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Managing Opiate Dependence.ppt
- 1. Managing Opiate Dependence Pharmacy Perspective HasrynAzzuar Mohd Khairy Pharmacist Methadone Pharmacy
- 4. 4 OPIOIDS OPIAT BAHAN ASASTEMPAT PENGELUARAN - Candu - Heroin - Morfin - Kodein Getah bunga popi Acetic, Anhydride, Acetone Acetic Acid (glacial) Calcium Oxide Potassium Carbonate Sadium Carbonate Sadium Hydroxide Sadium Hypoclorite Opium Alkaloid Opium Alkaloid Amerika Selatan Columbia Guatamala Mexico Asia Tenggara Burma Laos Thailand Asia Barat Afganistan Pakistan
- 5. NAMPAK CANTIK TAPIMEMBUNUH.
- 6. Opiates vs. Opioid Opiates—naturally occurring or semi-synthetic derivatives of opium poppy Eg. Morphine, heroin, opium, codeine Opioid—”opiate-like” drug; acts like an opiate, but different chemical structure Eg. Fentanyl, meperidine, methadone, oxycodone, hydrocodone (pain medications), buprenorphine
- 7. What is Heroin? • In the class of drugs known as "opiates" • Extracted from the white sap of the flowering poppy plant • Pure heroin is a white powder with a bitter taste • ‘Black Tar’ or ‘Brown Sugar’, a gooey black or brownish substance, is a less-refined form of heroin • Chemical name: diacetylmorphine
- 8. How is heroinused? Injected into a vein (‘shooting’) Inhaled as smoke through a straw (‘chasing’ or ‘chasing the dragon’) Snorted as powder (‘sniffing’) Injected into a muscle (‘skin popping’) Smoked in a water pipe or standard pipe Mixed in a marijuana joint or regular cigarette Mixed with benzodiazepines, MDMA, ATS, or cocaine (‘speed ball’)
- 9. Concentration levels inthe brain Source: The Brain: Understanding the Neurobiology of Addiction National Institute on Drug Abuse, NIH,
- 10. Immediate Effects ofHeroin Use Euphoria or the rush Injected into a vein: euphoria in 7-8 seconds Injected into a muscle: euphoria in 5-8 minutes Sniffed/snorted or smoked: euphoria in 10- 15 minutes Drowsiness or nodding After the initial euphoria, abusers become drowsy for several hours
- 11. Crashing Physicalsymptoms of withdrawal may occur within a few hours after last drug is taken Major withdrawal symptoms peak around 24 – 48 hours after the last dose of heroin and subside after about a week Craving Intense feeling to stop the crash and return to euphoria Continue…
- 12. Treatment of opiatedependence Untreated: high morbidity and mortality Treatment of opiate dependence is difficult rapid or short-term solutions are ineffective for majority of opiate dependent individuals (high rate of relapse) many opiate dependent individuals require multiple treatment attempts and/or long-term treatments above characteristics are not different from other medical treatments of chronic diseases
- 13. Treatment of opiatedependence Comprehensive treatments, combining medications with counseling, psycho-social treatments, are effective in reducing morbidity and mortality, as well as improving health, vocational, social, family, and legal functioning
- 14. Treatment Modalities Pharmacotherapy Detoxification + follow-up treatment Maintenance with agonist or antagonist medications Long term approach: opportunity for client to distance themselves from drug-using lifestyle To flood the brain with safe opiates, so it stops craving for heroin (unsafe opiates)
- 15. Treatment Modalities Psychosocial/behavioraltreatment Outpatient counseling Self-help programs Other Residential treatments Therapeutic communities Religious approachs
- 16. Methadone 1st producedby German Chemists in early 20th century and has been used clinically since end of WW1. Synthetic opiate without strong sedative effects. White crytalline powder. Widely used as a substitution therapy in the treatment of heroin addiction.
