Cracking Addiction

On Cracking Addiction this week

Residential withdrawal management is one of the hallmarks of addiction medicine as a specialty. Residential withdrawal management is for those patients for home a home-based alcohol withdrawal is unsafe or contraindicated doe to significant medical or psychiatric comorbidities.

These patients require closer monitoring and medical and nursing support and this can only be accomplished in a supervised setting. The rationale for the treatment of alcohol withdrawal is to prevent minor withdrawal symptoms to escalating into more severe or complicated withdrawal symptoms which can be distressing for the patient, those around them and in severe case can lead to significant adverse health outcomes or death.

The most severe complications of alcohol withdrawal include alcohol withdrawal seizures, delirium tremens and Wernicke’s encephalitis. The goals in residential withdrawal management is to decrease the chances of severe complications by preventing dehydration and electrolyte imbalance, preventing thiamine deficiency which can lead to Wernicke’s encephalitis and adequate dosing of diazepam (or oxazepam in select cases with significant liver impairment) to decrease the chance of withdrawal seizures or delirium tremens occurring.

Management of alcohol withdrawal in residential setting is usually guided by scales and is protocol driven. The two most commonly used scales to determine alcohol withdrawal are the Alcohol Withdrawal Scale (AWS) and Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) with the goal being to keep the AWS under 5 and CIWA-Ar under 10.

Although as mentioned alcohol withdrawal management is somewhat protocolised it is also important to acknowledge an individual’s particular risk and vulnerabilities. Diazepam loading may be required for some patients whose withdrawal scores are rising despite medication given or those who are at risk of a complicated withdrawal.

Similarly, for those with severe liver disease whose livers may not be able to process diazepam an alternative benzodiazepine oxazepam is used as this does not need to undergo phase 1 metabolism in the liver and thus there is no increased risk of a potential build up to toxic levels within the body. There are a number of such variations to the standard protocol which are utilised to ensure that a patient’s medical and psychiatric conditions as well as individual needs and requirements are catered for.

Residential withdrawal management is about managing potentially high-risk patient who may be at risk of significant complications during their alcohol withdrawal in a safe, humane and holistic manner using evidence-based tools and interventions. In this episode of Cracking Addiction we delve into more detail and practicalities of how to do this.

This week on MedHeads

Maintaining medication safety at home can be daunting as the prescriptions increase.
Medication errors at home can be fatal or leave you in harm’s way.

As complex health conditions can come with increased medications and specific times that they are required or other medications that cannot be taken at the same time, there can be increased stress and fear.

Reminders:
If you are tech savvy, there are apps that can assist in reminding to take medications with notifications. One such app is the Medadvisor app. It links to your local pharmacy, and you can upload prescriptions. Medications can also be delivered. Carer mode is also available – You can manage medications and prescriptions for kids, elderly, and other family members under one Medadvisor account. This is a free app but must be approved by your pharmacist. However, a lot of people either are not tech savvy or don’t want to rely on a reminder, this also may not be appropriate if you have many medications.

Dosette box:

A dosette box is an option for someone who has a few prescriptions. It may also be known to some as the Monday –Sunday pill box. These can be very beneficial for many reasons including travelling. However, the down side is that they also require the unpacking of medications form bottles, an awareness of each pill and an awareness of the time that the pill needs to be taken. Dosette boxes usually don’t facilitate medication dispensing at different times of day, but rather, act as reminders for daily dispensing.
Cost and accessibility: 5-10 dollars

Webster packs:
Webster packs are a useful option for clients who are prescribed multiple medications that need to be dispensed at multiple and specific times during the day. Webster packs are great for those managing complex regimes and can also relieve carer strain/stress and increase peace of mind for all involved in a person’s life.
Webster packs come in a range of options such as the vision impaired version, multilingual version, and the Parkinson’s disease specific version. They can be hung on the fridge and even have photo ID picture placed on the pack.

The generic webster pack has symbols for the time of day and the day of week across and down the side of the pack, the user just sees the time and date needed and pops the medications out of the blister.
Cost and accessibility: 5 dollars per week for pensioners, pending on pharmacy.

Sachet roll: dose aid :
Sachets- up to 5 medications in a pack
DoseAid’s range of medication management solutions are designed to increase medication compliance and reduce the frequency of adverse incidents.

DoseAid’s medicine sachets are a safe and effective way for people to keep track of their daily medicines. To complement its sachets, DoseAid has also partnered with Medido to make a one-of-a-kind compliance device available in Australia.

