1. Opioid Dependence Anne Kalvik Pearl Isaac

2. Learning Objectives 1.To develop an understanding of opioid dependence issues including tolerance, abuse, toxicity, overdose and withdrawal 2.To become familiar with various treatment strategies for the management of opioid dependence and develop an understanding of the advantages and disadvantages of each approach 3.To consider options available to pharmacists that can impact patient outcome in opioid dependence in its various stages. Students will be encouraged to examine their own attitudes to this issue

3. Opioid Dependence and Pharmacy Practice

4. Medical Uses for Opioids PAIN Cough Diarrhea

5. Undesirable Effects of Opioids Nausea and vomiting Sedation Some people don’t like effects, e.g., itching Physical and psychological dependence Respiratory depression DEATH

6. Why are Opioids Abused?

7. Some Examples of Opioids Codeine Oxycodone Hydromorphone Morphine Meperidine Hydrocodone Heroin Methadone

8. Street Value of Selected Rx Narcotic Drugs in Vancouver’s Downtown Eastside Sajan et al, CMAJ July 28, 1998; 159 (2)

9. Addiction Compulsive drug use Consequences: use despite harm Inability to Cut down Cravings

10. DSM-IV Criteria for Substance Dependence At least 3 of the following in 12-month period: Tolerance Withdrawal Taking larger amounts than intended Unsuccessful efforts to reduce drug use

11. DSM-IV Great deal of time spent acquiring and using the drug Reduction of important activities because of the drug Continued use despite knowledge of drug-related physical or psychological problems

12. Tolerance Neurobehavioural adaptation Rapid tolerance to psychoactive effects Tolerance to analgesic effects develops slowly Tolerance disappears within days

13. Heroin Dependence Short acting drug Cycles of intoxication and withdrawal Injection drug use –HIV, hepatitis, other medical issues –Contaminants Crime, unemployment, domestic problems Prostitution, unsafe sex

14. Effects of Heroin Physical effects on user –direct –indirect Physical effects on others Psychosocial effects on user Psychosocial effects on others

15. Bob 37-year old man buying 10 Oxycontin® per day off the street Currently lives alone, unemployed

16. Opioid Withdrawal (objective) Nausea and vomiting Diarrhea Runny nose, sneezing Lacrimation Dilated pupils Gooseflesh Tremor Feelings of hot and cold Yawning Tachycardia Blood pressure elevation

17. Opioid Withdrawal (subjective) Anxiety Restlessness Abdominal pain and cramps Muscle aches Bone pain Anorexia Craving Insomnia

18. Opioid Intoxication/Overdose Euphoria Dysphoria Motor retardation Sedation Slurred speech Pinpoint pupils Respiratory depression Circulatory collapse Cardiac arrest DEATH

19. Medical Detoxification Clonidine Loperamide Dimenhydrinate NSAIDs (Benzodiazepines) (Naltrexone) UROD

20. Why not detoxify? Opioid withdrawal not life-threatening BUT Alternative for many is return to drug use and not staying ‘clean’ Often a chronic and relapsing disorder Some cannot see themselves as able to function without opioids Harm Reduction

21. Why Methadone? Most effective pharmacological treatment for heroin dependence Well accepted Effective HIV/AIDS and Hepatitis prevention Reduces or eliminates heroin use (cont’d)

22. Why Methadone? Reduces criminal behaviour Improved employment rates Improved psychological status Decreased mortality Cost effective Availability

23. How does Methadone Work? Opioid (substitute for heroin) Orally effective Little or no euphoria / ‘high’ Long acting (at least 24 hours) Prevents withdrawal Reduces craving Blocks effects of other opioids Permits normal functioning: stability

24. A Day on Methadone vs. Heroin Sick Normal High

25. Comparative Profiles of Heroin and Methadone HeroinMethadone Route of Administration Injected Smoked, snorted Consumed orally Onset of ActionImmediate30 minutes Duration of Action Short-Acting (3-6 hours) Long-Lasting (24-36 hours) EuphoriaCommonRare Withdrawal Symptoms 3-4 hours after last use 24 hours after last use

26. Is Methadone ‘Safe’? Well tolerated Not associated with organ damage Some side effects (e.g., constipation and sweating) Correct dose is essential

27. Methadone Treatment Medication but also: Counselling –coping skills –nutrition –housing, job, child care, etc. Medical care Come to pharmacy often on daily basis

28. Methadone and Pregnancy Fluctuating levels not good for mother or baby Lifestyle Medical, psychosocial, nutritional care Methadone does pass to baby, but…

29. Other Treatments for Opioid Dependence Naltrexone (LAAM) Buprenorphine Heroin

30. Changing Patterns of Methadone Maintenance Treatment In Ontario, major thrust to get treatment into community settings Trend away from large centres like ARF Number of prescribers has increased Number of clients has increased Number of clients going to community pharmacies has increased

31. Stages of Change Pre-Contemplation Contemplation PreparationAction Maintenance Lapse/Relapse