Clinical 6: Opioid Dependence, Addiction, and Drug Misuse (University of Nottingham)

Clinical 6 Opioid dependence, addiction and drug misuse: Clinical and practice issues Louise Wilson Roger Knaggs  Lecture objectives ▪ To understand ways in which opioid dependence / addiction is managed in the pharmacy ▪ To know how to respond when illicit drug use is identified during p...

Clinical 6 Opioid dependence, addiction and drug misuse: Clinical and practice issues Louise Wilson Roger Knaggs  Lecture objectives ▪ To understand ways in which opioid dependence / addiction is managed in the pharmacy ▪ To know how to respond when illicit drug use is identified during practice ▪ To be able to describe how opioid dependence affects the clinical management of acute and chronic pain 2  Management of opioid dependence/addiction in the pharmacy ▪ Repeat purchasing of OTC opioids ▪ Early requests for repeat prescriptions of opioids ▪ Supply and supervision of Opioid Substitution Therapy (OST) ▪ Needle and syringe exchange programmes 3  Repeat purchasing of OTC opioids MEP 3.2.4 Codeine and Dihydrocodeine ▪ Legal restrictions and recommendations (Professionalism 2) ▪ Community pharmacists and pharmacy team have important role in: ▪ Making appropriate recommendations for pain relief ▪ Referring patients for management of long-term pain ▪ Warning about the risks of dependence and addiction ▪ Monitoring and responding to requests for repeat purchases 4  Responding to requests for repeat purchases ▪ May be driven by ongoing pain or opioid dependence / addiction or both ▪ Important not to judge ▪ Patients may be waiting to see another HCP (e.g. GP, dentist) ▪ Opioids are dependence-forming medicines – not the fault of patients ▪ Repeat purchase requests often during busy periods / Saturdays ▪ Less questions asked? ▪ Not the regular staff? ▪ Harder to recognise? ▪ What might happen if sale refused? ▪ Visit another pharmacy? ▪ Use an online pharmacy? ▪ Confrontation? 5  Responding to requests for repeat purchases ▪ If suspect a problem, try to speak with patient ▪ Demonstrate empathy and understanding about pain / need for medication ▪ Explain long-term OTC use is not recommended and why Patient safety card? ▪ Encourage to see GP for long-term pain management or support for dependence People may recognise they are dependent, but care needed about discussing Avoid confrontation ▪ Decision to sell or not on a case-by-case basis 6  Early prescription requests ▪ May identify a patient ordering or collecting their opioid prescription early ▪ GP practice or community pharmacy ▪ Is this happening regularly? ▪ If yes, try to speak with patient about how they are getting on with the medicine ▪ How many are they taking? (compared to prescribed) ▪ How are they working? (is the pain worsening / changing / tolerance?) ▪ Are they starting to feel unwell before the next dose is due? (dependence / withdrawal?) ▪ If concerns about any of the above ▪ Prescription quantity may not match quantity used ▪ Suggest making a GP appointment to discuss pain medication ▪ Avoid making the patient may feel judged or blamed Changes in pain, opioid dependence and tolerance are not the fault of patients 7  OST in practice Goals of treatment ▪ Harm minimisation – patient / friends and family / local crime ▪ Ability to function within family, workplace, community ▪ Recovery with OST in the community alone is possible but rare Accepting new patients ▪ Usually contacted by drug treatment clinic to: ▪ Agree new patients ▪ Provide relevant background information ▪ Provide prescription dose and quantity – ensure sufficient stock! ▪ Important not to judge / discriminate ▪ Dependence / addiction develops for a variety of reasons ▪ Treat the same as any other patient Challenges ▪ Potentially tricky patient group ▪ Potential misconceptions of staff – important to provide appropriate training 8  Starting and restarting doses Starting dose ▪ Based on prior opioid use / tolerance ▪ Start low and increase slowly as needed ▪ Methadone oral solution – 10-40mg ▪ Buprenorphine S/L tabs – 0.8-4mg ▪ Important to query with prescriber any dose concerns Restarting dose ▪ If ≥3 days of treatment missed → contact prescriber to discuss ▪ Tolerance to drug may have been lost ▪ Usual dose may → overdose ▪ New Rx for ↓ dose 9  Supervised consumption of OST ▪ Enhanced service (locally commissioned) ▪ Not all OST will be supervised ▪ Prescription will include directions for supervision (Professionalism 2) ▪ Patient-pharmacy agreement Collection times / conduct ▪ Prepare in advance? ▪ Supervise in consultation room – maintain confidentiality ▪ Provide water ▪ Try to ensure consumption 10  Needle and syringe exchange programmes Also local Enhanced Service: ▪ Less common than supervised consumption ▪ Often seen in city centre locations / high streets in areas of greater deprivation Service involves: ▪ Collection of injection packs (e.g. needles, syringes, sharps box, citric acid, swabs, sterile spoons) ▪ Pack number determines needle size