The medicines are sorted by day, dose, and time into individually labelled sachets with easy tear packaging in chronological date and time order. These sachets are then rolled up.
Each individual sachet can hold up to five different tablets. So, for example, if someone takes seven different tablets in the morning, their morning tablets will be divided between two sachets.

Every sachet is clearly labelled with:
•The patient’s name
•The date and day of the week
•The dose time
•Names and physical descriptions (shape, colour) of the medicines
•The quantity of each tablet.

This information can be easily adapted depending on the specific needs of the individual.
Cost and accessibility: similar to Webster packs under PBS

Where to get help
•Your doctor
•Pharmacist
•NPS Medicines Line call 1300 633 424
•Adverse Medicines Events Line call 1300 134 237

Taking your medication safely
•Your doctor will monitor your prescription medication, but you need to make sure you follow your medication instructions, including:

•Take all medication exactly as instructed by your doctor or pharmacist.

•Do not take medication prescribed for someone else.

•Learn about your medication and know the importance of taking your medicine correctly. Ask your pharmacist for a Consumer Medicine Information (CMI) leaflet, which answers common questions about your medication (or look for it online as many drug companies publish them on the web).

•When buying over-the-counter medication, ask your pharmacist about side effects and interactions with other medication (including vitamins and herbal supplements) you are taking.

•If you are not confident that you will remember the instructions for taking the medication (such as dosage and time of day), write them down, or ask your doctor or pharmacist to write them down.

•If you are taking multiple medications or find you are forgetting if you have taken a dose, talk to your pharmacist about dosage aids (as described above)

•Ask your doctor if making changes to your lifestyle (such as diet and exercise) could reduce your need for medication.

•Ask your doctor if you may benefit from a Home Medicines Review. This is where a pharmacist reviews all the medication you take, and it can be done annually. You may be able to stop taking medication you no longer need.

•Throw out unwanted and out-of-date medication, as the active ingredient may no longer be effective. You can also return it to your pharmacy for safe disposal.

•Do not stop taking a prescribed medication without discussing it with your doctor. If it is not working for you, speak with your doctor about an alternative.

 Watch this weeks show on MedHeads

This week on MedHeads

I have just chatted with Dr Andrew Rees about human needs and benzodiazepines. In both our clinical experiences benzodiazepines cause more angst and grief than opioids and alcohol misuse.

The question is often asked, why do I need to come off benzodiazepines. Well firstly they are harmful, and secondly, they impair engagement with psychosocial interventions. The harms of benzodiazepine use include respiratory depression, accidental overdose and unfortunately in extreme cases death. They increase the risk of falls and impair cognitive functioning. These effects are more pronounced as we age, so therefore the adage of “let sleeping dogs lie”, and failure to wean the elderly off a “stable” dose of benzodiazepines that have been used for years is not ethically tenable.

Getting off benzodiazepines seems to be more of a challenge than getting off prescription opioids or alcohol. But why is this the case?

I think that they are universally experienced as a sticking plaster. They help with the immediate sting of psychic pain. But unfortunately, unlike other sticking plasters which can facilitate healing, the benzodiazepine sticking plaster does not stimulate healing. I liken the psychic pain and suffering that benzodiazepine treat to a persistent hangover.

The open wound remains, and when the pills wear off (and when the plaster is ripped off) the pain and suffering come back. No healing occurs and in fact all we are doing when we use benzodiazepines for more than four weeks is contributing to the development and then perpetuation of an additional mental health condition i.e., a chronic benzodiazepine dependency associated with withdrawal symptoms that can be as bad or worse than the original symptoms for which the benzodiazepine was initially prescribed, and which are relieved by ongoing use of benzodiazepines. The perpetual cycle continues.

Th appropriate management of such dependency relies on two simultaneous approaches, firstly the gradual weaning of the dose of the benzodiazepine, and secondly the appropriate adequate treatment of the underlying condition for which the benzodiazepines were initially prescribed. These two approaches really do need to occur simultaneously, because on the one hand benzodiazepines impair engagement with psychosocial therapeutic interventions, and secondly without such treatment the underlying illness will continue to cause psychic pain.

The idea of having to Come off benzodiazepines can instil horror in some people. Immediate thoughts of “How will I cope” dominate our thinking. To those who react this way I offer a message of hope. Coming off benzodiazepines is not inevitably associated with severe withdrawal symptoms, and most people can tolerate a very gradual wean off benzodiazepines. The trick is to do it slowly, especially when you get to lower doses. During this time, it is also important to engage with other therapies to deal with underlying mental health disorders.