- 21. Pharmacological & ClinicalProperties Pharmacological property Clinical implication Substitutes for heroin Prevents withdrawal Mild opiate-like effects Reduces cravings Increases treatment retention ‘blocks’ other opiates Reduces heroin use Long duration of action Daily (or alternate day) dosing Ceiling effects Greater safety profile
- 22. Methadone Pharmacokinetic Onsetof effects : 30 minutes Peak effects : Approx 3 Hr Half life (in MMT) : Approx 24 Hr Time to reach stabilization : 3 -10 days (steady state)
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- 24. Benefits of MMT Reduced illicit drug use Improved health status as a result of access to treatment (by normalization of endocrine and immune system functioning) Decreased transmission of HIV, HCV, HBV (↓ harm) Decreased illegal activity Increased employment Decreased cost to society Decreased mortality High treatment acceptance and good retention
- 25. Continue… Long-acting oralopiate administered daily replaces short-acting drug used by injection, chasing, or smoking Steady-state plasma levels no “rush,” “nod” or withdrawal during maintenance Multiple targets: Low doses (30-40 mg daily) prevent withdrawal Higher doses (80-120 mg daily) Reduce craving Induce tolerance to street opiates Block/attenuate pleasurable opiate effects
- 27. Side Effects ofMethadone CNS- Sedation, dysphoria, weakness, headache, insomnia, agitation, disorientation, and visual disturbances. Gastrointestinal- Dry mouth, anorexia, constipation and biliary tract spasm. Cardiovascular- Flushing, bradycardia, palpitations, faintness, and syncope. Genitourinary- Urinary retention, anti-diuretic effect, reduced libido/potency. Allergic- Pruritus, urticaria, edema, and, rarely, hemorrhagic urticaria. Hematologic- Reversible thrombocytopenia has been described in a narcotics addict with chronic hepatitis.
- 28. Common Adverse Effectsand What To Do? Side Effect Common Causes Response Drowsiness after dose •Excessive dose •Use of other CNS depressants (alcohol, BDZ) •Review and maybe reduce dose •Reduce patient’s use of other drugs Craving for heroin Insufficient dose Review and maybe increase dose
- 29. Continue… Side Effect CommonCauses Response Constipation •Methadone •Dysfunctional diet •Other lifestyle behaviours •Advise a high fibre diet, adequate fluid intake & exercise •Pharmacotherapy of constipation if necessary Dental problems (decayed teeth, periodontal disease) •Drug induced reduced saliva volume (problem with all opioids) •Poor dental hygiene Advise enhanced dental hygiene (frequent brushing, avoid sugary foods/drinks, chew non-sugar gum)
- 30. Continue… Side Effect CommonCauses Response Weight Gain •Fluid retention •Improved appetite •Decreased activity •Review dose and reduce patient’s salt intake •Review and change patient’s diet •Advice patient to increase exercise carefully
- 31. Continue… Side Effect CommonCauses Response Insomnia •Excessive or insufficient dose •Timing of dose •Stimulation by other drugs (coffee, tobacco, stimulant drugs such as amphetamine or pseudoephedrine) •Review dose •Review timing of dose •Identify stimulant drugs and advise patient to avoid them •Review patient’s general sleep hygiene
- 32. Continue… Side Effect CommonCauses Response Lowered libido •Higher doses •Psychological or social/situational problems •Review dose •Check patient’s history and advise counselling
- 33. Continue… Side Effect CommonCauses Response Nausea/ Vomitting / Loss of Appetite • methadone • Do not take the dose while empty stomach. • Can be taken with milk if there is GI disturbance Skin Itchiness/ Urticaria • Histamine released by methadone • Review & identify the skin problem. • Symptomatic relief by antihistamine.
- 34. Continue… Side Effect CommonCauses Response Excessive Sweating • Excessive dose of methadone • Wear thin clothes Tachycadia/ Bradycardia • Excessive dose of methadone • Refer to see doctor immediately.
- 35. Drug Interactions Drug Effecton Methadone Action Alcohol Increase ↑ Avoid Antiepileptics ex. PHT Decrease ↓ Increase/split Methadone dose Benzodiazepines Increase ↑ Limit/stop use BDZ Cimetidine Increase ↑ Avoid Ciprofloxacin Increase ↑ Decrease methadone dose Efavirenz Decrease ↓ Increase/ split Methadone dose Fluoxetine Increase ↑ Change SSRI
- 36. Drug Effect on Methadone Action FluvoxamineIncrease ↑ Change SSRI Nicotine Decrease ↓ Advise stop smoking Rifampicin Decrease ↓ Increase/ split Methadone dose SLN (Stavudine+ Lamivudine + Nevirapine ) Decrease ↓ Increase/ split Methadone dose Tricyclic Antidepressants Increase ↑ Avoid Urine Acidifier (Ascorbic acid) Decrease ↓ Avoid Urine alkaliniser (NaHCO3) Increase ↑ Avoid Zidovudine None (Incr. AZT Decrease AZT
- 37. MMT for SpecialCases Pregnancy & Lactating Mother : Safe for both & enable stabilisation of drug use & lifestyle Reduces & eliminates illicit opioid drug use & can help stabilize the in utero environment. Does not increase the risk of congenital abnormalities, premature delivery & reduced weight in the fetus. Babies born may experience “fetal abstinence syndrome” (FAS) which can be relieved by symptomatic Tx eg. Phenobarbitone for asthma. Methadone is classed as Pregnancy Category C drug because of potential risk of respiratory depression in neonates (not significant).
