Opioid Use Disorder

Question 1

What are the psychosocial treatments of opioid use disorder?

Answer 1

Structured counselling
Motivational interviewing
Case management and care coordination
Psychotherapy
Cognitive Behavioural Therapy
Contingency management

Question 2

Which is more effective: psychosocial tx or pharm?

Answer 2

Psychosocial tx + pharm = more effective than either alone

Question 3

Describe the interaction of trauma, mental health and addictions

Answer 3

Most pt’s will have co-occurring mental health disorders or untreated trauma

Question 4

When caring for an individual with opioid use disorder, what should the focus be on?

Answer 4

Start with the person not with the medications

Every individual is a human being: Open to caring for them and meeting the where they are at

Question 5

What are some of the Canadian OUD guidelines?

Answer 5

2017 British Columbia Centre on Substance Use Guidelines
2018 Canadian Research Initiative in Substance Misuse (CRISM) Guidelines

Injectable Opiod Agonist Treatment - More severe spectrum of opioid use disorder

Question 6

Describe the clinical management of OUD

Answer 6

Question 7

Describe withdrawal management of OUD

Answer 7

Withdrawal management alone is not an effective treatment for opioid use disorder, and offering this as astandalone option to patients is neither sufficient nor appropriate

Similar to tapering off opioids with methadone, agonist taper involving buprenorphine/naloxone appears to reduce the severity of withdrawal symptoms, but the majority of patients still relapse to opioid use if a strategy involving only withdrawal management is employed.

Low intensity treatment is withdrawal management RARELY DO WITHDRAWAL MGT ALONE
–> Referring to completely withdrawing someone with OUD from opiods

Question 8

Describe the evidence of withdrawal management alone for OUD?

Answer 8

Withdrawal management alone is not an effective treatment for OUD and offering as a stand alone is inappropriate or sufficient

Relapse and rates of drop out to opiod use are high regardless of tx modality

Risks of serious harms, including fatal and non-fatal overdose and HIV and Hep-C transmission are higher for individuals who have recently completed withdrawl mgmt compared to individuals who recieved no tx

Withdrawal mgmt, if indicated by patient, should be provided with clear and concise info on the known risks to personal and public safety and be engaged in supportive, constructive discussion about safer tx options

Withdrawl mgmt alone is not recommended unless a discharge plan is in place for refrral to ongoing addiction tx

Much lower abstinence with withdrawal vs. ongoing OAT: instance, participants in the Prescription Opioid Addiction Treatment Study demonstrated significantly lower sustained abstinence rates eight weeks after tapering off buprenorphine/naloxone (8.6%) compared to abstinence rates during buprenorphine/naloxone treatment (49.2%).23

Chronic disease
We can’t just take them off the problematic opioid  Most patients will relapse if just withdrawal them from tx

Question 9

What medication can be used for withdrawal management with OUD?

Answer 9

Clonidine

Question 10

Describe a clonidine taper used in OUD wityhdrawal management

Answer 10

Clonidine Taper
Help with physical sx –> Relapse risk is high –> Rarely do this anymore

For most patients with mod-severe (even mild for the most part) will go onto opioid agonist therapy

Question 11

Describe the benfits and risks of withdrawal management alone

Answer 11

Detox can be an important 1st point of contact and a bridge to other treatment options

However, detox alone associated with:
↑ HIV-transmission
↑ HCV-transmission
↑ Relapse rates
↑ Morbidity
↑ Mortality

Withdraw in hospital for 10 days –> May be extremely desperate to seek opiods if just on RX

Lost tolerance –> Use same amount as before; risk of toxicities

Question 12

Describe the OUD treatment options

Answer 12

Naltrexone –> Opioid antagonist: More use in alcohol use disorder

Question 13

Describe the evidence of Naltrexone in OUD

Answer 13

Endogenous deficit of opioids –> Need some supplemental opiod –> Not making up deficit of opiods here

Shown that is not helpful for most pt’s in treating SUD

Question 14

Describe the MOA of naltrexone in OUD

Answer 14

Opioid receptor antagonist that blocks the euphoric effects of opioids

Question 15

Describe the benefits and risks of naltrexone in OUD

Answer 15

Benefits:
Ease of administration
No induced tolerance during prolonged tx
No potential for dependence/misuse

Risks:
↑ risk of overdose for patients who stop tx and relapse to opioid use due to ↓ tolerance
mortality 3-7x higher than methadone related mortality

Question 16

Describe the formulations and evidence of the various formulations of naltrexone

Answer 16

Only oral naltrexone available in Canada
Limited benefit over placebo
2011 meta-analysis found no significant difference in retention or abstinence rates vs. placebo

Extended-release naltrexone monthly IM injections available in US
Improved adherence vs. oral naltrexone
Several RCTs should ↑ retention in tx, ↑ abstinence rates, and ↓ opioid cravings

Question 17

What is the main-stay of OUD treatment?