Dr Andrew Rees suggests the use of a coaching approach, whereby rather than telling the patient why they need to come off benzodiazepines (and deflecting the almost inevitable rebuttal and assertion that they need to stay on their benzodiazepines) a doctor should ask the patient what their ideas concerns, and expectations are of their underlying disease process. What would health look for them? What would they want to do were they to be free of the shackles of their mental health disorder (and free of their benzodiazepines use)? Teaching the patient how their benzodiazepine use is impairing their dreams may be a way of unlocking both those dreams and the patient from their benzodiazepine dependency.

Our dreams are part pf our creativity, an essential human need. Tapping into this seam of common human experience may allow doctors to connect with patients with more empathy and understanding and hopefully less combatively.

As Andrew says: “If you don’t have dreams, how do you know if you have achieved them?”

On Cracking Addiction this week

Managing alcohol use disorder requires several interventions to ensure success. One of the most effective tools that best predicts against relapse prevention are behavioural interventions. Behavioural interventions force individuals to confront their thoughts and beliefs surrounding alcohol and develop strategies and modify behaviour in order to maintain alcohol abstinence or controlled drinking.

Alcoholics Anonymous (or AA) was founded in 1935 by Bill W and Dr Bob and in the ensuing 86 years has helped an untold number of people achieve meaningful and sustained behaviour change in their relationship with alcohol. The only requirement for membership of AA is a desire to stop drinking. AA is a close social network supportive of abstinence and is based around the 12 Steps and 12 principles outlined in the AA manuals. The 12 step model is based around themes of powerlessness, self-awareness and spirituality. New members are encouraged to attend90 meetings in 90 days. A Cochrane review in 2020 by John Kelly and his team found that manualised AA and 12 step framework programs were more effective than other behavioural based interventions in achieving abstinence.

SMART Recovery is an acronym for ‘Self Management and Recovery Training’. The program is based around four points of:

• Build motivation

• Coping with urges

• Problem solving

• Lifestyle balance

The program is based around weekly classes of 90 minutes facilitated by a trained peer or AOD clinician and focusses on the addiction behaviour rather and on any substance. Patient goals are identified and the participant is set achievable goals and tasks for the upcoming week. The focus is to concentrate on the present and future rather than the past. The basis of SMART Recovery is around cognitive behavioural therapy and motivational interviewing. This is also an extensively studies and reviewed methodology with good evidence for it’s success.

On Cracking Addiction this week

Alcohol use disorder is a common, well known but at the same time large and mystifying field. It can sometimes appear confusing how to manage patient with alcohol use disorder given it’s chronic relapsing and remitting nature. There is a plethora of information out in both the medical literature and journals as well as common media about alcohol, treatment and management and it can be easy to be overwhelmed with all the varying information sources.

Furthermore, patients can also come in with their own agendas or treatment preferences and it can be difficult to find the balance between being patient centred but practice evidence based and safe medicine.

The answer to dealing with the glut of information is to find trusted resources and paradigms for the management of alcohol use disorder.

One must know the rationale for managing withdrawal, how to manage complications related with alcohol withdrawal, how to risk stratify patient for home versus residential withdrawal, which medications to prescribe, how to management relapse, how to prescribe anti-craving medications and which services to refer patients to treatment manage the underlying behavioural issues which assisted in the formation in alcohol use disorder.

In our episode of Cracking Addiction this week we address all of the above issues and complexity and provide simple and evidence based guidelines to treat patients with alcohol use disorder.

On Cracking Addiction this week

Illicitly used opioids are the third most common form of illicit drug use worldwide and in most high income countries less than 1% of population has used illicit opioids in the last year. Opioids can be associated with overdose, deaths and other health harms but contributes to less of the global burden of disease than licit substances like alcohol and tobacco.

In a local context more people die of prescription drug overdose in Victoria than all the illegal drugs combined. Prescribed opioids were the third largest cause for overdose deaths (usually in combination with other medications).

Opioids include naturally occurring opiate compounds such as morphine an alkaloid of opium obtained from the poppy plant Papaver somniferum as well as synthetic chemicals. Other examples of opioids include: morphine, methadone, buprenorphine, oxycodone, pethidine, codeine, diacetylmorphine (heroin), fentanyl, pentazocine, hydromorphone, dextropropoxyphene

Opioids act on opioid receptors in CNS to produce analgesia and varying amounts of euphoria and sedation. There are three main types of opioid receptors and they produce the following effects:

• mu receptors: euphoria, sedation, analgesia, miosis, reduced GI motility, respiratory depression and physical dependence

• kappa: (spinal cord, basal ganglia and temporal lobes) drowsiness and dysphoria

• delta: analgesia and cardiovascular effects (hypotension and bradycardia)

The simulation of mu (and delta) receptors are involved in reward systems.

