Opioid Agonist Therapy The Skinny on Methadone et al Christopher Levesque Physician 20 years ER TMH 15 years correctional medicine Dorchester Institution 9 years community addictions Christopher Levesque ID: 204715
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Slide1
DOUGHNUTSSlide2Slide3
Opioid Agonist Therapy
The Skinny on Methadone et al. Slide4
Christopher Levesque
Physician
20 years ER TMH
15 years correctional medicine
Dorchester Institution
9 years community addictionsSlide5
Christopher Levesque
Lawyer
– retired
UNB Law School 1975 (LL.B.)
London School of Economics (1976)Slide6Slide7
Doughnuts
(Adaptive behavior)
Slide8
PLEASURESlide9
Pleasure
Brain
reward
system
DopamineSlide10
Brain Reward PathwaySlide11
Maladaptive Behavior
(Substance Use Disorders/Addiction)Slide12
Brain Reward PathwaySlide13
Maladaptive behavior – Drugs
Continued use despite significant use related problemsSlide14
SUDS or Addiction
Change in brain circuitryPersists
Relapses
Drug cravingsSlide15
Substance Use Disorders, DSM – V
10
separate classes of drugs:
Alcohol
Caffeine
Cannabis
Hallucinogens Slide16
Inhalants
Opioids
Sedatives
Hypnotics
Anxiolytics
S
timulants
(amphetamine-type substances, cocaine, and other stimulants
)
TobaccoSlide17
Common drugs in Moncton
Prescription opioids
Dilaudid
,
hydromorphone
,
oxycontin
,
Morphine, … fentanyl
Cocaine, crack cocaine
Speed - crystal methamphetamine
BenzopiazapinesSlide18
Substance Use DisorderSlide19
Diagnosis SUDs
Criterion:
Impaired control
Social impairment
Risky use
Pharmacological criteriaSlide20
Impaired control
Longer than intended, larger amounts
Unsuccessful efforts to stop
Excessive time pre-occupation
Finding, using, recovering
Craving
Could think of nothing elseSlide21
Social Impairment
Neglect work, school, homeInterpersonal relationships
withdrawsSlide22
Risky use
Continued use despite knowledge of physical or psychological problem
Failure to abstain despite recognition of riskSlide23
Pharmacological criteria
Tolerance
Dose
Respiratory depression
Sedation
Motor coordinationSlide24
Pharmacological Criteria
Withdrawal
(N.B., not now a requisite to dx SUDs)Slide25
Opioid Agonist Therapy
(Substitution Therapy)Slide26
Abstinence
Harm reductionSlide27
Y substitution
Intense withdrawal (physical)CravingsSlide28
Methadone
Suboxone (buprenorphine + naloxone)Slide29
Methadone
U AgonistLong half-life (8-100hrs)Slide30
Suboxone (Subutex)
Combination drug
Buprenorphine
Naloxone
Unique characteristicsSlide31
Analgesic properties
Both
Rarely utilized in management of acute painSlide32
So what about your practice !Slide33
Peri
-operatively
Take their usual dose same time~
Methadone as clear undiluted liquid
Buprenorphine sublingual dissolutionSlide34
Post-operatively
Entitled to appropriate pain management
With mutually agreed careful monitoring
No magic formula
Combination of short acting morphine and long acting depending on the expected duration of pain.Slide35
Post-operative pain control
Manage acute post-op pain
Same approach as with non-substitution patients
Recognize there may be a requirement for increases doses
Avoid the “drug seeking” badgeSlide36
Post-operative pain control
Fixed schedule….preferable to PRN
Do Not Use Agonist-Antagonists
Talwin
(act at non-u receptors)
Stadol
Antagonist action on u receptorsSlide37
Simple Approach !!!
Prescribe adequate doses of opioidsMaintain maintenance methadone doseSlide38
Couple of issuesSlide39
Missed doses
They will always be “ok” in the face of missed doses
Better that they receive or take their dose around the same time of day
For my purposes, 3 missed doses results in a 50% reduction in their dose and a re-titration.Slide40
Pregnancy
slowed gastrointestinal absorption
expanded fluid load/body fat
Hepatic enzyme activity (CYP3A4)
increased glomerular filtrationSlide41
Again
Patients in substitution programs for opiate addiction…..
Are people…talk to them about pain control
Must be accorded the same access to appropriate management under any circumstance
Will most likely require higher doses to manage pain (tolerance/cross tolerance)