Opioid Dependence

Anne KalvikPearl Isaac

Learning Objectives1. 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

Opioid Dependence and

Pharmacy Practice

Medical Uses for Opioids

• PAIN• Cough• Diarrhea

Undesirable Effects of Opioids

• Nausea and vomiting• Sedation• Some people don’t like effects, e.g.,

itching• Physical and psychological

dependence• Respiratory depression• DEATH

Why are Opioids Abused?

Some Examples of Opioids

• Codeine• Oxycodone• Hydromorphone• Morphine• Meperidine• Hydrocodone• Heroin• Methadone

Street Value of Selected Rx Narcotic Drugs inVancouver’s Downtown Eastside

Sajan et al, CMAJ July 28, 1998; 159 (2)

Addiction

• Compulsive drug use

• Consequences: use despite harm

• Inability to Cut down• Cravings

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

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

Tolerance

• Neurobehavioural adaptation• Rapid tolerance to psychoactive

effects• Tolerance to analgesic effects

develops slowly• Tolerance disappears within days

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

Effects of Heroin

• Physical effects on user– direct– indirect

• Physical effects on others• Psychosocial effects on user• Psychosocial effects on others

Bob

• 37-year old man buying 10 Oxycontin® per day off the street

• Currently lives alone, unemployed

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

Opioid Withdrawal (subjective)

• Anxiety• Restlessness• Abdominal pain and cramps• Muscle aches• Bone pain• Anorexia• Craving• Insomnia

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

Medical Detoxification

• Clonidine• Loperamide• Dimenhydrinate• NSAIDs• (Benzodiazepines)• (Naltrexone)• UROD

Why not detoxify?

• Opioid withdrawal not life-threateningBUT

• 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

Why Methadone?

• Most effective pharmacological treatment for heroin dependence

• Well accepted• Effective HIV/AIDS and Hepatitis

prevention• Reduces or eliminates heroin use

(cont’d)

Why Methadone?

• Reduces criminal behaviour• Improved employment rates• Improved psychological status• Decreased mortality• Cost effective• Availability

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

A Day on Methadone vs. Heroin

0 6 12 18 24Time (hrs)

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Comparative Profiles of Heroin and Methadone

Heroin Methadone

Route of Administration

InjectedSmoked, snorted

Consumed orally

Onset of Action Immediate 30 minutes

Duration of Action

Short-Acting(3-6 hours)

Long-Lasting(24-36 hours)

Euphoria Common Rare

Withdrawal Symptoms

3-4 hours after last use

24 hours after last use

Is Methadone ‘Safe’?

• Well tolerated• Not associated with organ damage• Some side effects (e.g.,

constipation and sweating)• Correct dose is essential

Methadone Treatment

• Medicationbut also:

• Counselling– coping skills– nutrition– housing, job, child care, etc.

• Medical care• Come to pharmacy often on daily basis

Methadone and Pregnancy

• Fluctuating levels not good for mother or baby

• Lifestyle• Medical, psychosocial, nutritional

care• Methadone does pass to baby,

but…

Other Treatments for Opioid Dependence

• Naltrexone• (LAAM)• Buprenorphine• Heroin

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

Stages of Change

Pre-Contemplation

Contemplation

PreparationAction

Maintenance

Lapse/Relapse