequalities” RPSGB 2007 RPSGB 2007

““Pharmacists have the highest number of contacts Pharmacists have the highest number of contacts with people with problem drug use, often seeing with people with problem drug use, often seeing them & their families on a daily basis”them & their families on a daily basis” Road toRoad to Recovery 2008Recovery 2008

Essential Care – SACDM 2008Essential Care – SACDM 2008

““people with substance use problems have people with substance use problems have aspirations, and should have access to the aspirations, and should have access to the same services as anyone else.”same services as anyone else.”

Getting Serious about Stigma in Getting Serious about Stigma in Scotland: Scotland: the problem with the problem with

stigmatising drug usersstigmatising drug users

““being made to wait while other being made to wait while other people who arrived later are seen or people who arrived later are seen or served”served”

““having to wait in a separate area”having to wait in a separate area”

““having confidentiality breached by having confidentiality breached by loud remarks such as “Here’s your loud remarks such as “Here’s your methadone”.”methadone”.”

However there are good However there are good experiences…….experiences…….

““I personally wouldn’t change a thing about this I personally wouldn’t change a thing about this pharmacy. All the time I have used it I have never pharmacy. All the time I have used it I have never had any problems whatsoever. The pharmacist and had any problems whatsoever. The pharmacist and staff are great. Also they don’t judge you on why or staff are great. Also they don’t judge you on why or what you are there for. I have never been treated what you are there for. I have never been treated differently from anyone else using the pharmacy.”differently from anyone else using the pharmacy.”

““I am very happy with the level of service I receive I am very happy with the level of service I receive at present. I am diabetic, epileptic and require a lot at present. I am diabetic, epileptic and require a lot of prescriptions. Staff look after me very well to of prescriptions. Staff look after me very well to ensure I am never left without anything”ensure I am never left without anything”

CommunicationCommunication

Build a supportive therapeutic relationship Build a supportive therapeutic relationship – staff attitudes are important to patients– staff attitudes are important to patients

4-Way Treatment Agreement – 4-Way Treatment Agreement – recommended in Road to Recoveryrecommended in Road to Recovery

Regular contact with professionals Regular contact with professionals involved in careinvolved in care

What community pharmacy can What community pharmacy can offer..offer..

Access to other pharmacy services Access to other pharmacy services

Minor Ailments Scheme (MAS)Minor Ailments Scheme (MAS) Smoking cessationSmoking cessation Sexual HealthSexual Health Local services e.g. condom provision, prescription Local services e.g. condom provision, prescription

ordering/collectionordering/collection

SignpostingSignposting

Addiction teamAddiction team HospitalHospital GP/Practice nurseGP/Practice nurse Sexual Health servicesSexual Health services Harm ReductionHarm Reduction

Patient EducationPatient EducationProvide patient information and adviceProvide patient information and advice Risk of overdose, polydrug use – Risk of overdose, polydrug use –

benzodiazepines, alcoholbenzodiazepines, alcohol Prevention and management of overdosePrevention and management of overdose Loss of tolerance – missed dosesLoss of tolerance – missed doses Opioid naive e.g. childrenOpioid naive e.g. children

Safe storageSafe storage Advice – dietary, alcohol, dental care, Advice – dietary, alcohol, dental care,

medicationmedication Safer injecting, BBVsSafer injecting, BBVs

Good Practice Guidance (1)Good Practice Guidance (1)

What guidelines & training are available in What guidelines & training are available in your Health Board area?your Health Board area?

SOPs e.g. preparation, supervision, missed SOPs e.g. preparation, supervision, missed dosesdoses

Individual bottlesIndividual bottles

CD regulations – instalment dispensingCD regulations – instalment dispensing

Communication between the pharmacy team, Communication between the pharmacy team, locums, patient, prescriber and workerlocums, patient, prescriber and worker

Good Practice Guidance (2)Good Practice Guidance (2)

How can you minimise the risk of error?How can you minimise the risk of error? Check start date on prescriptionCheck start date on prescription Fill in PC70 form and CD register correctlyFill in PC70 form and CD register correctly Collected/Uncollected prescription Collected/Uncollected prescription

separated?separated? Finished prescription removed?Finished prescription removed? How will you confirm patient identity?How will you confirm patient identity? How are missed doses flagged?How are missed doses flagged?

