AP401+Substance+Misuse

= AP401 Substance Misuse =

Resources
Sample Questions [|2008] [|2007] Sample Answers 2008 2007
 * **Subject** || **Lecture Notes** || **mp3** ||
 * Drug Dependence || [|2008] [|2007] || [|2008] ||
 * Determinants of Drug Use || [|2008] [|2007] || [|2008] ||
 * Pharmacotherapies for Drug Dependence || [|2008] [|2007] ||  ||
 * Harm Minimisation || [|2008] [|2007] ||  ||
 * SOP for Dispensing || [|2008] [|2007] ||  ||

Outline
Date: Friday, September 14 Handouts: [|Drug Dependence] & [|Determinants of Drug Use] Audio: [|Substance Misuse 1a] & Substance Misuse 1b Note: The lecture audio for this presentation is posted in mp3 format and provided for the purpose of revision support only At the conclusion of this lecture students should be able to: • Provide basic discussion on the factors influencing the drug experience developed by Zinberg • Discuss the concept and basis of addictive potential (rankings and specific values not required) • Define dependence according to both ICD-10 and DSM-IV criteria and discuss • Discuss the use and outcomes of use of drugs (illicit an licit) that significantly contribute to drug dependence in the community • Discuss major determinants of drug use including the theory of deservingness and the concept of actor-observer bias
 * Substance Misuse 1: Libby Hotham**

Date: Monday, September 17 Handouts: [|Pharmacotherapies for Drug Dependence] Audio: [|Substance Misuse 2a] & [|Substance Misuse 2b] Note: The lecture audio for this presentation is posted in mp3 format and provided for the purpose of revision support only At the conclusion of this lecture students should be able to discuss methods for assessing dependence (where discussed), withdrawal symptoms, supportive therapy options, maintenance pharmacotherapy options and other associated management considerations with regard to the use of:
 * Substance Misuse 2: Libby Hotham**

//Assessing dependence// - How often do you smoke your first cigarette of the day within 30 mins of waking? - Number of cigarettes?
 * • Nicotine**

//Withdrawal symptoms// - irritability, impatience, anxiety, restlessness, difficulty in concentrating - may even re-emerge years after quitting - intense contextual cues: level of nicotine use only one predictor of severity

//Supportive therapy options// - motivation (must want to quit) - self-efficacy ("I'm just a hopeless addict" - instil confidence) - light smokers (<10/day): behavioural therapies, cognitive restructuring, environmental change ('everyone I know smokes')

//Maintenance pharmacotherapy options// All evaluated in conjunction with counselling __NRT__ - all now unscheduled - choice dictated by customer - no evidence for weaning (except psychological) - use of two forms together or double the dose? //combine a continuous release (patch) with quick release? (lozenge)// - use in pregnancy? (better than smoking) - better to use a quick release form

__Bupropion__ - schedule 4

__Varenicline__ - schedule 4 - 23% using varenicline quit smoking after a year compared to bupropion (15%) and placebo (10%) - better safety profile than bupropion (which triggers seizures)

//Other associated management considerations// - relapse does not equal failure (generally 6-8 attempts)

//Assessing dependence// - <5% become dependent - major issues related to intoxication/bingeing (psychosocial interventions) - implicated with other CNS depressants in suicides/suicide attempts
 * • Alcohol**

//Withdrawal symptoms// May be life threatening - tremors, seizures (in 15%, typically 1-3 days after last drink) - worsening withdrawal at 3-10 days after last drink may indicate onset of delirium tremens (medical emergency - fatal in 10%) Predictor of withdrawal severity: assess number of standard drinks - quantity: >8 standard drinks daily for men (or >6 for women) - drinking daily for at least 2 weeks - >30 year old Hospitalisation Home Care if: - mild to moderate withdrawal predicted and no medical/psychiatric contraindications - daily GP management and supportive carer

//Supportive therapy options// - controlled drinking an option for some (learn to drink moderately) - if viewed as a disease, abstinence the only option (alcoholics anonymous) - may be poly-drug dependence/use and psychiatric issues

//Maintenance pharmacotherapy options// Benzodiazepines: diazepam (lorazepam/oxazepam) - sedative + anticonvulsant Thiamine, multivitamins, other anticonvulsants, antipsychotics, analgesics, anti-emetics Inpatient: - alcohol withdrawal assessment scales - loading dose (diazepam): 60mg-100mg (weight determined), then 20mg oral 2-hourly until withdrawal score lowered (10 or less) Home - 10mg qid and tapering

