Substance misuse 2 - harm reduction and choice of opioid Flashcards
(19 cards)
Harm reduction - Needle and syringe programmes - what does it enable
Enable pharmacies to provide access to sterile needles and syringes, as well as containers to store sharps for the return of used equipment
Harm reduction - Needle and syringe programmes PUBLIC HEALTH MEANS
Support people who inject substances to remain healthy until they are ready to move away from injecting as part of their recovery journey
To protect the health of people who misuse substances and reduce the rate of infections, and drug related deaths, through reduction in the rate of equipment sharing in the local communities, reduction in high-risk injecting behaviour, and providing sterile equipment and other harm reduction advice (safe sex)
Improve the health of local communities by reducing the spread of BBVs infections and by ensuring the safe disposal of used injecting equipment.
To help service users access treatment, including opioid substitute therapy, by offering a referral service to local specialist substance misuse services and other health and social care professionals where appropriate.
To maximise the access and retention of people who inject substances in the service. Especially the highly vulnerable individuals who may not have access to mainstream services.
Harm reduction - Needle and syringe programmes
equipment provided
Syringes +
Needles+
Acidifiers
Change the pH of the solution to make the drug more soluble and easier to inject. Sterile citric acid and ascorbic acid (vitamin C) are the most commonly used acidifiers to dissolve heroin and crack cocaine for injection
Disinfecting swabs
+Spoons- To Cook heroin in to make a liquid
Filters- To Remove debris from solution before injecting
Foil- Allows for switching from injecting to smoking
Sharps bins – pharmacy to not accept returns if not in a sharps bin
Water for injection
Harm reduction – Take-home naloxone service
Developed to prevent people from having an opioid (heroin) overdose
Is a POM, however, it can be supplied to any individual who may witness, or be at risk of, an opioid overdose. This includes, but is not limited to, an outreach worker, a hostel manager, a person who uses substances, or their carer, friend, or a family member
Any person can administer naloxone in the UK in an emergency for the purpose of saving life. They, however, require training to do so
Available as:
Prenoxad Injection
Nyxoid nasal spray
Recovery and treatment journey
Prescribed interventions – which is opioid substitution therapy
First = Titration
Opioid substitute introduced at a low dose and gradually increased to an optimal dose where the person is neither over-sedated or experiencing withdrawal symptoms and is no longer using substances ‘on top’ of the opioid substitute
Maintenance (patient on the dose)
Optimal dose continues to provide the person with a period of stability
Detoxification
Opioid substitute is gradually reduced and eventually discontinued
Psychosocial interventions
Non-pharmacological treatments - support package
Aftercare
Includes psychosocial interventions to support people to sustain abstinence from substances
Factors influencing recovery and treatment
A person’s desired outcomes throughout their treatment may change as they progress through their recovery. For example, they may move to wanting to become abstinent where there is no illicit substance use on top of opioid substitute prescribing, with the aim to reduce and eventually stopping any opioid substitute
A good predictor of recovery being sustained and preventing relapses is an individual’s ‘recovery capital’
Recovery capital
Resources needed to start and sustain recovery from substance misuse
Elements:
Physical capital
Money, having a safe place to live
Social capital
Relationships – family, friends (changing relationships)
Cultural capital
(Might be) Values, beliefs and attitudes held by the individual
Human capital
(Might be) Skills, mental and physical health, employment
Building a person’s recovery capital in these four areas will support their recovery and help to prevent relapse
Substance misuse multidisciplinary team - the prescriber
Prescriber
GP with special interest
Independent prescriber (pharmacist or nurse)
(they) Undertakes initial medical assessment, helps reduce withdrawal symptoms through the development of an appropriate pharmacological treatment plan, conducts reviews and adjusts prescriptions as necessary according to the individual’s needs
(they will liaise) Liaises with the individual’s key worker (social carer or nurse) and community pharmacy team
Substance misuse multidisciplinary team - key worker
Keyworker
Social carer or nurse
Works closely with the individual to help them develop their care plan and treatment goals
Meets with the individual regularly to see how they are getting on, address any social needs these maybe related to their substance misuse of not.
