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Opioid replacement therapy.pptx
The document discusses addiction replacement therapy (also known as opioid substitution therapy) for treating opioid use disorder. It begins by outlining the objectives and magnitude of the global and Egyptian opioid problems. It then describes medication-assisted treatment using opioid agonists/antagonists like methadone and buprenorphine. The benefits of opioid substitution therapy include reducing illegal opioid use and associated harms while increasing social functioning. Common myths about substitution therapy are addressed. Treatment algorithms are provided to guide patient assessment and selection of optimal replacement therapies like methadone, buprenorphine or naltrexone based on their different pharmacological profiles and patient characteristics.
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Opioid replacement therapy.pptx
- 1. Leut.Col.Dr.Yasser AbdEl-Ghany El-Ghazzawy PsychiatricHospital,Maadi Armed Forces MedicalComplex Addiction Replacement Therapy
- 2.
- 3. Objectives Magnitudeoftheproblem 1 2 3 AddictionReplacementTherapy(OpioidSubstitutionTherapy) “Medication-AssistedTreatment(MAT)”forOpioidusedisorder Agonist/ Antagonistpharmacology 4OpioidSubstitutionTherapy(OST): Methadone Buprenorphine Comparison / Flowchart for assessment and management Harm reduction concept History of OST The perfect drug Benefits of OST Myth about substitution therapy/ challengesand threats. Inclusion Criteria and special groups.
- 4.
- 5. Magnitudeof theProblem Consequences oftheopioid crisis: • Increased HIVand HCV. • Risingincidenceofinfants born dependentonopioidsas a result of opioiduse duringpregnancy. Worldwide In2020, 2.7 million peopleaged 12 orolder, inU.S with OUD OpioidUseDisorder: Overdose deaths: • The UnitedNations attributes76% of addiction-related deaths worldwidetoopioids • More than quadrupled from 1999
- 6. Magnitude of theProblem InEgypt: All indicatorspoint to an increaseinthebehaviorof drugabuse by injection,whichis accompanied by an increasein the rates of infection(HIV,HBV, HCV) • By the end of2020, the cumulativenumber of people infectedwithHIV/AIDS was: 18,196,ofwhom 6,080 are injectingdrug users, representing 33.5 %ofthe total number of cases detectedfrom 1986to 2020. • Out of the total6080,in the last fiveyears only: 4803, or 79%. • In 2019and 2020alone, the percentageof HIV through injectingdrugs increased by 31% compared tothe previous twoyears.
- 7. Magnitude of theProblem InEgypt: • A Survey bythe government shows that the narcotic problem costs the country’s economy $800 millionannually • According to theUNODC 51% of injecting drug users are infectedwith HCV with the highestNumbers in Egypt globally(10%) . • In additionto 150,000 new infections annually. UNOCD= UnitedNationsOffice onDrugs and Crime
- 8. “Medication-AssistedTreatment(MAT)” for Opioid UseDisorder 1 Detoxification 2 Early and late recovery 3 Maintenance Methadone Buprenorphine Naltrexone Alpha-2-AdrenergicAgonist Medications (Lofexidine)
- 9. Agonist/Antagonist o Affinityfor binding plus efficacy oMethadone PureAgonist o Affinityfor binding butlow efficacy o Buprenorphine PartialAgonist o Affinityfor binding butno efficacy;blocks action of endogenous andexogenous ligands. o Naltrexone PureAntagonist
- 10. Heroin/Methadone Buprenorphine Naloxone/Naltrexone FullAgonistPartialAgonist Antagonist Activity Zone Affinity Zone
- 11.
