opiods abuse
TRANSCRIPT
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