Errors occur whenErrors occur when SOP is not followedSOP is not followed Patient identity is assumed and not confirmedPatient identity is assumed and not confirmed Inadequate prescription filing (extra doses)Inadequate prescription filing (extra doses) Extended opening hours/ 2 pharmacistsExtended opening hours/ 2 pharmacists Missed doses not recordedMissed doses not recorded Communication lacking between Communication lacking between

staff/pharmacists/workersstaff/pharmacists/workers ORGANISATION AND COMMUNICATION ARE THE ORGANISATION AND COMMUNICATION ARE THE

KEY!!KEY!!

What can pharmacists do to help reduce the number of What can pharmacists do to help reduce the number of drug-related deaths and promote the provision of drug-related deaths and promote the provision of

naloxone?naloxone? Identify your local naloxone leadIdentify your local naloxone lead

Display the National Naloxone Programme materialsDisplay the National Naloxone Programme materials

Provide information about overdose prevention Provide information about overdose prevention

Signpost to a local training sessionSignpost to a local training session

Observations and clinical impressions are important. Observations and clinical impressions are important. Monitor service users Monitor service users

Important to remember that the pharmacist may be the Important to remember that the pharmacist may be the only contact with a healthcare professional that the client only contact with a healthcare professional that the client has has

Role of Hospital PharmacistRole of Hospital Pharmacist

Patients with drugs misuse issues will be found in Patients with drugs misuse issues will be found in many settings, e.g.many settings, e.g.

General Hospitals – A&E, Medical/Surgical wards, General Hospitals – A&E, Medical/Surgical wards, ITU, Infectious Diseases etcITU, Infectious Diseases etc

Maternity HospitalsMaternity Hospitals Mental Health UnitsMental Health Units Older People’s UnitsOlder People’s Units Specialist Addiction UnitsSpecialist Addiction Units

Role of Hospital PharmacistRole of Hospital PharmacistIssues include:Issues include:

Medicines Reconciliation on admission / Medicines Reconciliation on admission /

transfer / dischargetransfer / discharge Management of withdrawal e.g. opiates, Management of withdrawal e.g. opiates,

benzodiazepines, alcoholbenzodiazepines, alcohol Pain managementPain management Admission to hospital can be an opportunity Admission to hospital can be an opportunity

to engage drug users into drug treatmentto engage drug users into drug treatment

Discharge PlanningDischarge Planning Post-discharge may be a ‘high risk’ timePost-discharge may be a ‘high risk’ time All patients should be given:All patients should be given:

harm reduction adviceharm reduction advicelocal IEP informationlocal IEP informationprevention of overdose advice, prevention of overdose advice,

including including risks of reduced tolerancerisks of reduced toleranceavailability of naloxone training and availability of naloxone training and

supplysupply

Role of the Specialist Pharmacist Role of the Specialist Pharmacist in Substance Misusein Substance Misuse

National group - SSPiSMNational group - SSPiSM Most Scottish Health Boards (contact list)Most Scottish Health Boards (contact list) Health Board – advisory, strategic Health Board – advisory, strategic Alcohol and Drug Care PartnershipsAlcohol and Drug Care Partnerships Liaison between specialist and community Liaison between specialist and community

servicesservices Service review & developmentService review & development Training & support Training & support Pharmacist prescribersPharmacist prescribers

Any questionsAny questions

Further readingFurther reading

• Drug Misuse and Dependence: UK Guidelines on Clinical Management (2007)

• The Road to Recovery (Scottish Government 2008)The Road to Recovery (Scottish Government 2008)• Substance Misuse. Clinical Pharmacist (Sept 2009)Substance Misuse. Clinical Pharmacist (Sept 2009)