VolumeVolume C,C, ModuleModule 22 Opioids:Opioids: BasicsBasics ofof Addiction;Addiction; TreatmentTreatment withwith Agonists,Agonists, PartialPartial Agonists,Agonists, andand AntagonistsAntagonists Treatnet Training Volume C: Module 2 – Updated 18 October 2007 ModuleModule 2:2: TrainingTraining goalsgoals ToTo describedescribe the:the: ¾ KeyKey componentscomponents ofof opiateopiate addictionaddiction andand itsits medicalmedical // psychiatricpsychiatric consequencesconsequences ¾ BenefitsBenefits andand limitationslimitations ofof methadonemethadone asas aa pharmacotherapypharmacotherapy forfor opiateopiate dependencedependence ¾ BenefitsBenefits andand limitationslimitations ofof buprenorphinebuprenorphine asas aa pharmacotherapypharmacotherapy forfor opiateopiate dependencedependence ¾ BenefitsBenefits andand limitationslimitations ofof narcoticnarcotic antagonistsantagonists forfor overdoseoverdose (naloxone)(naloxone) andand relapserelapse preventionprevention (naltrexone)(naltrexone) forfor opiateopiate dependencedependence ModuleModule 2:2: WorkshopsWorkshops WorkshopWorkshop 1:1: Opiates:Opiates: WhatWhat theythey are,are, problemsproblems associatedassociated withwith theirtheir use,use, andand medicalmedical treatmenttreatment implicationsimplications WorkshopWorkshop 2:2: OpiateOpiate addictionaddiction treatmenttreatment withwith methadonemethadone WorkshopWorkshop 3:3: OpiateOpiate addictionaddiction treatmenttreatment withwith buprenorphinebuprenorphine WorkshopWorkshop 4:4: OpiateOpiate AntagonistAntagonist Treatment:Treatment: NaloxoneNaloxone forfor overdose,overdose, NaltrexoneNaltrexone forfor relapserelapse preventionprevention Icebreaker:Icebreaker: OpiateOpiate medicationmedication inin mymy countrycountry 15 Min. DoesDoes youryour countrycountry useuse opiateopiate medications,medications, andand ifif so,so, whatwhat typetype ofof medication?medication? WhatWhat areare thethe mainmain problemsproblems inin youryour countrycountry regardingregarding thethe useuse ofof thesethese medications?medications? WorkshopWorkshop 1:1: OpiatesOpiates WhatWhat theythey are,are, problemsproblems associatedassociated withwith theirtheir use,use, andand medicalmedical treatmenttreatment implicationsimplications PrePre--assessmentassessment 10 Min. PleasePlease respondrespond toto thethe prepre--assessmentassessment questionsquestions inin youryour workbook.workbook. (Your(Your responsesresponses areare strictlystrictly confidential.)confidential.) TrainingTraining objectivesobjectives AtAt thethe endend ofof thisthis trainingtraining youyou willwill understandunderstand the:the: 1.1. EpidemiologyEpidemiology ofof opiateopiate addictionaddiction worldwideworldwide andand itsits relationshiprelationship toto infectiousinfectious diseasesdiseases 2.2. BasicBasic neurobiologyneurobiology ofof opiateopiate addictionaddiction 3.3. MedicalMedical // psychiatricpsychiatric coco--morbiditiesmorbidities andand treatmenttreatment strategiesstrategies forfor thesethese disordersdisorders usedused withwith opiateopiate addictsaddicts 4.4. KeyKey issuesissues inin engagingengaging opiateopiate addictsaddicts intointo treatmenttreatment withwith lowlow thresholdthreshold approachesapproaches IntroductionIntroduction GlobalGlobal abuseabuse ofof opiatesopiates Overview:Overview: Regional Breakdown of Opiate Abusers ¾ Sixteen million (0.4%) Africa Oceania of world’s population 6% 1% aged 15-64 abuse Americas opiates 14% ¾ Heroin abusers make up about 71% of opiate Asia 54% abusers Europe ¾ Opiates account for 25% 2/3 of all treatment demands in Asia and Sources: UNODC, Annual Reports Questionnaire Data, Govt. reports, reports of regional bodies, 60% of treatment UNODC estimates. demand in Europe AnnualAnnual PrevalencePrevalence ofof OpiateOpiate Abuse,Abuse, 20032003 -- 20052005 Trends in Opiate Use ChangeChange inin AbuseAbuse ofof HeroinHeroin andand OtherOther OpiatesOpiates (2004, or latest year available) OpioidsOpioids OpiateOpiate (n)(n) ““AnAn unlockedunlocked doordoor inin thethe prisonprison ofof identity.identity. ItIt leadsleads toto thethe jailjail yard.yard.”” Ambrose Bierce The Devil’s Dictionary (1906) OpioidOpioid--relatedrelated problemsproblems ¾¾ MostMost prominentprominent problemsproblems areare associatedassociated withwith heroinheroin dependencedependence ¾¾ NotNot allall usersusers ofof heroinheroin developdevelop dependence.dependence. BetweenBetween 11 inin 44 to1to1 inin 33 regularregular usersusers developdevelop dependencedependence ¾¾ DevelopmentDevelopment ofof heroinheroin dependencedependence usuallyusually requiresrequires regularregular useuse overover monthsmonths (or(or longer,longer, whenwhen useuse isis moremore irregular)irregular) TheThe revolvingrevolving doordoor ¾¾ HeroinHeroin dependencedependence isis aa chronic,chronic, relapsingrelapsing disorder.disorder. ItIt isis aa dependencydependency thatthat isis veryvery difficultdifficult toto resolve.resolve. ¾¾ RelapseRelapse isis extremelyextremely common.common. ItIt isis partpart ofof thethe processprocess ofof resolvingresolving thethe dependencedependence –– muchmuch likelike givinggiving upup tobacco.tobacco. ¾¾ AA principleprinciple healthhealth carecare objectiveobjective isis toto getget thethe patientpatient intointo treatment,treatment, helphelp keepkeep themthem inin treatment,treatment, andand returnreturn themthem toto treatmenttreatment whenwhen relapserelapse occursoccurs.. PolydrugPolydrug use:use: PatternsPatterns andand risksrisks ¾ PolydrugPolydrug useuse isis thethe normnorm amongamong drugdrug usersusers ¾ MostMost peoplepeople whowho useuse illicitillicit drugsdrugs useuse aa varietyvariety ofof differentdifferent drugsdrugs ¾ HeroinHeroin usersusers alsoalso areare heavyheavy usersusers ofof alcoholalcohol andand benzobenzodiazepinesdiazepines ¾ AsAs CNSCNS depressants,depressants, thesethese combinationscombinations areare especiallyespecially dangerousdangerous andand knownknown toto bebe significantsignificant contributorscontributors toto overdoseoverdose ¾ PatientsPatients shouldshould bebe advisedadvised againstagainst thethe useuse ofof thesethese combinationscombinations andand toldtold ofof thethe risksrisks involvedinvolved DetectingDetecting opioidopioid dependencedependence Look for a pattern (not an isolated event): ¾ In which a patient frequently runs out of scripts for a prescribed opioid ¾ In which a patient is on a high and increases the dose of prescribed opioids ¾ In which a patient injects oral medications ¾ Of observed intoxication or being in withdrawal ¾ Which presents plausible conditions that warrant prescribed opioids, but with specific requests for medication type and amount ¾ In which the patient threatens or harasses staff for a fit- in appointment ¾ In which a patient alters, steals, or sells scripts ¾ In which a patient is addicted to alcohol or other drugs ClassificationClassification ofof OpioidsOpioids Pure Opioid Agonists Semi-synthetic opium Synthetic papaverine heroin morphine hydromorphone LAAM codeine oxycodone fentanyl meperidine hydrocodone Partial Agonists/Antagonists methadone pentazocine naltrexone pethidine buprenorphine LAAM Opioids:Opioids: PharmacologyPharmacology (1) PETPET scanscan ofof µµ opioidopioid receptorsreceptors Opioids:Opioids: PharmacologyPharmacology (2) ¾ 3 main families of opioid receptors (µ, κ, and σ) ¾ Agonists including morphine and methadone act on the µ system, while partial agonists, including buprenorphine, also act at that site but have less of a maximal effect as the dose is increased. ¾ Opioid receptors and peptides are located in the CNS, PNS, and GI tract ¾ Opioid receptors are inhibitory inhibit release of some neurotransmitters (e.g., 5-HT, GABA, glutamate, acetylcholine) enable the release of dopamine (considered to contribute to the dependence potential of opiates) Opioids:Opioids: PharmacologyPharmacology (3) HeroinHeroin MorphineMorphine isis producedproduced throughthrough heroinheroin hydrolysishydrolysis heroinheroin →→ monoacetylmorphinemonoacetylmorphine (MAM)(MAM) →→ morphinemorphine HeroinHeroin andand MAMMAM areare lipophilic,lipophilic, hencehence moremore rapidrapid actionaction HeroinHeroin excretedexcreted inin urineurine asas freefree andand conjugatedconjugated morphinemorphine HeroinHeroin metabolitesmetabolites areare presentpresent inin urineurine forfor approximatelyapproximately 4848 hourshours followingfollowing useuse Morphine:Morphine: ImmediateImmediate effectseffects (1) ¾¾ PerceptionPerception altered,altered, possiblepossible deliriumdelirium ¾¾ Analgesia,Analgesia, toto somesome degreedegree ¾¾ ImpairedImpaired cognition,cognition, thoughthough consciousnessconsciousness maymay bebe preservedpreserved ¾¾ AutonomicAutonomic nervousnervous systemsystem affectedaffected ¾¾ SuppressionSuppression ofof coughcough reflexreflex ¾¾ GIGI systemsystem affectedaffected ¾¾ HypothermiaHypothermia Morphine:Morphine: ImmediateImmediate effectseffects (2) ¾ Miosis ¾ Urinary retention ¾ Reduced GI motility ¾ Endocrine ¾ Non-cardiogenic pulmonary oedema ¾ Coma or death (from respiratory depression) ¾ Other pruritis; flushed skin; dry mouth, skin, and eyes Opioids:Opioids: LongLong--termterm effectseffects (1) ¾ Little evidence of long-term direct toxic effects on the CNS from opioid use ¾ Long-term health-related complications may result from: dependence poor general self-care imprisonment drug impurities or contaminants, BBV Opioids:Opioids: LongLong--termterm effectseffects (2) Possible:Possible: ¾ Constipation