- 38. Management in Pregnancy Pregnant women should be maintained on an adequate dose/ current dose of methadone to achieve stability. Opioid withdrawal at 1st trimester -- ↑ risk of miscarriage; 3rd trimester – risk of fetal distress & death. The bioavailability of methadone is decreased in the later stage of pregnancy due to increased plasma volume, an increase in plasma proteins which bind methadone & placental metabolism of methadone. may divide the daily dose & increase the dose in the 3rd trimester.
- 39. Management in Breastfeeding Breast milk contains only small amount of methadone & mothers can be encouraged to breastfeed of methadone dose provided that they are not using other drugs. Breastfeeding may reduce the severity of the neonatal withdrawal syndrome. Women receiving high doses of methadone should be advised to wean their babies slowly to avoid withdrawal in the infant.
- 40. Management in HIVPatients HIV positive patients must have access to specialist HIV medical care In general, these patients are able to comply with the requirements and conditions of the program Doses must be monitored due to interactions between methadone and HIV medications and the effects of related illnesses Higher doses may be necessary if HIV medications increase methadone metabolism.
- 41. Management in HepB Patients Recommend Hepatitis B vaccinations to all clients on the methadone program who are found to have no immunity to the hepatitis B virus Clients who are acutely infected or who are chronic carriers of hepatitis B should be referred to a specialist
- 42. Management in HepC Patients A high percentage of clients - Hepatitis C antibody positive Hep. C positive + 3 normal serum ALT and AST over 6 months , LFT’s repeated at 6 monthly intervals Hep. C positive + 3 abnormal serum AST and ALT over 6 months, referral for specialist care is indicated
- 43. Self Care forMMT Patients Do not give Methadone to other people because it is extremely dangerous & may cause toxicity or unwanted effects. Do not inject Methadone as it may cause dangerous complications. Advice patients to see dentist for dental check up at least 2 times per year. Increase fluids (water) intake. Do more exercise. Eat balance diet with high fibre food. Involved in religious activities to seek for peace & enhance confidence & motivations
- 44. When should westop treatment? Chronic condition needs long term treatment Premature cessation of treatment usually results in relapse to dependent heroin use Consider ending treatment when no illicit drug use for months / years stable social environment stable medical / psychiatric conditions patient has a life that does not revolve around drugs patient informed consent
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- 48. M1M (Methadone 1Malaysia)
- 49. M1M (Methadone 1Malaysia)
- 50. Problems We AreFacing Aggressive Patients Divertion of Methadone Bring another bottle (not TA bottle) Cheating
- 52. KECICIRAN RTG METHADONE Pesakit tidak hadir untuk rawatan RTG Methadone di pusat rawatan lebih daripada 14 hari berturut-turut.
- 53. FAKTOR PENYEBAB KECICIRAN RAWATAN Tidak dapat dikesan/ dihubungi (TDK) Ditahan polis/ lokap Masuk penjara Masalah kewangan Lokasi jarak Masa rawatan kurang sesuai
- 54. Duration oftreatment Dose of medication Quality of therapeutic relationship Regular review, supervision & monitoring Psychosocial supports for the patient Motivation / goals of clients Principles of Effective Maintenance Treatment
- 55. How far isfar, how high is high? We will never know until we try. The door to success is the one marked “PUSH”…… Persevere Until Success Happens
- 57.
