Module 1876 [PDF]

Clinical

Module 1876 Opioid misuse: dependence, management and pharmacy services From this pharmacy CPD module on drug misuse and dependence you will learn about: • • • •

The level of drug misuse in the UK Pharmacological management of opioid dependence The role of pharmacy in managing opioid dependence Important aspects of offering a dispensing service to opioiddependent patients

PHILIP CRILLY, PHARMACIST Drug misuse in the UK is a growing problem. In 2015, there were 2,479 deaths associated with drug misuse and 15,074 hospital admissions linked to poisoning by illicit drugs, according to NHS Digital. Aside from the health issues, drug misuse and dependence also have social consequences, including increased crime, child protection issues, antisocial behaviour and economic repercussions. This article will consider the most commonly misused drugs in the UK and look at how those working in community pharmacies can have a positive impact on this problem. According to a 2016 report by DrugWise and data from NHS Digital, cannabis is the most widely used illegal drug in the UK. Other widely abused illicit drugs include heroin, cocaine, ecstasy (MDMA), ketamine, amphetamine, methamphetamine and mephedrone. Commonly, these illicit drugs are used alongside alcohol and benzodiazepines, increasing the risks of overdose and death. This article focuses on the misuse of opioids.

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Misuse of prescription and over-thecounter drugs Around 10 million people in the UK receive regular prescriptions for opiate painkillers. Of particular concern is the fact that some patients share their prescribed painkillers with other family members, exacerbating the problem of misuse. Those working in community pharmacies have a responsibility to support their healthcare colleagues when advising patients about the potential risks and challenges associated with overusing these medications. In addition, there is a growing trend to prescribe opiate users prescription drugs outside of clinical guidelines. Drugs such as pregabalin, gabapentin and tramadol feature in prescriptions for drug misusers, as doctors try to reduce benzodiazepine prescribing. In terms of over-the-counter (OTC) painkiller

abuse, some adults are buying codeinecontaining products and then taking up to 40 pills per day, according to DrugWise. The risk of serious harm or death is significant in these circumstances, especially as many of these combination products also contain paracetamol. There are even YouTube videos on how to use so-called ‘cold water extraction’ to isolate the codeine from these products. Worryingly, young adolescents are also becoming more creative with new drug concoctions, using codeine, in the form of cough syrups, and mixing it with lemonade – creating a product called ‘dirty Sprite’. Alcohol is then added to this, putting the young person at serious risk of harm.

The demise of legal highs A number of years ago novel psychoactive substances (NPS) and synthetic cannabinoid receptor agonists (SCRA), also known as ‘spice’, were increasingly cited as gateway drugs to strong opioid drug misuse. In an attempt to stem this problem, the UK government introduced the Psychoactive Substances Act (PSA) in 2016. This resulted in a dramatic reduction in the use of these, once legal, substances and led to a significant decrease in the number of hospitalisations associated with their use.

Is there a link between learning disabilities and substance misuse? The UK government has produced guidance on substance misuse among people with learning disabilities, available at tinyurl.com/GovMisuse. While it is not clear why, there does appear to be a link between people with mild learning disabilities and drug misuse. For such patients, it is important to consider their individual needs and tailor service provision to ensure they have the best opportunity to recover.

Harm minimisation Pharmacy services such as the needle and syringe programme (see tinyurl.com/NeedleProg) are

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important to reduce the risk of harm to drug misusers, particularly those who are unable to commit to substitute prescribing or detoxification programmes. Those who inject regularly are at risk of blood-borne viruses, such as HIV, hepatitis B and C, and other infections. In addition to helping to minimise harm to patients, needle and syringe programmes bring patients and pharmacists into contact. This means that if a patient decides to withdraw from illicit drugs, a pharmacist is at hand to support them.

Management of opioid dependence The management of opioid dependence with methadone and buprenorphine is now commonplace in many community pharmacies (see guidance from the National Institute for health and Care Excellence (Nice) at tinyurl.com/NiceMethadone). The aims of treatment are to promote reduction or abstinence from illicit drug use, while also preventing withdrawal symptoms. Patients are able to progress from maintenance therapy to detoxification and then abstinence. Pharmacological support is accompanied by psychosocial support to prevent relapse.

When is substitute prescribing deemed necessary? For patients who want to stop misusing drugs, substitute prescribing may be of benefit. According to Nice, evidence suggests that the highest success rates in ending drug misuse are noted when a user’s physical and psychological health and their personal circumstances are stable. Patients should also be committed to the process and be willing to adhere to the treatment plan. Patients should be warned that when starting substitute prescribing they may experience withdrawal symptoms, such as sweating, abdominal pains, nausea, vomiting, anxiety and irritability. How long these symptoms last will depend on their substitute medication dose and the opioid they are trying to withdraw from.