- 12. HarmReduction WhatisHarm Reduction? Can be viewedasthe preventionof adverse consequencesofillicitdrug use without necessarilyreducingtheirconsumption. A range of different strategies withthe goal of minimizingthe riskof the patient contractinginfectiousdiseases,overdosing, orsufferingother consequencesrelated to the use of substances. The increasingnumbers of patients infectedwithbloodbornediseases through sharing injectingequipment, the model ofharm reductionhas been adaptedinEgypt
- 13. HarmReduction Vaccinationagainst HBV ProtectedSex Harmreduction strategies: Overdose reversal medications supply (Naloxone) Treatmentfor infectiousdiseases (HCV/HIV) Reducestigmaassociated withsubstanceuseand co-occurringdisorders NotSharing Needles OpioidSubstitution therapy(OST)
- 14. History During world WarII Asa synthetic alternative 1960s The supplyof Opiumwas cutoff from Germany. As a resultpainkilling Morphine became a medicinein short supply. Methadone was developed as a pain killing alternative by German chemist as an Opioid receptoragonist successfully relievedpain. • Methadone used as a treatment for opioid dependenceas a response topost- world War IIHeroinepidemic inNew YorkCity. • FDA approved for opioiduse disorder in1972
- 15. o One ofthe most effective treatment options for opioid dependence. o It is a safe andcost-effective. o Extensively researched. AddictionReplacementTherapy OpioidSubstitutionTherapy(OST) WHO addedMethadone and Buprenorphine tothe “Listof EssentialMedicines” "intended to beavailablewithinthecontext of functioning health care systemsat all times in adequate amounts, in the appropriatedosageforms,with assured quality,and at a pricetheindividualand the community can afford."(WHO,2009)
- 16. “ThePerfectDrug”Characteristics: • Slowonset ofAction. • Relieves withdrawalsymptoms. • Longduration of action. • Prevents relapse. • Slowoffset of action. • Has impact onnegative reinforcement generated by stress neural circuits. • Oral orpreferable depot form. • Inhibitsthe reinforcing properties(Euphoria) by drugs and associated cues.
- 17. Benefitsof implementing OpioidSubstitution Therapy (OST) 1 4 2 3 The reductionorcessation of opioiduse,andopioidusedisorder-related symptoms withLessharmrelated tomode of use /impurity of substance. The reductionorcessation of opioid-relatedoverdosedeaths. The reductionorcessation of opioid-relatedcriminalactivity The reductionof injectionand the associated risk of transmission of blood- borne viruses(HIV),(HBV)and(HCV).
- 18. Benefitsof implementing OpioidSubstitution Therapy (OST) 5 8 6 7 OST Increases socialfunctioningandretentionintreatment. Treatment of opioid-dependentpregnant womenwith methadone or buprenorphineImproves birthOutcomesfortheirbabies Reduces suicidalityandco-morbidpsychiatricsymptoms Decreasescraving,Resetstolerance,Relapseprevention,Safeand comfortablewithdrawal,Controlleduse givenundermedical supervision.
- 19. Benefitsof OST Abuse SubstitutionTherapy vs. High chances of HIV & other blood borne infections Not prescribed medically Severe withdrawal symptoms High chances of overdose and intoxication injuries Craving Criminal activity Lost productivity Infants born dependentson opioids. High cost of medical service Low chances of HIV & other blood borne infections Given under medical supervision Mild withdrawal symptoms if discontinued Low chances of overdose Less Craving Less Criminal activity More productivity less cost of medical service
- 20. Misconceptions/ Mythabout OST PatientsarestillAddicted Addictionis the pathologicaluse of a substance OST is medicallysupervised and regulated Myth #1 Mythabout OST OSTis simplya substituteof illegaldrugs OST ensures commitment torecovery programs that allows persons to function normally Myth #2 Providingmedicationsaloneis sufficient: Combiningpharmacotherapy and other recoveryservicesis mandatory. Myth #3 Posters in the Media : Methadoneis A Narcotic Thatkills
- 21. MainrelevantthreatsagainstOST programin Egyptare: Risksin caseof a negativeviewandperception by themedia/community, dependingon the stigmaand low knowledgeofthe harm-related injected drug use. The relatively strong stigmaanddiscriminationagainst peoplewhouse drugs, as( it is the casein several Arab countries). Lack of fundingpossibilitiesand sustainability. The riskof diversionis the case ofnon-control and insufficientmonitoring throughout thewholeprogram.
- 22. RecommendationforadmissioncriteriaforOST TheInclusioncriteria: Diagnosisofopioiddependence according toclassificatorysystems, Minimumof one tothree yearsof opioidaddiction; Methodofadministration by injection A minimumageof18; Historyoffailedtreatment attempt(s)and long duration ofuse Strong motivation and willingto come daily Ableto giveinformedconsent Specialgroupsare givenpriority over the general opioiddependent population: Pregnant women; Peoplewith HIV/AIDS Peoplewith viralhepatitis; Peoplewith mental health problems; Poly-drugusers; and In custodial settings (prisons, jails)and under policearrest.
