OPIATE SUBSTITUTION THERAPY IN THE 21ST CENTURY

OMAR HENRIQUEZ M.D.

AIM OF SUBSTITUTE TREATMENT

•HARM REDUCTION APPROACH: response to addiction, difficulty of abstinence and chronic nature of opiate dependence•HARM REDUCTION GOALS: reduction of illicit drugs, cessation of injection, decrease in morbidity and mortality

THE EVIDENCE BASED FOR MAINTENANCE TREATMENT

METHADONEBUPRENORPHINE

ASSESSMENT FOR MAINTENANCE TREATMENT

AGELENGHT OF DRUG-TAKING HISTORY AMOUNT OF DRUG USEDEXAMINATION: stigmata, objective signs of withdrawalTESTING: urine and blood

METHADONE

MIXTURE PRESENTATIONLONG HALF LIFE: stable blood levelsSAFE IN PREGNANCYFEW CLINICALLY INTERACTIONSDANGER OF OVERDOSE: pure agonist effectSECONDARY EFFECTS

BUPRENORPHINE

SUBLINGUAL TABLETSAGONIST / ANTAGONIST: safer and ceiling effectLIMITED MAXIMUM EFFECTIVE DOSEFIRST LINE MAINTENANCE DRUG: preferred in non-heavy users, those who are ready.

DOSE INDUCTION

METHADONE

LOW DOSE: up to 30 mg for daily dispensingRISING GRADUALLY: 10-20 mg every few daysSTABLE LEVEL: holds the patient comfortablyOPTIMUM DOSAGE: should be maintainedSUPERVISED DISPENSING: until user is stable

DOSE INDUCTION

BUPRENORPHINE

LOW DOSEEXPERIENCING WITHDRAWAL SYMPTOMS: to avoid early symptomsESCALATED DOSAGE: dose should be increased by incrementsMAXIMUM DAILY DOSE: 32 mgCAN BE PRESCRIBED FOR ALTERNATE DAY-DOSING

CONTINUING A MAINTENANCE TREATMENT

LONG TERM: every 6-8 weeksPOST-DATED PRESCRIPTIONSRISK OF OVERDOSE: after maintenanceARRANGEMENTS INTO WITH PHARMACISTS: to notify the prescriberNOT IMPOSED DRUG REDUCTIONS

PSYCHOLOGICAL APPROACHES

CBT: time management and relaxation techniquesRELAPSE PREVENTION: triggers and learning techniquesPSYCHOTHERAPY: individual and familyMOTIVATIONAL INTERVIEWING: moves the patient along a cycle of change

OPIATE DEPENDENCE?

NOYES

OPIATE FREE

YES NO

IS THERE A PHYSICAL WITHDRAWAL SYNDROME?

YES

IS IT NECESSARY TO PRESCRIBE A

SUBSTITUTE DRUG?

NO

ASSESS STABILISING DOSE

MAINTENANCE TO ABSTINENCE

CHOOSE WITHDRAWAL SCHEDULE

ADVISE ON HARM MINIMISATION SUPPORT OF MENTAL HEALTH, PHC TEAMS

YOUNG PEOPLE SERVICES GENERAL HEALTH CARE

FOLLOW-UP APPOINTMENTS COUNSELLING

VOLUNTARY AGENCYRESIDENCIAL PLACEMENT IN THERAPEUTIC COMMUNITY

DECIDE PHARMACOLOGICAL T.

CONCLUSION

SUBSTITUTE TREATMENT IS A POTENTIALLY LIFE-SAVING INTERVENTION

OFFERS A WIDE RANGE OF HEALTH AND SOCIAL BENEFITS

RELATIVELY STRAIGHTFORWARD AND GENERALLY SAFE

SUBSTITUTION PRESCRIBING IN ISOLATION IS OF LIMITED EFFICACY