1. Prepared by J. Mabbutt & C. Maynard NaMO September 2008 9: Pharmacotherapies – Pain Management

2. 1.During the session, pharmacotherapies, their uses & nursing practice issues will be overviewed 2.Pain management related to the opiate pharmacotherapies will also be highlighted providing key issues for practice 3.At the end the session, nurses & midwives will have a basic understanding of the pharmacotherapies used in the drug & alcohol field & pain management issues related to these 9: Pharmacotherapies & Pain Management: Objectives

3.  There is a range of pharmacological therapies that are effective in the treatment of alcohol, opioid & nicotine dependence in Australia  All nurses, midwives, medical officers & allied health professionals need to know about these treatments, the rationale & benefits of use  Pain management for opioid pharmacotherapies is often misunderstood and patients may not receive effective pain relief 9: Pharmacotherapies for dependence and related pain management

4.  One of the most researched treatment modalities for dependence, & an overall assessment of its effectiveness can be made with more confidence than for other treatments  It is more effective at higher daily doses (at least 60mgs) as a maintenance therapy  A synthetic opioid with a long half-life – longer acting than heroin  It is active orally as syrup, can be administered once a day under medical or nursing supervision at a clinic, or dispensed from a specified community pharmacy or hospital 9: Opioid pharmacotherapies Methadone (1)

5.  There are criteria for admission into methadone maintenance programs  A specialist doctor or GP prescribes methadone, with the client being registered with the local relevant authority such as the health department  Methadone should be used as part of a program that includes treatment for a comorbid psychiatric disorder, & where counselling for personal problems is available  Caution needs to be observed regarding patients receiving high doses if there is concurrent alcohol or benzodiazepine dependence as there is a risk of respiratory depression 9: Opioid pharmacotherapies Methadone (2)

6. Short term  Related to the central nervous system depressant properties of opioids:  Constipation  Nausea/vomiting  Drop in body temperature  Bradycardia, palpitations  Hypotension 9: Opioid pharmacotherapies Methadone – Side effects (1)

7. Long term  Weight gain  Tooth decay due to decreased oral secretions Contraindications  Kidney disease  Liver disease For further information, see Appendix 7: Drug interactions with Methadone 9: Opioid pharmacotherapies Methadone – Side effects (2)

8.  Buprenorphine is a partial opioid agonist – an opioid analgesic  It has a high affinity (binds) to the opioid receptor sites not allowing other opiates to act but at the same time it gives a partial opioid effect  Buprenorphine is as effective as methadone for people with moderate levels of dependence, & possibly for those with higher levels (Hulse et al. 2002, p. 91)  However, retention on buprenorphine appears to be less than that achieved with methadone  Patient selection is important 9: Opioid pharmacotherapies Buprenorphine (1)

9. Buprenorphine is available in two forms: –buprenorphine (Subutex) & –buprenorphine-naloxone (Suboxone)  Both forms are usually administered sublingually (usually takes 5 minutes to dissolve)  The tablet (s) can be used whole or in crushed form, as this does not affect sublingual absorption directly  The drug reaches its peak effect after about 3 hours 9: Opioid pharmacotherapies Buprenorphine (2)

10.  It is easier to taper buprenorphine than methadone, & as a partial agonist is safer in overdose  It results in less respiratory depression than full agonists, such as methadone  A wider safety margin & strong receptor binding leading to a long half-life make alternate day dosing a convenient option for many patients 9: Opioid pharmacotherapies Buprenorphine (3)

11. Some side effects have been reported, however, these are relatively mild and include:  Headache  Sedation  Nausea  Constipation  Anxiety  Dizziness and itching 9: Opioid pharmacotherapies Buprenorphine – Side effects

12.  Effective nursing care includes appropriate management of a person receiving opioid maintenance treatment during their hospital stay  Because they are taking methadone or buprenorphine, the continued provision of their opioid maintenance treatment is important  This will help maintain their comfort & safety, assist in planning pain management, & prevent the harms associated with poorly managed opioid withdrawal, thus reducing the risk of relapse &/or unplanned early discharge 9: Opioid maintenance treatment in acute hospital setting

13.  Consult with the drug & alcohol specialist or drug & alcohol nurse practitioner about the care of all patients admitted to hospital who are receiving opioid maintenance treatment  Ensure that their methadone or buprenorphine dose is known & confirmed with prescriber and dosing point, and that the dose is quoted in both mg and mls for methadone  Find out from the prescriber &/or the dispensing pharmacy the timing of the last dose of medication and any takeaway doses 9: Opioid maintenance treatment in acute hospital setting – General principles

14.  The patients most likely to have altered tolerance are:  Those who have been on regular prescribed opioid medication for long periods – they may be said to have iatrogenic dependence (medically caused)  Those currently receiving opioid maintenance treatment program or who are currently dependent on opioids  Those who regularly take liver enzyme-inducing drugs (e.g. alcohol, dilantin, interferon and rifampicin etc) 9: Altered tolerance and effective pain management

15.  Clear communication regarding changes in their medication will help to lessen any anxiety and provide reassurance  It is critical that analgesia is not withheld from the person unless medically indicated  Providing pain relief will not make the person more drug dependent 9: Altered Tolerance and effective pain management – Acute Pain Management