- 58. Hasryn Azzuar MohdKhairy Pegawai Farmasi Y/M Farmasi RTG Methadone HKL hasryn@moh.gov.my Kepentingan ‘Compliance’ (Kepatuhan) Terhadap Rawatan Terapi Gantian Methadone
- 59. Di dalambidang perubatan, ‘compliance’/kepatuhan bermaksud sejauh mana seseorang pesakit itu mengikut dengan betul rawatan atau nasihat-nasihat perubatan yang telah diberikan. Ketidakpatuhan pada rawatan adalah suatu halangan utama dalam memberikan penjagaan kesihatan yang berkesan kepada pesakit. Kepatuhan = Bil dos yang diambil x Apa itu 'Compliance'
- 60. Kerjasama Pelbagai PihakDalam Menjayakan RTG Methadone
- 61. Mengapa RTG Methadone? Semejak 40 tahun lalu, methadone telah membantu jutaan penagih meninggalkan ketidakstabilan hidup yang dialami ketika bergelumang dgn dadah. ↓ penularan penyakit bawaan darah (HIV & Hepatitis) ↑ tahap kesihatan √ pekerjaan stabil Belajar semula Diterima keluarga semula √ kehidupan sosial Keyakinan diri (feel good about themselves)
- 62. ↓ penggunaandadah jalanan ↓ jenayah ↓Beban masyarakat dan negara ↓ Kematian Penerimaan terhadap rawatan yang bagus Mengapa RTG Methadone? Bantu AADK capai ‘Negara Bebas Dadah 2015’ ☺
- 63. Keselamatan Pesakit Kayu Pengukur Kejayaan Retention Rate (WHO Standard - 65% retention rate selepas satu tahun rawatan) Peningkatan Kualiti Hidup (QOL) Disiplin Kepentingan 'Compliance'
- 64. Staf –galak pesakit untuk berhenti ambil dadah lain supaya tidak ganggu rawatan → kepatuhan kepada rawatan. Heroine Morphine Syabu/’ice’ Alkohol Ganja Ubat Tidur Komplian – penting dalam pemulihan Elak ‘relapse’ Mengawal fungsi otak Tidak komplian – regimen methadone akan gagal → ↑ kos keseluruhan penjagaan
- 65. PENTING BAGI ANDA MENGETAHUITUJUAN RTG METHADONE SUPAYA ANDA DAPAT MEMBANTU PENAGIH
- 66. Methadone –Hanya perlu ambil sekali sehari. Methadone - Long-acting oral opiate (berada dalam badan lebih lama) → elak suntik,’chase’ / hisap heroine/opiat Kenapa Perlu Ambil Dos Secara Harian?
- 67.
- 68. Concentration levels inthe brain Source: The Brain: Understanding the Neurobiology of Addiction National Institute on Drug Abuse, NIH,
- 70. Seeloknya diminumpada waktu PAGI Dalam proses induksi methadone ‘overdose’ selalu berlaku semasa di rumah bila tidur Administrasi methadone pada waktu pagi akan pastikan tahap methadone optimum berlaku semasa pesakit berjaga & org lain masih ada jika overdose berlaku. Kenapa perlu ambil pada waktu yang sepatutnya?
- 71. Minum methadonepada waktu yang sama setiap hari Untuk mencapai konsentrasi methadone dalam badan yang selamat (underdose/overdose) ≈ setiap 24 jam ± 1 jam Bagi pesakit yang mempunyai dos dua kali sehari Minum dos malam yang dibawa balik pada waktu sama yang ditetapkan setiap hari. Habiskan isi kandungan DBB (JANGAN dibahagi2kan) Kenapa perlu ambil pada waktu yang sepatutnya?
- 72. Pesakit yangmempunyai Dos Bawa Balik (DBB) Perlu minum seperti yang tertulis pada label Minum sekaligus (habiskan isi kandungan botol) Tidak boleh dibahagi-bahagikan Perlu disimpan dengan selamat dan betul Kenapa perlu ambil pada waktu yang sepatutnya?
- 73. Methadone adabanyak interaksi dengan ubat2an lain dan makanan Diproses di hati Ubat-ubatan lain boleh menyebabkan ↑ konsentrasi methadone dalam darah – kesan sampingan ↓ konsentrasi methadone dalam darah - gian Saya ada makan ubat2an lain…
- 74. Ubat-ubatan Alkohol UbatGastrik Ubat tidur Ubat sawan Antibiotik Ubat HIV Ubat TB Nikotin (Rokok/Patch) Vitamin C Buah – buahan masam Minuman/makanan berkaffein Kopi Teh Coca- cola/pepsi dll Contoh bahan-bahan yang berinteraksi dengan Methadone Makanan
