Opioid Dependence

Question 1

What is an opioid?

Answer 1

Any substance (natural or man-made) that binds to opioid receptors in the brain?

Question 2

What are examples of natural substances?

Answer 2

Codeine
Morphine
Heroin

Question 3

What are examples of synthetic substances?

Answer 3

Fentanyl
Methadone

Question 4

What are examples of semi-synthetic substances?

Answer 4

Oxycodone (Oxycontin)

Question 5

What is an opiate?

Answer 5

Naturally-occurring narcotics derived from natural-source only
eg. morphine, codeine + heroin (opium plant)

Question 6

What prevention is put in place?

Answer 6

Codeine should be limited to NO more than 3 days (OTC)
Watch for overuse in paracetamol

Question 7

How quickly can physical + psychological dependence develop?

Answer 7

2-10 days

Question 8

What patient risk factors should be screened for with opioid prescriptions?

Answer 8

Depression, anxiety + common mental health
Previous history of alcohol/substance misuse
Previous history of opioid misuse

Question 9

What drug risk factors should be screened with opioid prescriptions?

Answer 9

High doses
Multiple opioids
Multiple formulation of opioids
More potent opioids
Concurrent benzodiazepines/sedative drugs

Question 10

What is consider a extremely high opioid dose?

Answer 10

Dose greater than oral morphine 120mg/day

Question 11

What do you need to be careful with when changing formulation/administration route with opioids?

Answer 11

Oral = 1st pass effect = only 30% received
IV = 100% bioavailability = whole dose received
= WOULDN’T give the same dose for IV as oral

Question 12

What needs to be understood when reducing opioid dose?

Answer 12

That once you go down you CAN’T go back up
=go at the patient’s pace

Question 13

What does OA stand for?

Answer 13

Osteoarthritis

Question 14

What does L THR stand for?

Answer 14

Left total hip replacement

Question 15

What does MST stand for?

Answer 15

Morphine sulphate tablet

Question 16

What does BD stand for?

Answer 16

Twice daily

Question 17

What does TTO stand for?

Answer 17

To take out = discharge medications

Question 18

What does PRN stand for?

Answer 18

When required

Question 19

What would cause scratch marks?

Answer 19

Urticaria = itchy reaction to opioids

Question 20

What are some risk factors for opioid dependence?

Answer 20

Current or past psychiatric illness
Reports of concern by family
Concerns expressed by pharmacists = going through prescription too fast

Question 21

What can be the first option for deprescribing of opioids?

Answer 21

Keep modified release dose stable + wean down PRN dose
= keep same frequency of immediate release dose + decrease dose each week
OR
= maintain same dose BUT reduce frequency each week

Question 22

What can be the second option for deprescribing opioids?

Answer 22

Reduce MR dose first by 10% per week + keep PRN IR dose steady
BUT have to caution patient against increase PRN frequency

Question 22

What is the MAX you can reduce an opioid dose by?

Answer 22

10%

Question 22

What can also be helpful for when tapering opioid doses?

Answer 22

Exercise
Coping mechanisms = meditation
Acupuncture

Question 23

What can you consider when tapering a dose if it is really hard for the patient?

Answer 23

Conversion to methadone/buprenorphine Involving drug/alcohol services

Question 24

What are the opioid withdrawal signs?

Answer 24

Shivers Diarrhoea Difficulty sleeping Sweating Widespread/increased pain Body aches Irritability/agitation Nausea + vomiting

Question 25

What needs to happen with patients who are receiving opioid substitution therapy (OST)?

Answer 25

Need on-going reassurance that their pain will be assessed OST does NOT provide analgesia Existing OST should be continued Opioid for analgesia need to be prescribed in addition Larger doses than usual = tolerant May have increased pain sensitivity = long term exposure

Question 26

What should happen for patients on methadone?

Answer 26

Split dose + administer 2-3x a day Titrate additional analgesia to effect

Question 27

What should happen for patients on buprenorphine?

Answer 27

Split dose + administer 2-3x a day Titrate additional analgesia OR Discontinue + provide alternative analgesia Change to methadone

Question 28

What may occur in patients taking opioids?

Answer 28

Tolerance + opioid-induced hyperalgesia = decrease pharmacological response = increase in pain perception

Question 29

When can be patients be at most risk to addiction?

Answer 29

Post-operative opioids

Question 30

What must be done to manage the risk of addiction post-surgery?

Answer 30

Patients taking opioids identified before surgery Identify risk factors for opioid misuse Ensure communication between patient + GP on deprescribing mechanisms Ensure chronic post-surgical pain is recognised

Question 31

What is the goal of maintenance therapy?

Answer 31

Harm reduction + stabilisation of lifestyle Detoxification to come off opioids all together

Question 32

How does supervised methadone work in practice?

Answer 32

1mg/ml used Observed whilst taking dose Designated area of supervision = privacy Identity of patient confirmed Usually 3 months minimum

Question 33

What are the risks of long term opioid use?

Answer 33

Serious bodily harm, overdose + death Increased pain levels Hormone changes = infertility Drowsiness Increased risk of physical dependence Decrease immune function Increased risk of fall/fractures Depression/anxiety Dry mouth = dental cavities