//Other associated management considerations// __Staying stopped__ Acamprosate - orally 3 divided doses (1.3-2g/day) for 1 year (poor absorption/variability)

Naltrexone - blocks effects of endorphins (endogenous opioids) - reducing craving for alcohol - 50mg once daily orally

//Assessing dependence// - variable and may not relate to quantity smoked/duration of use
 * • Cannabis**

//Withdrawal symptoms// up to 1-2 weeks - craving, anxiety, restlessness, irritability, anorexia (and weight loss), disturbed sleep, vivid dreams, other GIT (e.g abdominal pain), night sweats, tremor

//Maintenance pharmacotherapy options// __immediate:__ short-term symptomatic medications - diazepam 5-10mg qid prn for maximum of 7-10 days - metoclopramide 10-20mg tds prn - analgesia (e.g. paracetamol) - pericyazine 2.5-5mg tds prn (and benztropine)

//Supportive therapy options// __longer-term__ - pattern of use major determinant - psychosocial counselling (extended) - cognitive behavioural therapy, motivation enhancement therapy - lifestyle modifications - relapse prevention strategies - oral THC (cannibanol) maybe useful; lithium limited

//Other associated management considerations// __future__ - CB1 cannabinoid antagonist rimonabant - more research management complicated if concomitant mental illness

//Assessing dependence// influenced by pattern of use - regular use over years - days of use followed by a 'crash' - 'amphetamine induced psychosis' when IV use 2-3 hourly for several days
 * • Amphetamines**

//Withdrawal symptoms// crash as stimulant effects wear off (1-2 days) - prolonged sleeping, depressed mood (some irritability), overeating (stimulants are anorectic), limited craving several days to weeks of - mood lability (irritability, depression, anhedonia), craving, disturbed sleep, lethargy, psychotic symptoms may re-emerge during first 1-2 weeks

__emergency department__ medical complications - hyperthermia, CVA, seizures, myocardial ischaemia and infarction, serotonin toxicity, rhabdomyolysis, hypoglycaemia, hyponatraemia, hyperkalaemia concurrent use of other drugs - alcohol, benzodiazepines, opiates, 'party drugs' - other medications (antidepressants) presence of - concomitant physical illness (BBV - blood borne virus, cardiac disease) - physical injury (particularly head injury) - concomitant psychiatric illness or psychiatric symptoms (psychosis, paranoia, depression, suicidal ideation etc)

//Supportive therapy options// - security - behavioural management (inc. verbal de-escalation) - all necessary supportive medical management

__short-term__ hospitalisation necessary if significant psychotic symptoms - involve mental health services: can occur among both experimental and regular users of psychostimulants - short-term use of benzodiazepines, analgesics, and anti-psychotics for control of irritability (care to avoid development of benzodiazepine dependence)

sedation - diazepam 10-20mg oral (preferred) repeated after 30mins to max of 120mg - or IV 2.5-5mg repeated after 10mins to max of 60mg - or IM midazolam 5mg (to max of 25mg) - geared for 'rescue' (CNS depression etc. - psychotic, anxious)

__longer-term__ - relapse prevention - lifestyle changes

//Maintenance pharmacotherapy options

Other associated management considerations// __future__ most research done with cocaine or with poly-drug users; research ongoing eg modafinil

//Assessing dependence// more severe if: - abrupt cessation - short-acting agent - high dose A wide variation in half-life and some benzodiazepines have active metabolites
 * • Benzodiazepines**

//Withdrawal symptoms// anxiety and related symptoms - anxiety, panic attacks, hyperventilation, tremor, sleep disturbance, muscle spasms, anorexia, weight loss, visual disturbance, sweating, altered mood perceptual distortions - hypersensitivity to noise, abnormal body sensations, depersonalisation/derealisation major medical complications - generalised seizures, precipitation of psychosis

//Supportive therapy options// outpatient unless: - other major medical or psychiatric problems co-exist - polydrug dependence - high dose injecting use - patient requires stabilisation of other medication (eg methadone, buprenorphine)

//Maintenance pharmacotherapy options// convert daily intake into equivalent dose of diazepam prescribe diazepam equivalent with gradual reduction (5-10% of dose/week) weekly medical review/daily pharmacy collection [|benzodiazepine conversion chart]

//Other associated management considerations//

Date: Monday, September 17 Handouts: [|Harm Minimisation] & [|SOP for Dispensing] Audio: [|Substance Misuse 3a] & Substance Misuse 3b Note: The lecture audio for this presentation is posted in mp3 format and provided for the purpose of revision support only At the conclusion of this lecture students should be able to:
 * Substance Misuse 3: Phi Le**