- 75. Dadah jalanan: alkohol, heroine, ice, ganja, ubat tidur, ecstasy → boleh sebabkan overdose jika dicampur bersama Methadone. Simptom2 Overdose Pengecilan Anak Mata Loya / Muntah Pening-pening Mengantuk Pergerakan tidak stabil / Percakapan tak jelas Berdengkur Pernafasan cetek Berbuih di mulut Selain itu…
- 76. KESAN SAMPINGAN KESAN SAMPINGAN FAKTOR PENYEBABTINDAKAN Mengantuk selepas pendosan Gian kepada heroin Dos berlebihan/ Penggunaan dadah depresi Dos tidak mencukupi Elakkan dari memandu kenderan/ mengendalikan mesin sekurang-kurangnya dalam masa 2 minggu pertama Beritahu doktor
- 77. KESAN SAMPINGAN KESAN SAMPING FAKTOR PENYEBAB TINDAKAN Sembelit Gangguan tidur/ Insomnia Masalah gigi Metadon Terlebih/ Kurang dos Metadon Banyakkanambil buah,sayur berserat tinggi Kesan dadah/ bahan lain (kopi,rokok) Buat senaman ringan Kerap memberus gigi,elakkan mengambil makanan/minuman bergula,kunyah gula getah
- 78. KESAN SAMPINGAN KESAN SAMPINGFAKTOR PENYEBAB TINDAKAN Berpeluh berlebihan Kadar denyutan jantung laju/perlahan Pengurangan fungsi sex Dos berlebihan Dos berlebihan Dos yang tinggi Pakai pakaian yang tidak terlalu tebal. Segera berjumpa doktor Beritahu doktor
- 79. INTERAKSI METHADONE Campuransebarang dadah lain dengan metadon amat berbahaya. Boleh menyebabkan gejala mengantuk, lali dan tidak sedarkan diri
- 80. Bahan/ Dadah Kesan ke atas Metadon Caramengatasi Efavirenz Nikotin Rifampicin Urine acidifiers cth. asid askorbik Mungkin perlu tingkatkan dos metadon ataupun split dose Nasihatkan pesakit berhenti merokok Tingkatkan dos Metadon/split dos Elakkan INTERAKSI METHADONE
- 81. Bahan/ Dadah Kesanke atas Metadon Cara mengatasi Zidovudin Benzodiazepine Alkohol Tiada ( mungkin meningkatkan paras zidovudin ) Kurangkan dos zidovudin Hadkan penggunaan benzodiazepine Elakkan INTERAKSI METHADONE
- 82. Mengandungi Burprenorphine+ Naloxone Apakah itu buprenorphine? Adakah ia lebih baik dari methadone? Buprenorphine ialah ubat yang berpotensi utk sesetengah penagih opioid. Ia seakan methadone, dimana ia menghalang kesan opioid lain seperti heroine, morphine dan methadone. Tetapi mempunyai kesan yang kurang dari methadone Bahaya jika diambil bersama methadone → sebabkan gian teruk. Suboxone?
- 83. Pesakit sukacampur Bila rasa gian, pesakit salahkan methadone
- 84. Rawatan Terapi Gantian DenganMethadone Hasryn Azzuar Mohd Khairy Pegawai Farmasi, Hospital Kuala Lumpur
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- 86. Ketagihan Dadah Ketagihandadah adalah satu penyakit yang kompleks dan kronik (berpanjangan) SAMA seperti penyakit kencing manis dan darah tinggi Ketagihan – suatu penyakit otak
- 87. Apa perbezaan ketagihandengan penyakit kronik lain Ketagihan Diabetes Melibatkan faktor biologi badan Ya Ya Rawatan Ubat - ubatan Ya (Methadone) Ya (Ubat-ubatan anti- diabetes) Implikasi jika tidak mengikut rawatan Simptom gian, penggunaan dadah haram Peningkatan gula dalam darah Komplikasi jika tidak dirawat HIV, Hep B & C, Penyakit-penyakit psikiatri, jenayah Kegagalan organ-organ penting dalam badan
- 88. Kajian saintifikmenggunakan tikus menunjukkan Tikus yang diberi heroine akan menunjukkan kesan ketagihan Tikus akan menekan butang secara kerap untuk mendapatkan heroine seterusnya Ketagihan mempunyai sifat galakan berulangan (self- reinforcing property)
- 90. Penagih juga perludirawat sama seperti orang yang berpenyakit!!!
- 91. Jadi, apa itumethadone?