Symptoms of withdrawal are usually short-lived, lasting just two or three days, but during this window patients may be tempted to revert to drug misuse.

Including substance misuse services in the pharmacy schedule The decision to offer substance misuse services in the pharmacy will depend on factors such as whether such a service is commissioned locally, and the time and resources needed to deliver the service, eg preparation of doses and supervision of consumption in the pharmacy. As with any new service, staff members involved in its delivery must undergo training and be deemed competent to do so. Standard operating procedures (SOPs) must be in place and followed by all staff involved in the service delivery.

What are the different stages of treatment? Drug misuse treatment has a number of different stages. The first stage is to decide whether or not a patient wants to stop opioids immediately or whether they want to go onto maintenance therapy with an opioid substitute. Those who want to quit opioids go through a process called detoxification, but they must be able to demonstrate that they are highly motivated and have the right support to quit successfully. For those who go onto maintenance therapy, the goal is to reduce harm and stabilise their lifestyle. Over time those on maintenance therapy may decide they are ready to undergo detoxification.

term treatment. These decisions are made by a qualified clinician, taking into consideration the patient’s views. If all factors are equal then methadone is the preferred pharmacological treatment.

minutes to fully dissolve under the tongue. Some pharmacists crush buprenorphine for patients, but this is against the product licence. Pharmacists that do this should ensure that the prescriber has written on the prescription that the tablets should be crushed.

Methadone Methadone is usually dispensed as a greencoloured oral solution. The dose, according to the BNF, is initially 10-30mg daily, increased in steps of 5-10mg daily if needed (with a maximum weekly dose increase of 30mg) until the patient no longer experiences symptoms of withdrawal or intoxication. The usual dose of methadone will be within the range of 60-120mg daily.

Buprenorphine combined with naloxone (Suboxone) Suboxone is a combination product containing buprenorphine and naloxone. It is intended to prevent buprenorphine being injected. However, it is not widely used in the UK and there is limited research on its effectiveness in comparison with buprenorphine alone.

Buprenorphine Buprenorphine is also indicated for the treatment of opioid dependence and, according to the BNF, the starting dose is 0.8-4mg for one dose on the first day, adjusted in steps of 2-4mg daily if needed. The maximum dose of buprenorphine is 32mg per day, while the usual dose is 12-24mg daily. Buprenorphine is given as a sublingual tablet that can take between three and seven

Switching between methadone and buprenorphine As patients move through their treatment plan, they may want to change from the liquid methadone formulation to sublingual buprenorphine tablets. For these patients, the dose of methadone needs to be reduced to a maximum of 30mg daily before starting buprenorphine treatment. Buprenorphine is then

Drug choice The choice of the most appropriate pharmacological intervention (methadone or buprenorphine) depends on a number of factors (see the British National Formulary (BNF) monograph for buprenorphine at tinyurl.com/BNFBupren). These include the patient’s history of opioid dependence, a risk/benefit analysis of each treatment for that patient, and the patient’s commitment to long-



taken when signs of withdrawal start to appear, but not less than 24 hours after the patient last used methadone.

Opioid overdose – use of naloxone Naloxone is an opioid-receptor antagonist and is an antidote for opioid overdose. Due to its short duration of action, naloxone may need to be administered in repeated doses or as an infusion to reverse the effects of opioids with a longer duration of action. People in close contact with drug misusers, eg key workers, may be trained to administer naloxone as they are likely to be some of the first people to see a drug misuser who has overdosed.

Supervised consumption For patients newly started on maintenance therapy with methadone or buprenorphine, supervision is required for at least the first three months of treatment. This is to ensure adherence to the treatment plan, and reduce the risk of overdose on the prescribed treatment. Some flexibility may be required if, for example, a patient has a job or other commitments. In the first few weeks of treatment, patients will also meet regularly with their doctor or key worker to provide urine samples for drug testing. Aside from ensuring patients are adhering to treatment for the health benefits, pharmacy staff also need to be aware that methadone and buprenorphine have high street values. Some drug misusers may be tempted to sell their prescribed dose to others, so supervision to ensure that the full dose is consumed is essential. Challenges may arise with buprenorphine, which can take time to dissolve. Guidance, however, indicates that the drug will have started to dissolve within the first two to three minutes, so the street value of the drug will already be greatly reduced at this stage. As mentioned previously, crushing buprenorphine before giving it to the patient may reduce the time needed to dissolve, but needs to have been agreed previously with the prescriber.

You should consider the rights of patients to receive their treatment in a confidential environment and establish each individual’s preferences in terms of whether or not they would like privacy when consuming their supervised dose. Some patients may be happy to be supervised in a quiet area of the pharmacy, while others may prefer to use the consultation room.