Answer 17

Heart of treatment of opiod use disorder

Suboxone is first line, methadone is 2nd, and slow-release morphine is 3rd line

Question 18

Rank the treatments for OUD: 1st line, 2nd line and 3rd line

Answer 18

Buprenorphine/naloxone (Suboxone) now 1st line for OUD treatment

2nd line: methadone

3rd line: slow-release oral morphine

Question 19

Describe the opiate agonist effect of the treatment options for OUD

Answer 19

Partial Agonist effect of buprenorphine

Question 20

What is suboxone? What is the dose based upon?

Answer 20

Suboxone = buprenorphine + naloxone
Dose based on buprenorphine component

Question 21

Describe the available formulations of suboxone

Answer 21

Most will be on SL tabs (buccal film available)

Question 22

Describe the components of suboxone and why they are included?

Answer 22

Naloxone – Cant inject it, snort it, or crush it

Prevents diversion–> Fully in there as a diversion mechanism

Buprenorphine is the main drug

Naloxone has 0% bioavailability from the gut

Question 23

Describe the available buprenorphine formulations

Answer 23

Buprenorphine patches (Butrans)
Available in Canada
Indication: pain

Buprenorphine/naloxone buccal films (Suboxone)
Newer on the Canadian market as of Jan 2021

Buprenorphine extended release injection (Sublocade)
Indication: OUD
Subcutaneous abdominal monthly injection
Saskatchewan pharmacists with injection training can administer Sublocade!

Question 24

For initiation of Sublocade….

Answer 24

Sublocade: patient must be stabilized on buprenorphine containing products

Question 25

Describe the risk of switching between the formulations of Suboxone? Why?

Answer 25

Suboxone (buprenorphine and naloxone) and the risk of overdose or underdose when switching between dosage forms or routes of admin Slight difference in dosing; slight different bioavailability --> need to look at recommendation in product monograph Start on SL tabs then move to the film Slight differences in dosing – check cdose on monograph and have close monitoring in place when transitioning

Question 26

Describe the pharmacology of buprenorphine

Answer 26

High affinity (strong binding ability) for μ opioid receptor Displaces heroin or other opiates from receptors Occupies receptor and blocks other opiates’ effects Partial agonist at μ opioid receptor Antagonist a kappa and delta opioid receptors Slow dissociation (leaving) from opioid receptor Duration of action increases with increased dose

Question 27

Describe the labelled max of buprenorphine

Answer 27

Labelled max =24mg/day but dosed up to 32mg/day for some

Question 28

Describe the duration of action of buprenorphine doses and the duration of action

Answer 28

Dose-related increase in duration of action

Question 29

Describe the moa of buprenorphine and an opioid

Answer 29

Mu Opiod Receptor: Purple Sending signals out – withdrawal sx If give opiod, takes away withdrawal Yellow: Buprenorphine Not full effect (euphoria), takes time to get out of the receptor --> protects them from overdose --> people can overcome the effects by using high amounts of substances But protective safety measure

Question 30

Describe buprenorphine pharmacology agonism and its associated response

Answer 30

Partial agonism --> opiate ceiling effects No further opioid effects above a certain dose Safer in overdose

Question 31

What is suboxone formulated with? Why?

Answer 31

Suboxone formulated with naloxone Naloxone oral or sublingual is not absorbed No effect unless injected May negate opiates effects if injected

Question 32

What are some of the common and other adverse effects of bup/nal?

Answer 32

Common: Headache, pain, withdrawal syndrome Constipation, nausea, abdominal pain Insomnia Runny nose, sweating Other: Flu-like symptoms, muscle aches Tooth disorder, dyspepsia Depression, anxiety, nervousness, somnolence, dizziness, paresthesia

Question 33

What opioid agonist therapy is the most effective?

Answer 33

Suboxone is better tolerated than full opioid agonist therapy