- 92. Methadone Ditemui padazaman perang dunia pertama (1940) Mula digunakan sebagai ubat penahan sakit Didapati mempunyai ciri-ciri untuk memulihkan penagih Dadah sintetik dari jenis opiat
- 93. Keberkesanan Methadone Menutuprangsangan Heroin dan dadah lain pada otak Kurangkan kesan gian Kesan drastik: 30 minit Kesan kemuncak: 3 jam Jangka Hayat : 24 jam Masa penstabilan : 3-10 hari
- 94. Apa itu RawatanTerapi Gantian Dengan Methadone Pada awal 1960an – 2 orang doktor dari New York telah mendapati jika methadone diambil secara harian dan ditambah dengan khidmat sokongan, ia adalah kaedah yang efektif untuk merawat ketagihan terhadap dadah opiat
- 95. Apa itu RawatanTerapi Gantian Dengan Methadone (2) Methadone ini digunakan sebagai kaedah mengurangkan mudarat bagi membendung risiko penularan penyakit berjangkit yang berkaitan dengan perkongsian jarum Dos methadone yang betul TIDAK akan menyebabkan pesakit “high” atau “lalok” – mereka boleh menjalani kehidupan seperti normal
- 96. Walaubagaimanapun, Methadonemasih boleh disalah guna, jadi rawatan ini mesti dipantau dan diselia dengan perhatian dari pelbagai pihak (pegawai farmasi, doktor, pihak AADK, kaunselor dan AHLI KELUARGA)
- 97. Soalan cepu emas!!! Berapa lama nak minum? Gian lagi teruk bila nak berhenti? Minum methadone boleh mati! Minum methadone tak boleh berhenti! Sy adjust dose sendiri so lagi senang berhenti…
- 98. Berapa lama nakminum? Jangka masa rawatan adalah berbeza bergantung kepada penggunaan heroin sebelum ini Pemerhatian, lebih lama mengambil methadone, lebih baik peluang untuk pulih sepenuhnya dari ketagihan Pengambilan dalam masa yang singkat – kebarangkalian tinggi untuk ‘jatuh’ semula.
- 99. Ketagihan –sakit otak kronik Sama macam diabetes – perlu komitmen sepanjang hayat, proses yg berterusan Lebih lama lagi bagus – lepas 1 tahun 80% pengurangan pengambilan dadah Pulih sepenuhnya – makan masa bulan/tahun Methadone – titik permulaan proses pemulihan, selebihnya dan berapa lama bergantung pada pesakit itu sendiri. Berapa lama nak minum?
- 100. Berapa dos yangsesuai untuk saya? Jangan bandingkan dos anda dengan orang lain Dos methadone anda adalah unik bagi setiap individu Dos penstabilan 60 – 120mg Anda mungkin perlu lebih atau kurang dari dos tersebut untuk stabil
- 101. Faedah Rawatan TerapiGantian Dengan Methadone Diberi secara oral, bukan secara suntikan. Oleh itu dapat mengurangkan risiko jangkitan hepatitis B dan C serta jangkitan HIV. Mengurangkan kebergantungan opioid. Mengurangkan kesan pengunduran (withdrawal). Membantu mengurangkan kesan psikologi dan emosi semasa proses pengunduran. Pendosan sekali sehari . Dengan itu, meningkatkan komplians pesakit. Selamat digunakan oleh ibu yang mengandung dan menyusukan anak. Membantu meningkatkan status sosial dan peluang pekerjaan
- 102. Pendispensan Methadone Screening ofMethadone Prescription Patient Drinking their ‘DOT’ Dose Make sure patient throw away their cup(s) into the designated bins. Patient rinses their cup to make sure there are no more medication left and also to make sure they drink and swallow their dose.
- 104. Kajian –gian methadone tidak seteruk heroine/morphine Jika diberhentikan dengan prosedur yang betul tidak akan rasa gian dan senang untuk berhenti Jika diberhentikan secara ‘cold turkey’ – rasa tidak selesa akan ada lebih lama kerana methadone berada lebih lama dalam badan Methadone lagi susah nak berhenti…Gian lagi teruk…
- 105. Sejak diperkenalkan(2005) – tiada kes kematian yang disebabkan oleh RTG Methadone Semua ubat ada kesan sampingan Jika dipantau oleh ahli professional kesihatan – terapi yang selamat (terdapat rawatan yg lebih bahaya dari RTG Methadone) Pada dos yang selamat – pesakit tidak rasa ‘high’ dan boleh berfungsi seperti normal. Minum Methadone boleh mati!!!