On Cracking Addiction this week

Legacy patients on high dose opioids or on combination hypno-sedatives including the combination of opioids and benzodiazepines are at an elevated risk of death. The OPQRST mnemonic can be used to conceptualise the strategies that help to mitigate legacy patients’ risk of death and to trend them towards a position of safer prescribing.

• O= opioid antagonist therapy: take home naloxone

• P = pharmacotherapy

• Q = quantity: reduced

• R = referral to allied health and or psychology

• R = rotation of opioids

• S = staged supply

• T = tapering

Opioid antagonist therapy.
Opioid antagonist therapy in the form of naloxone is available as “Narcan” vials, “Prenoxad” prefilled syringes and as “Nyxoid” nasal spray.

The Pennington institute’s community overdose prevention education program (COPE) provides useful resources and advice regarding the use of naloxone in the management of accidental opioid overdose. It should at this point be stated that naloxone therapy should not be reserved for patients with opioid substance use disorders, but rather should be a widely available therapy for all patients who are at risk of opioid overdose.

Regarding this point, Jauncey and Nielson stated in their 2017 paper that “Regardless of whether opioid use is licit or illicit, anyone at risk of opioid overdose should be considered for naloxone.” It is the author’s opinion therefore, that any patient who is prescribed a total opioid load of more than 50 mg oral morphine equivalent per day should be prescribed naloxone and that they and their carers should be provided with training on its use.

Pharmacotherapy
Suboxone pharmacotherapy can be considered as one option for the treatment of those patients on high dose prescription opioids who meet the diagnostic criteria for an opioid use disorder as defined DSM 5. The distinction needs to be made between physiological dependence and opioid use disorder. Any patient on long term prescribed opioids has the potential to become physiologically dependent on their opioid medication and can therefore present to their clinician requesting higher doses of opioids to treat an apparently worsening pain.

This group of patients can be dealt with by various interventions including a reassessment of underlying medical conditions, alternative pain management interventions (pharmacological or otherwise) opioid rotation or opioid tapering (if deemed appropriate). They must also be distinguished from those patients who present with aberrant behaviours. Such behaviours have been extensively described and include the following.

• Medically unsanctioned use of prescription medication including use of higher doses, unsanctioned indications (non-pain indications e.g. a “bad day”) and unsanctioned routes of ingestion (e.g. snorting or injecting crushed tablets)

• Prescription forgery

• Selling medication

• Doctor shopping

Patents who demonstrate aberrant behaviours with regard to their prescription opioids should be considered for long term pharmacotherapy either with methadone or buprenorphine (with or without naloxone). Each state in Australia has its own rules and regulations regarding the accreditation of clinicians to provide pharmacotherapy and it behoves clinicians to consider their own local requirements before prescribing pharmacotherapy.

Quantity: reduced
It is not mandatory to prescribe quantities as per the original pack size. Smaller quantities of medication should be prescribed per prescription by clinicians who are concerned about the supply of hypno-sedative drugs to their patients.

Referral
Referrals to allied health practitioners and or psychologists should be encouraged as part of a multimodal system of chronic pain management in which the provision of psychological and physical therapies supersede the emphasis on prescribing.

Rotation of opioids
Opioid rotation provides a rapid and effective means of reducing the total daily oral morphine equivalent (OME) daily dose. For patients on more than 100 mg OME, opioid rotation can be used to rapidly reduce the OME to less than 100 mg. It relies on the fact that patients do not usually demonstrate cross tolerance between opioids so converting a patient from one opioid to another necessitates a reduction in dose of the second opioid to approximately fifty percent of the equivalent dose of the first opioid. For instance, if a patient has been prescribed 60 mg b.d. of “Targin” this equates to approximately 200 mg OME. If the patient were to be transferred to 200 mg daily of a long acting morphine, e.g. “MS Contin” or “Kapanol” the patient would likely suffer an overdose because of the lack of cross tolerance between opioids. Therefore, as per the usual practice of only prescribing 50% of the calculated OME for the second opioid, the patient should be started on only 100 mg daily of long acting morphine. It can be seen in this example that converting from oxycodone to morphine has reduced the overall OME from 200 mg to 100 mg. A reduction in OME is an important step in trending the legacy patient to a position of reduced risk of death.