- 23. Methadone ( throughspecializedmethadoneclinics) Modeof Action DurationofAction Preparations Dosing A fullmu-opioid receptor agonist methadoneliquid, Oral tablets, methadonePowder, IV methadone Adequate dosing ranges from60 – 120 mg,typically beginning with adaily doseof20–30mg with increases of5 or 10mguntil the optimaldoseis reached slowonset of action(30 min. withpeakeffect(2-3 hrs.) with long elimination ½ life(24-36h)
- 24. SideEffects Deaths 1 Respiratory depression 2 Cardiac ( QTcprolongation) ECGas baseline andfollow-up during treatment 3 The mainthreat is theriskof overdosing, especiallyatthe start oftreatment and when methadoneis combined with other sedativemedications or illicitdruguse Abuseispossible
- 25. Contraindications: 1 4 2 5 36 Does notmeet DSM 5/ICD-11 criteria Seriousand problematic use of alcoholand or sedative hypnotics Less than 1yr history of opioidaddiction Unable to attend program as required Allergicresponse Cardiac complications Caution: Highlyactive antiretroviral treatment medications used in HIV infection treatment affect the pharmacokinetics of methadone; therefore, it is vital to practice caution in the case of patients who receive highly active antiretroviral treatment
- 26. Buprenorphine Modeof Action Durationof Action PreparationsDosing History Partial agonist at the mu receptor. It has lowactivitybut high affinity. o Poorbioavailabilitywhen taken orallyand must be dissolvedsublingually o Co-administration withnaloxone (Suboxone®) (not absorbed sublingually)to preventthe buprenorphine from beinginjected(Abuse) o Other forms : 6-month subdermal implant and a once-monthly buprenorphine injection o Discoveredin1966 o (FDA) approved in2002 o Onset of effect in 30– 60minutes. o Peak effect inabout 1– 4 hours. o Half-life 20–72hours (36hours onaverage). Tolerabledose range (4to 24 mg )
- 27. Comparison( The 3-FDAapproved drugs) Treatment Methadone Buprenorphine Naltrexone Pharmacologic action Full opioid agonist Partial agonist Full opioid antagonist FDA-approved clinical indication Opioid-use disorder, pain Opioid-use disorder, pain Opioid-use disorder, alcohol-use disorder Routeof administration Oral, parenteral Sublingual, subcutaneous extended- release injection, subdermal implant, transdermal patch Oral, parenteral Frequencyof administration Daily Orally: daily,every other day, 3 times a week; subcutaneously:monthly implant: every 6 months Orally: daily,every other day or every third day; intramuscularly: monthly (Vivitrol)
- 28. Treatment Methadone BuprenorphineNaltrexone Challenges • Potentialfor abuse • cardiac complications in cardiac patients • Higherriskof overdose • More severein withdrawal Safe in pregnancy and breastfeeding • Potentialfor abuse if not combined with naloxone • saferfor peoplewith cardiacproblems • Better for modestly motivated patients • low risk of overdose • Less severe withdrawal so easier transition in and out of treatment Not recommended in pregnancy • No potential for abuse but Less complianceyet better in long acting injections • Betterfor highly motivatedpatients • Hepatic complications in hepatic patients Contraindicated in pregnancy
- 29. Is the patient willingto participate in CD treatment? Is patient pregnant and/or has chronic pain ? 1. Evaluate key comorbidities 2. Prescribe naloxone to treat overdose 3. Develop a detox plan 4. MI to encourage treatment participation YES 1. Refer to an ASAM certified addiction treatment provider 2. Review all three medication option risks and benefits NO Is patient willing to participate in a methadone maintenance program and is one locally available? YES Refer to methadone treatment program NO Recommended naltrexone (long-acting injectable preferred) unless pregnant Ifpregnant MI= Motivational interviewing ASAM=American Societyof Addiction Medicine CD=Chemical dependency OO=opioid overdose OUD= Opioid-usedisorder KEY Continue to monitor for relapse and maintain contact withCD treatment provider No toall Is patient highly motivated and/or would preferto avoid agonist therapy? Agreed to treatment Patient diagnosed with an opioid use disorderthrough assessment
- 30. No toall Is patienthighly motivated and/or would preferto avoid agonist therapy? Ifyes to any Recommended methadone or buprenorphine No Methadone Buprenorphine Refertomethadone clinic and continueto monitorcomorbidities Office-based induction and maintenance strategies perdata waiver training guidelines. Maintain contact with CDtreatment provider to assess progress Yes Recommendedlong-acting naltrexone Continue to monitor for relapse and maintain contact withCD treatment provider Ifno improvement Is patient pregnant and/or has chronic pain? ALGORITHMICAPPROACH TO CHOOSINGTHE OPTIMAL THERAPY : Oesterle,TylerS., et al. "Medication-assistedtreatmentforopioid-usedisorder." Mayo ClinicProceedings.Vol. 94. No. 10.Elsevier,2019.
- 31.