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addictions
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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
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