Staged supply
Staged supply denotes the practice of requiring that a patient attend a pharmacy or other dosing point on a regular basis to receive a daily dose of the medication in question. Clinicians can arrange staged supply of any drug, not just Suboxone or methadone. Therefore, staged supply of opioids would be entirely reasonable as part of a plan to manage high dose or high-risk opioid prescribing.

Tapering of opioids
Patients can be weaned off high doses of opioids by gradually reducing their dose over weeks to months. This process, called tapering, is usually done in conjunction with opioid rotation.

The process of tapering involves the following steps.

• The daily dose of short acting opioids is incorporated into a long acting dose of equivalent opioid.
• If multiple opioid combinations are used, then all opioids are converted into an oral morphine equivalent and an opioid rotation is performed as described above.
• One long acting opioid is commenced
• The taper starts at a rate of approximately ten percent per week of the original starting dose
• The use of short acting opioids or prn doses is strictly limited.

The recommended taper rate is a reduction of ten per cent of the original dose of opioid per week or fortnight such that over a period of ten to twenty weeks patients can be completely weaned off their opioids if appropriate or otherwise weaned down to a dose of less than 100 mg OME.

On Cracking Addiction this week

The natural history of opioid use is characterised by the development of dependence relatively rapid after 6-8 weeks of regular use or many years of intermittent use and once dependent users may struggle to control their use for substantial proportions of their lives.

 The terms dependence and addiction are often used interchangeably but theses terms actually refer to two different phenomena. Dependence refers to a physiological response and is characterised by tolerance to a substance and withdrawal symptoms when one cannot access this substance. It is characterised by a neuroadaptation to this substance.

 Addiction refers compulsive and uncontrollable use of a substance even in negative circumstances and even when harms are occurring due to this substance usage. Thus one can be dependent on a substance and not addicted and one can use opioids prescribed or illicitly and not have an opioid use disorder.

 The criteria for opioid use disorder is listed below and:

• meeting 2-3 criteria characterises mild opioid use disorder

• meeting 4-5 criteria characterises moderate opioid use disorder

• meeting 6-11 criteria characterises severe opioid use disorder

Opioid use disorder (DSM-5)

2-3 criteria mild, 4-5 moderate, 6-11 severe opioid use disorder

• 1. impaired control over use

• 2. Great deal of time spent obtaining, using or recovering from effects of opioids

• 3. Craving or compulsion to use

• 4. Unsuccessful attempts to cut down on use

• 5. Preoccupation with opioid use to the detriment of all other responsibilities

• 6. Continued opioid use despite negative repercussions

• 7. Social, occupational or recreational activities abandoned due to opioid use

• 8. Recurrent opioid use in physically hazardous situations

• 9. Tolerance

• 10. Withdrawal or use of opioids to prevent withdrawal

• 11. Persistent use despite clear evidence of physical or psychological adverse consequences

The ICD 11 criteria for substance dependence recognises that this is a disorder of regulation and requires that two out of three of the following themes need to be present for a diagnosis of substance dependence to be made and that is:

• impaired control

• increasing priority of substance use over all other priorities

• presence of some physiological features whether that be tolerance, withdrawal or neuroadaptation.

Thus one can see that dependence and addiction are two quite different phenomena and how important it is to be clear in our definition and language when discussion both addiction and dependence.

On Cracking Addiction this week

Methadone was developed in Germany in 1941 as a synthetic opioid agonist. It was in 1961 that Dole and Nyswander suggested it could be used as opioid agonist therapy in the treatment of heroin addiction.

Methadone is an extensively investigated treatment in opioid agonist therapy. A 30 year observational study by Grella and his colleagues in 2011 found that 25% of patients on Methadone decreased their heroin use quite rapidly and stopped using heroin in 10-20 years, 15% achieved a modest decrease in their heroin usage but also subsequently stopped using heroin in the next 10-20 years and another 25% decreased their heroin usage.

Methadone has also been found to reduce the frequency of injecting and the sharing of injecting equipment thus also decreasing the risks of transmission of blood borne viruses.

Methadone maintenance treatment improves health, reduces illicit heroin usage, reduces infectious diseases transmission and overdose death. However it’s effectiveness is compromised if low maintenance doses of Methadone are used. Studies have shown that those receiving greater than or equal to 60mg daily doses of Methadone are 70% more likely to remain in treatment than those on doses less than 60mg daily. Degenhardt and his colleagues in 2009 found that Methadone decreases mortality by 29% in this cohort of patients.

Thus in summary Methadone is of vital importance in the optimal treatment of patients in opioid agonist therapy.