Opioids inhibit GABA firing (inhibitory) which disinhibits DA neurons in the ventral tegmental area (VTA). This leads to an increase in DA release in the Nucleus Accumbens (NAcc). It can also inhibit DA reuptake.
 * • Describe and discuss opioid dependence**

Three principles of harm minimisation: __supply reduction:__ scheduling of medications __demand reduction:__ health and education campaigns __harm reduction:__ opioid substitution treatment program, clean needle program
 * • Define the principles of Harm Minimisation in particular the concept of Harm Reduction**

-** treatment of heroin dependence - prevent opioid withdrawal symptoms and reduces cravings for heroin - treatment for an extended period, allowing clients to make changes in their lives (harm reduction) which may eventually allow them to live drug-free - enables clients to make positive lifestyle changes
 * • Describe the basic features of an Opioid Substitution Treatment Program

//Maintenance program// __Assessment and stabilisation__ (6-8 weeks) - daily supervision of patient __Maintenance__ (months-years) - Implement healthier lifestyle changes, counselling and employment/education, can have 'take away' doses __Reduction__ (weeks-months) __Abstinence__

__Security:__ methadone/buprenorphine must be stored in locked cupboard __Valid Prescriptions:__ name, address, DOB, signed, dated by accredited prescriber (w/ name, address and ph. no.) - daily dose in WORDS and FIGURES, no. of take away doses authorised - expiry date (period of supply - usually less than 3 months) - the receipt of a new script cancels previous scripts __Methadone and buprenorphine:__ no emergency supply provision for S8 medications __DDA register records:__ all S8 Rxs must be forwarded to the DDU by 7th of the following month - if methadone/buprenorphine Rx is current, make a copy and forward with monthly return - when Rx has expired, forward to DDU - DDA records for receiving, balancing and ordering (DDA count) - register corrected at regular intervals - daily, weekly or at least monthly - records retained for two years __Take-away doses:__ each individual dose labeled and dated - lost, stolen or broken T/A doses cannot be replaced without authorisation from the prescriber
 * • Describe process issues relating to Opioid Substitution Treatment Programs (including use of the standard relevant SOP)**

//Common errors/problems -// wrong dose (mg confused with mL) - continuing to supply after the expiry date - not advising prescriber of non-attendance or problems - delegating preparation/dosing to assistant - exceeding take away allowance - tolerating excessive credit/unacceptable behaviour

- administering repeated doses for claimed vomiting (only affects methadone) - no replacement doses without new prescription - prescriptions not in monthly return - patient transfers - must get new prescription for next pharmacy - dosing intoxicated patients

//How to avoid problems// - client pharmacy-client contract: credit limit, attendance - communication diary - consistency between all pharmacists

//Report// __1) Missed doses if:__ daily dosing: miss 3 consecutive doses OR miss 10 doses in a 30 day period (lost tolerance towards methadone etc. or using other methods) alternate daily dosing: miss two consecutive doses OR miss 5 doses in a 30 day period __2) Suspension of dosing enforced:__ e.g. abuse of staff members/customers, threats, violence, diversion, attempting to get more than entitled dose - three day suspension if on daily dosing - two dose suspension if on alternate daily dosing - incident report __3) Client presents intoxicated:__ do not dose, and report - sedated - slurred speech - ataxia (benzos, alcohol, stimulants) if this is a chance occurrence: - "come back later for your dose" if ongoing problem: - report

containing preparations in an Opioid Substitution Treatment Program** //Methadone (5mg/mL solution) -// supervised doses - T/A doses diluted - 25mg methadone = 5mL methadone (it is always a small amount)
 * • Discuss specific considerations regarding the use of methadone and buprenorphine (including combination products)

//Subutex (buprenorphine) -// low oral bioavailability (sublingual) - first treatment dose 12 hours after last heroin use (prevent withdrawal by administering partial agonist) - patients on suboxone will not be eligible for subutex take-away doses (must attend a 7 day pharmacy) - patients must be transferred to suboxone if T/A doses initiated or suspicion of diversion (exceptions: pregnancy, naloxone allergy)

//Suboxone (buprenorphine/naloxone)// - should not interchange with subutex (buprenorphine) - naloxone is included to prevent IV use (does not precipitate withdrawal symptoms when taken sublingually) - taken IV in a heroin/methadone user not in withdrawal will worsen symptoms (due to naloxone being a pure agonist) - taken SL in heroin/methadone user in withdrawal will experience improvement in symptoms (as only the buprenorphine will be absorbed - partial agonist)


 * Practice Questions:** [|Sample Questions (Substance Misuse)]