- 106. Jika tidakpatuh pada rawatan – PASTI tidak boleh berhenti Maklumkan doktor/pegawai farmasi jika ingin berhenti Ada cara yang betul untuk berhenti tanpa merasa apa-apa/sedikit kesan yang tidak menyenagkan Minum Methadone tak boleh berhenti? Saya 'adjust' sendiri dos saya…
- 107. Kesan – kesanyang tidak diingini Boleh berlaku pada permulaan rawatan Sesetengah simptom yang dialami mungkin disebabkan oleh kesan sampingan Metadon
- 108. Kesan – kesanyang tidak diingini Juga boleh berlaku sekiranya dos metadon yang diambil adalah terlalu tinggi atau rendah Kebanyakan orang yang pernah mengambil heroin akan mengalami kesan sampingan dengan Metadon yang minimal
- 109. Kesan sampingan PENGURANGAN FUNGSI SEKS MULUTKERING SEMBELIT HILANG SELERA MAKAN KULIT LEBAM & GATAL SAKIT OTOT & SENDI BERPELUH BERLEBIHAN MENGANTUK KESAN SAMPINGAN METADONE
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- 111. Penjagaan Diri Pesakit Jangan berikan metadon kepada orang lain Jangan menyuntik metadon kerana ianya boleh menyebabkan komplikasi yang membahayakan Sila berjumpa dengan doktor gigi anda sekurang- kurangnya 2 kali setahun
- 112. Minum sekurang-kurangnya2 liter air sehari Banyakkan senaman Makan makanan seimbang Jaga kebersihan diri Banyakkan aktiviti keagamaan untuk mencari ketenangan diri
- 113. Pengambilan Alkohol Dinasihatkantidak mengambil alkohol. Terlebih dos alkohol mengganggu rawatan methadone Boleh menyebabkan terlebih dose jika diambil bersama Jika berbau alkohol atau mabuk, dos methadone akan ditangguhkan
- 114. Interaksi Methadone danUbat-ubatan Campuran sebarang dadah lain dengan metadon amat berbahaya Boleh menyebabkan gejala mengantuk, lali dan tidak sedarkan diri dan kematian Sila beritahu dengan pegawai farmasi, doktor jika anda mengambil sebarang ubat lain!!!
- 115. Elakkan / kurangkan… Alkohol Buah – buah masam Vitamin C Minuman berkaffein (kopi, teh, coke) Merokok Ubat tidur
- 116. Outline Missed Dose Vomited Dose Take Away Dose Storage of Methadone Overdose Underdose
- 117. MissedDose When patientmiss their methadone doses, they may use other drugs (i.e. Alcohol / Benzo) When missed 3 or more days, tolerance to opioids may be reduced – increase risk of overdose when methadone is reintroduced Patient should be assessed for signs of intoxication & withdrawal If dose has not been collected for 3/more days, dose should be withheld or reduced – Dr’s review
- 118. If apatient misses their dose : One Day No changes in dose Two Days If no evidence of intoxication, administer normal dose Three Days Administer half dose in discussion with the prescriber Four Days Patient must see prescriber. Recommence at 40mg or half dose whichever is lower Five Days or more Regard as a new induction
- 119. Scenario1 Mr ESShas drank methadone 120mg on 25/10/2013, he came again on 28/10/2013 for his next dose. After that, he only came again on 1/12/2013 because he claimed that he was being arrested by the police. What should you do? a) On 28/10/2013? b) On 1/12/2013?
- 120. Whatshouldyoudo? a) Continue 120mg. b)Obtain letter of release (if available as proof). Refer prescriber before continuing patient’s methadone treatment, regard as new case.
- 121. VomitedDose If patienthas vomited after dose has given, steps for replacement dose should be taken A new prescription is needed for the replacement dose
- 122. Less than 15minutes after dosing Replace whole dose In between 15 – 30 minutes after dosing Replace 50% of dose After 30 minutes of dosing No replacement dose VomitedDose(2)
- 123. Scenario2 Miss AFdrank her methadone dose at 1030am, 30 seconds after drinking she vomited at the waiting area of your pharmacy. What should you do?
- 124. Steps tobe taken Obtain new prescription for replacement dose Replace full dose of methadone Call cleaner to clean up
- 125. Scenario3 • “Encik, sayamuntah la, baru je, saya nak minum lagi la encik, kalau tak minum saya gigil-gigil la encik…tolonglah…” What should you do? On what basis can you give or cannot give…
- 126. “ Encik, dudukdulu…” Calm patient down Check the time when patient drank on that particular day from the prescription Ensure patient is not lying Do not prejudge (patient might be genuine) Consume methadone after food Less than 15 minutes after dosing Replace whole dose In between 15 – 30 minutes after dosing Replace 50% of dose After 30 minutes of dosing No replacement dose
- 127. Take-AwayDoses Take awaydoses are allowed When patient are stable 6 week into the program Through observation on stability & misuse, urine Review notes on evaluation for TA doses should be kept clearly in the clinical notes Pt’s stability indicator (i.e. urine, behaviour) No contraindication towards treatment Other usage of psychoactive agents (if any)