16.  If a person is being prescribed methadone as a maintenance pharmacotherapy for opioid dependence, even at high doses, they will require additional opioids over & above their daily methadone dose for effective pain relief due to tolerance  Accident & emergency & other nursing & medical staff need to know that a person is taking methadone so that effective pain relief can be offered  Refer to NSW Health Policy Directive PD 2006_ 049. Opioid-dependent Persons Admitted to Hospitals in NSW – Management 9: Opioid pharmacotherapies Methadone – Pain Relief

17.  Standard doses of opioid analgesia are not likely to be effective in any patient who has used buprenorphine within the 3-4 days prior to requiring such analgesics  Advice should be sought from a Medical Officer skilled in drug & alcohol or D&A nurse practitioner in these instances  Accident & emergency & other nursing & medical staff need to know if a person is taking buprenorphine so that effective pain relief can be provided by using non-opioid analgesics, local anaesthetic approaches or higher dose opioid prescriptions in these situations 9: Opioid pharmacotherapies Buprenorphine – Pain relief

18.  As an antagonist, naltrexone blocks both the euphoric & analgesic effects of opioids  It is long acting, with effects lasting between 24 & 72 hours  Use of naltrexone while still opioid-dependent will bring on severe withdrawal symptoms and there are particular management issues for nurses when this drug has been self-administered by opioid users 9: Opioid pharmacotherapies Naltrexone (1)

19.  If depression occurs as a side effect of Naltrexone, an alternative pharmacotherapy is often considered  Research into its effectiveness shows that there is a high drop-out rate from treatment  Relapse could run the risk of overdose due to reduced opioid tolerance (Gowing et al. 2001; Young et al. 2002) 9: Opioid pharmacotherapies Naltrexone (2)

20.  Opioid analgesia is not likely to be effective in any patient who has used naltrexone within the previous 7 days  In these instances, advice should be sought from a Medical Officer skilled in drug & alcohol or a D&A nurse practitioner  Accident & emergency & other nursing & medical staff need to know if a person is taking naltrexone so that effective pain relief can be provided by using non-opioid analgesics in these situations 9: Opioid pharmacotherapies Naltrexone – Pain relief

21.  This form of detoxification is known by a number of names, including “ultra-rapid detoxification”, “accelerated detoxification”, “sedated detoxification” & “detoxification under anaesthetic”  Rapid opioid detoxification is the process of accelerating acute withdrawal by administration of an opioid antagonist, while providing symptomatic relief to enable patients to tolerate the procedure  The detoxification is followed with daily naltrexone treatment either tablets or implants 9: Opioid pharmacotherapies Naltrexone – Withdrawal – Rapid opioid detoxification (ROD) (1)

22.  For treatment guidelines for the management of opioid withdrawal inadvertently precipitated by naltrexone, see the relevant section in Chapter 9.1, Opioids  Some significant risks have been associated with sedation during ROD, including death as a result of aspiration or respiratory depression  For further information on methadone & buprenorphine treatment, refer to: NSW Opioid Treatment Program: Clinical Guidelines for methadone and buprenorphine treatment. Doc No. GL2006_019. www.health.nsw.gov.au/policies/gl/2006/GL2006_019.html 9: Opioid pharmacotherapies Naltrexone – Withdrawal – Rapid opioid detoxification (ROD) (2)

23.  Methadone is the drug of choice for opioid dependent pregnant women  Buprenorphine is not approved but a patient can continue on it if pregnant  Withdrawal for the baby is likely to occur with both of these maintenance drugs as it would with heroin dependence  For information regarding pharmacotherapies for dependence and maternal/neonatal care, refer to the National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. (March 2006) http://www.health.nsw.gov.au/pubs/2006/ncg_druguse.html 9: Pharmacotherapies for dependence & maternal & neonatal care

24.  Acamprosate is a pharmacotherapy used to prevent alcohol relapse post-withdrawal  It assists in the reduction of cravings for alcohol, where the person is seeking to abstain or reduce their consumption  Compliance can be an issue as dosage is usually two tablets x three times/day (333mg in each tablet)  Acamprosate does not interact with alcohol, and does not have hypnotic, anxiolitic or antidepressant effects 9: Alcohol pharmacotherapies – Acamprosate (Campral)

25.  Naltrexone suppresses the priming effect of alcohol (blunts the euphoric effects of alcohol and reduces the positive reinforcement of alcohol use) & can assist in achieving goals of reduction in consumption &/or abstinence  Monitoring the liver profile is recommended during the course of naltrexone treatment, which is usually three to six months  A dose of 50mg daily has shown positive outcomes with relapse rates, craving & number of non-drinking days 9: Alcohol pharmacotherapies – Naltrexone

26.  The goal in prescribing disulfiram is to provide a powerful disincentive to drink – it inhibits the ALDH in the liver, and if the person drinks alcohol, causes an accumulation of acetaldehyde – making them feel sick  Within 15 minutes of drinking the person may experience the following: flushing; feeling heat & sweating; nausea; vomiting; palpitations & rapid pulse; headache; difficulty breathing blood pressure increase then decrease 9: Alcohol pharmacotherapies – Disulfiram (Antabuse)