and use ▪ Disposal of used sharps ▪ Take-home naloxone? (Professionalism 2) Important role in harm minimisation to: ▪ Drug user ▪ Public spaces (used needles) 11  Illicit drug use identified during practice Several ways in which this may occur Most commonly: ▪ Conversations with patients during FP10MDA instalment collections ▪ Drug history taking / medicine reconciliation in hospital ▪ Medication review with a patient in general practice / primary care How do we respond? ▪ Different for each of the situations above ▪ Make patient first concern ▪ Maintain confidentiality – except when disclosure is necessary in the public interest (Y2 Confidentiality) 12  Unknown / illicit drugs brought into hospital Speak to the patient to determine the source of the medication ▪ Prescribed for them or others? ▪ Purchased OTC? ▪ Illicit drug? Suggest any illicit drugs are handed over to you for disposal ▪ Cannot immediately confiscate – try to get patient to agree ▪ Follow local NHS Trust policy / maintain confidentiality, but… ▪ If patient refuses to hand over – may need to contact police ▪ Reports to police may also be made for suspicious behaviour or if suspect possession with intent to supply (disclosure in the public interest) – seek advice before disclosing Illicit drugs are usually controlled drugs ▪ Store in safe custody (separately from medicines for supply) until can be appropriately destroyed ▪ Home Office licence is required to possess Sch 1 CDs (CVS controlled drugs) – pharmacists can take possession for the purpose of destruction or handing over to police Document the situation in the patient’s notes 13  Disclosure of illicit drug use during medication review ▪ Drug use may be related to a medical condition ▪ E.g. patient with chronic pain using marijuana ▪ Responding to disclosure: ▪ Document in patient’s notes as part of their medication history ▪ Explain the potential risks of illicit drug use ▪ Review management of the patient’s condition(s) make any appropriate changes including pharmacological and non- pharmacological treatments ▪ Confidentiality should be maintained unless disclosure is necessary in the public interest (to police or other relevant services) 14 Clinical management of acute and chronic pain in people with opioid dependence  Common misconceptions 1) Maintenance opioid substitution therapy (methadone or buprenorphine) provides analgesia; 2) Use of opioids for analgesia in people with opioid dependence may result in addiction relapse; 3) The additive effects of opioid analgesics and OST may cause respiratory and central nervous system depression; 4) The pain complaint may be a manipulation to obtain opioid medicines, or drug- seeking, because of opioid addiction 16  Managing acute pain in opioid dependent people ▪Pre-operative ▪ Discussion and preoperative education with the patient about: ▪ Previous effective pain management strategies; ▪ The patient's chronic baseline opioid requirements; ▪ Patient fears and expectations; and ▪ Plans for a balanced, multimodal regimen postoperatively ▪Intra-operative ▪ Administration of opioids to meet the following requirements: ▪ Chronic requirements to avoid withdrawal issues; ▪ Intraoperative surgical stimulation; and ▪ Anticipated postoperative pain requirements ▪ Administration of adjuvant medications ▪ Appropriate regional technique such as nerve block or epidural analgesia 17  Managing acute pain in opioid dependent people ▪Post-operative ▪ Continue multimodal analgesics: ▪ Paracetamol, NSAID, opioid ▪ Consider other adjuvants ▪ Ketamine, gabapentin ▪ During the transition phase of postoperative care: ▪ Need ensure transition from regional and parenteral techniques to oral opioids/adjuvants; ▪ Plan to taper from postoperative opioid doses toward preoperative doses and discuss with the patient and outpatient care providers; ▪ Do not supply OST on discharge but may require small quantity for acute pain; and ▪ Determine whether there is a need for specialty follow-up if the regimen is particularly complex 18  Chronic pain in people with opioid use disorder ▪Non-drug treatment options preferred and should be maximized ▪ Physical rehabilitation ▪ Exercise ▪ Psychological treatments ▪Mental health conditions and emotional difficulties need to be identified and managed ▪Medicines should be part of a wider plan to support self management ▪ Avoid opioids and other dependence forming medicines with current OUD ▪ Limited role for opioids and other dependence forming medicines with OUD history 19  Chronic pain in people with opioid use disorder ▪Principles of prescribing ▪ Short periods ▪ Regular monitoring ▪ Small quantities on each prescription ▪Requires close collaboration with drug services and GP 20  Reminder - Lecture objectives ▪ To understand ways in which opioid dependence / addiction is managed in the pharmacy ▪ To know how to respond when illicit drug use is identified during practice ▪ To be able to describe how opioid dependence affects the clinical management of acute and chronic pain 21