- 128. Take-AwayDoses(2) Take awaydoses Dosage of methadone To add water ≤ 25mg Up to 50mL > 25mg Up to 100mL
- 129. Take-AwayDoses(3) Prepare completelabel for the bottle Methadone ……mg Minum pada…(tarikh)…(masa) Nama …………………………………………. No Pendaftaran…………………………… Tarikh Dibekal…………………………….. AMARAN JAUHI DARI KANAK-KANAK Nama pusat rawatan RTG, Alamat, Telefon Perlu diambil / ditelan oleh penama yang tercatat pada label di atas pada hari yang telah dinyatakan Boleh menyebabkan kemudaratan / kematian Jikalau diambil oleh orang lain In front of bottle Back of bottle
- 130. Take-AwayDoses(4) WEEKLY TA DEATH /BIRTH FESTIVE SEASONS FASTING MONTH
- 131. Take-AwayDoses(5) Only 3/7per week After being 6/52 into the program Dr’s approval (1st time) Specific day must be assigned Defaulters – withhold TA 1/12 (subject to Dr’s evaluation) Weekly TAs
- 132. Take-AwayDoses(6) Death/birth offamily members Can be given up to 3/7 Submit death cert/birth cert (compulsory) Pharmacist Death / Birth
- 133. Take-AwayDoses(7) 3/7 ofTAs After being 6/52 into the programme Patients who are celebrating Pharmacist Festive Seasons
- 134. Take-AwayDoses(8) 1/7 ONLYgiven at a time 1st dose given 1 day before fasting month Very high possibility for misuse Further discussion??? Standard guideline??? Fasting Month
- 135. Storageof Methadone Storageof take away doses In a safe place ( cabinet or locked drawer) Away from children Room temperature ( not in fridge) Cool dry place
- 136. OverDoses Overdose happenswhen a drug is taken excessively or in combination with other agent(s) Very dangerous, fatal In Australia, death following methadone induction often occurs at home during sleep Administration of methadone in the morning ensure peak methadone concentrations occur when patients are normally awake & other people may be around if overdose should occur
- 137. OverDoses(2) Symptoms Pinpointpupils Nausea Dizziness Feeling intoxicated Sedation/ Nodding off Unsteady gait, slurred speech Snoring Hypotension Slow pulse (Bradycardia) Shallow breathing (hypoventilation) Frothing at the mouth (pulmonary oedema) Coma
- 138. OverDoses(3) Depressants (actby reducing nervous system activity to a dangerous level where pt stops breathing) Heroine Morphine Methadone Sleeping pills Alcohol Benzodiazepines Stimulants (Increases body activity & can cause the increase in blood pressure, heart rate & body temperature) Amphetamines Ecstasy Caffeine Nicotine
- 139. OverDoses(4) Overdose canhappen easily either to an experienced or new addicts Factors that affect the effects of drugs on individuals Tolerance Amount of drugs Drug combination(s) Route of administration
- 140. OverDoses(5) Things thatcant be done when patient has overdose Force patient to vomit Take a cold shower Injecting salt water
- 141. OverDoses(6) Treatment IVNaloxone 0.4-2mg every 2-3 minutes according to patient’s need
- 142. Underdose Happens betweenfew minutes or days after stopping or reducing dose of opioids Important to identify to retain patient in the programme Symptoms Dysphoria Nausea & vomiting Muscle aches Runny nose , watery eyes Pupillary dilatation Diarrhea Excessive yawning (sangap) Fever Insomnia
- 143. SEKIRANYA TERBUKTI MASIH TERLIBATDALAM PENYALAHGUNAAN DADAH TETAP TIDAK AKAN TERLEPAS DARI TINDAKAN UNDANG-UNDANG
- 144. MMT Patients’ Outcome WhenWe Were Addicts Now … We can already function like normal
- 145. Real Quotes FromMMT Patients “You all are really doing a very noble job helping these addicts” – patient’s brother “Terima kasih la kat kerajaan sebab sudi tolong orang macam kami,akak je yang tak jemu tengok muka kitorang (penagih) ni” - pesakit “Dulu 24 jam saya keje nak cari duit, sebab ‘barang’ punya hal, sekarang dah minum metahdone, satu kerja je cukup boleh jimat dan saya pun dah boleh jaga mak bapak saya. Hari-hari saya jenguk diorang” -pesakit Saya nak pegi hantar anak saya pegi sekolah ni, tulah minum methadone dulu” –pesakit “Boleh tak saya nak schedule kan balik take away saya, nak pegi Singapore keje, ni flight itenary saya” – pesakit “Saya sekarang dah keje dah, driver Dato’ ********* *****” – pesakit “You are really giving them (addicts) a second chance in life” – patient’s family member
- 146. Terima Kasih Ingin berkongsicerita? Ingin bertanya soalan?
- 147. SEKIAN TERIMA KASIH Jikaanda ingin mendapatkan maklumat atau belajar dengan lebih lanjut cara-cara mengendalikan klien anda, sila lawati www.atforum.com atau berhubung terus dengan saya ;)