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DOUGHNUTS DOUGHNUTS

DOUGHNUTS - PowerPoint Presentation

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DOUGHNUTS - PPT Presentation

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

doses pain dose methadone pain doses methadone dose control brain agonist post substitution time criteria school drug substance suds

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Slide1

DOUGHNUTSSlide2
Slide3

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)Slide6
Slide7

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)