Help individual address any physical or mental issues, build social networks and develop their resilience
Supports with harm reduction – BBV testing, needle exchange etc
Liaises with the community pharmacy team
Substance misuse multidisciplinary team - substance misuse service
Substance misuse services pharmacist
Prescribing opioid substitutes
Medicines optimisation
Audits and prescribing analysis
Education and training
Liaises with community pharmacy team to support seamless care
Choice of opioid substitute and the factors influencing the choice
methadone and buprenorphine
Level of opioid dependency
Underlying health issues
Interacting medicines taken
Previous treatment response to opioid substitute
Individual’s preference
Methadone
Full opioid agonist
Well absorbed orally
NICE – recommends methadone first line
OD doing due to long duration of action
Usually given as 1mg/1ml SF green liquid to prevent dispensing errors
Concentrated solution could be given to those who take high doses
Injections only prescribed by specialists and is not 1st line
SE’s: sedation, confusion, nausea, vomiting, dry eyes, mouth, nose
In overdose: respiratory depression
Sweating: SE and in withdrawal
Doses for ≥ 100mg, individual’s need electrocardiograph’s (ECG’s) due to dose-related QT-interval prolongation
ECG’S should be considered if there are other risk factors for QT-interval prolongation:
Presence of cardiovascular disease
Other medication: macrolides, many antidepressants and anti-psychotics
Renal and hepatic impairment – decrease dose due to accumulation
(Methadone can) Reduce seizure threshold (this needs to be monitored)
Other medicines may interact so must be taken into consideration when starting or stopping medication
Methadone titration
Titration:
Starting dose – decided at initial assessment following a confirmatory drug test, the presence of visible track marks from injecting heroin and the information the individual provides
Community – starting dose usually 10-30mg OD. If tolerance is low or uncertain – 10-20mg to avoid accidental overdose
Dose is (usually) increased by 10mg every 3-4 days. Maximum recommended increase of a dose should not be any greater than 5-10mg at a time and nor more than 30mg increase above the starting dose each week
Takes 5 half-lives (3-10 days) for methadone to reach steady state so they may continue to rise and become toxic
Essential to inform drug team if any doses are missed during the titration period. Risk of accidental overdose is greatest during the titration period – may still be using illicit drugs during titration until dose is stabilised
Optimal doses usually – 60-120mg OD
Buprenorphine
Partial opioid agonist, and a partial antagonist
Poor bioavailability – relatively inactive if swallowed – given as a S/L tablet because of this
Could be given as an S/C injection
Also available as a combination tablet with naloxone – if the patient diverts the buprenorphine by injecting it the buprenorphine will have minimal effects. The naloxone may precipitate withdrawal and further misuse is discouraged
SE’s: Similar to methadone but less sedation due to it being a partial agonist
Lower risk of overdose due to it being a partial agonist and respiratory depression less likely (unless high doses of other opioids have been taken – overcome the blocking effects of buprenorphine or unless taking with other additive respiratory depressant effects such as alcohol and benzodiazepines
Buprenorphine - what is required
LFT’s required periodically – can cause hepatic dysfunction
Blood levels affected by drugs such as macrolides and phenytoin (should speak to the prescriber)
Useful alternative when patient is at risk of QT-prolongation with methadone
Method of dispensing opioid substitute
Individual risk assessment (supervised/take-home does):
Storage
Safeguarding issues – bullied for medication, children etc
Diversion
Concurrent or increasing use of other substances e.g. alcohol
Impact on other activities – employment, childcare
Engagement and adherence to treatment and appointments
Transportation and mobility issues – pharmacies with longer hours, prefer pharmacy closer to work
Progress with recovery goals
Physical and mental well-being – risk of suicide
Missed doses
The drug team must be notified electronically every time an individual misses a dose
If 3 or more consecutive doses are missed the dose must be held and the prescriber informed. The prescriber will need to assess the suitability of the prescribed dose due to a potential loss of tolerance which may result in an accidental overdose
The individual may need to be re-titrated
Switching from methadone to buprenorphine
Reduce methadone dose to as low as possible, no more than 30mg OD before starting buprenorphine – minimises the risk of precipitating withdrawal symptoms due to partial antagonist effects of buprenorphine
Take 1st dose of buprenorphine at least 24 hours after the last dose of methadone or 8 hours after the last heroin dose (if using this on top)
Inform prescriber of any missed doses during titration
Buprenorphine can be titrated much more quickly, optimal dose usually 12-16mg OD
Detoxification
Can be completed safely within 12 weeks
Methadone reduced by 5mg every 1-2 weeks
Buprenorphine reduced by 2mg every 2 weeks
Lots of advanced planning and aftercare required