Important relationships It is important that there are strong relationships between pharmacists, drug misusers, their prescribers and their key workers. These patients should be treated with the same respect afforded any other patient and a non-judgemental relationship should be formed. All pharmacies will have SOPs in place that specify exactly how they will deliver any drug misuse service and this should take into account the needs of drug misusers and other patients using the pharmacy. If you feel you need to contact a prescriber or key worker about a patient, it is extremely important you consider the patient’s right to confidentiality and obtain their consent before sharing any private information about them.

into account factors such as missed doses and days when a pharmacy may be closed, eg bank holidays. The approved wording for bank holidays is: “Please dispense instalments due on pharmacy closed days on a prior suitable day”; and for missed collections: “If an instalment’s collection day has been missed, please still dispense the amount due for any remaining day(s) of that instalment.” It should also be noted that if a patient misses three or more days of prescribed treatment they should be referred to their prescriber, as their tolerance to the drug may be reduced and they may be at risk of overdose if they take their usual dose. Collection by a representative of a drug misuse patient If a drug misuse patient needs a representative to collect their medication on their behalf (assuming they are not supervised), they need to give the pharmacy a letter authorising and naming the

representative. A new letter must be obtained on each occasion. The pharmacist must be satisfied that, on each occasion, the letter is genuine and the details of who the medication is supplied to should be recorded. If a patient is normally supervised and requests that a representative collects their medication, then the pharmacist must confirm verbally with the prescriber that this arrangement is acceptable. Disposal of empty methadone bottles Once a methadone bottle is finished it must be rinsed and the liquid poured into a denaturing kit. There is no need to record this disposal. The clean, empty container should then be disposed of, either in the recycling bin or in the general waste bin. While no record needs to be made in the controlled drug register, it would still be good practice to have the destruction of this irretrievable amount of methadone witnessed by a store colleague.

Practical considerations The Royal Pharmaceutical Society’s Medicines, Ethics and Practice guide sets out a number of practical issues that need to be considered when dispensing medication for drug misuse. The appropriate date on instalment prescriptions Instalment prescriptions for controlled drugs are valid for 28 days from the appropriate date. This date is either the date of the prescription itself or another date stated in the body of the prescription indicating when it should start. Instalment directions, approved wording and missed doses In 2015, the Home Office issued approved wording for instalment prescribing to take



Opioid misuse: dependence, management and pharmacy services CPD Reflect What is the starting dose of buprenorphine for the treatment of opioid dependence? How long should supervised consumption be continued for? What is the Home Office approved wording for instalment prescribing? Plan This article provides information about the level of drug misuse in the UK, the pharmacological management of opioid dependence and the role of the pharmacy in managing opioid dependence. Important aspects of offering a dispensing service to opioid-dependent patients are also discussed. Act

• Read more about opioid abuse and dependence on the Patient website at tinyurl.com/opioiddependence1 • Find out more about substitute prescribing for opioid dependence on the Patient website at tinyurl.com/opioiddependence2 • Read more about methadone dispensing and instalment dispensing on the Pharmaceutical Services Negotiating Committee (PSNC) website at tinyurl.com/opioiddependence6 and at tinyurl.com/opioiddependence7 • Find out about reliable sources of information and support for the families affected by drug addiction, such as Adfam at tinyurl.com/opioiddependence4 and DrugFam at tinyurl.com/opioiddependence5 Evaluate Are you now confident in your knowledge of the management of opioid dependence? Could you give advice and support to patients and carers about its treatment?

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Update module A typical module that allows you to read the content and then complete the short 5 minute quiz to test.


Take the 5-minute test online 1. Heroin is the most widely used illegal drug in the UK. True or false 2. When starting substitute prescribing, patients may experience withdrawal symptoms such as sweating, nausea, vomiting, anxiety and irritability. True or false 3. Methadone is initiated at a dose of 10-30mg daily and increased in steps of 5-10mg daily if needed. True or false 4. The starting dose for buprenorphine is 4-8mg daily. True or false 5. The maximum dose of buprenorphine is 24mg daily. True or false

7. For patients changing from methadone to buprenorphine, the dose of methadone needs to be reduced to a maximum of 60mg daily before buprenorphine is started. True or false 8. For patients newly started on maintenance therapy with methadone or buprenorphine, supervision is required for at least the first six months of treatment. True or false 9. Instalment prescriptions for controlled drugs are valid for 28 days. True or false 10. If a patient misses three or more days of prescribed treatment they should be referred to their prescriber. True or false

6. Buprenorphine is given as a sublingual tablet that can take between three and seven minutes to fully dissolve under the tongue. True or false

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