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Clinical considerations

Clinical considerations . Rob van der Waal. Contents. Introduction Medication Injecting Street drugs & alcohol Treatment interruptions. 5 Treatment Stages . Assessment Induction Stabilisation Maintenance Reduction . Medication. Assessment – convert to or increase methadone?

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Clinical considerations

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  1. Clinical considerations Rob van der Waal

  2. Contents Introduction Medication Injecting Street drugs & alcohol Treatment interruptions

  3. 5 Treatment Stages • Assessment • Induction • Stabilisation • Maintenance • Reduction

  4. Medication • Assessment – convert to or increase methadone? • Induction -rapid increase injectable and oral • Stabilisation -fine tuning • Maintenance – steady or → • Reduction – of frequency and/or dose

  5. Dose Conversion • Methadone • 2/3 converted to diamorphine • 1/3 retained as oral methadone • The higher the methadone dose the higher the diamorphine dose and oral methadone dose • Ceiling for higher doses

  6. Injectable Diamorphine Doses are titrated by up to 30 mg day Stepped approach to diamorphine increase (3 x week = common) Maximum dose 900mg day (450mg x 2) In every day practice much lower

  7. Injectable Methadone • 200mg maximum • Usually between 100-150mg daily • Conversion 0.8 x oral dose • Stepped titration • Increase by 10mg 3 x week • Maximum 30 mg week

  8. Oral methadone Important part of medication regime especially in diamorphine treatment Increase regularly during induction, then as indicated Patients more keen on injectable dose increases

  9. Flexible dosing Option A Diamorphine 250mg IV am Diamorphine 250mg IV pm Methadone oral 30mg (or MXL) or Option B Diamorphine 250mg IV / day Methadone oral 100mg (or MXL) or Option CMethadone oral 170mg (or MXL)

  10. Conversion is based on the total daily dose of diamorphine!! Diam 250mg = 80 Diam 250mg = 80 Diam500mg = 115 Divide 115 in 2 = appr 60

  11. Flexible dosing Depends on treatment stage Planned in advance (24hrs) → Formulation used ( e.g. If injectables are prepared in advance ) Not always therapeutic or safe! (e.g. Problematic alcohol use) Regime A during induction & until stabilised

  12. Flexible dosing Conversion works well in general but caution has to be applied when doses are high Patients were reluctant to increase methadone to sufficient levels Introduction of slow release morphine capsules (MXL) only after stabilisation and not for take home

  13. MedicationDose conversion • Oral methadone  injectable diamorphine • Oral methadone  injectable methadone • Oral Methadone  MXL • Injectable methadone  injectable diamorphine • Injectable diamorphine  oral methadone/MXL • Injectable methadone  oral methadone/MXL

  14. Injecting Assessment – complete injecting plan Induction –monitor, evaluate and plan Stabilisation - monitor, evaluate and plan Maintenance – routine Change needs directive approach!

  15. Injecting Assessment • Injecting sites • Condition of peripheral veins • Complications e.g. abscesses, ulcers, DVT • Groin injecting? • Injecting technique • Competence • Rituals • Hygiene • Injecting plan (based on assessment)

  16. Street Drugs • Assessment – type, frequency, severity → compatibility with IOT → plan of action • Induction – monitor & evaluate, problematic? • Stabilisation - monitor & evaluate, if remains problematic → treatment review • Maintenance & reduction– monitor

  17. Drug & Alcohol use Clinical implications Therapeutic implications Benzodiazepines Alcohol Crack cocaine Street heroin

  18. Alcohol Policy: operationalised by alcolmeter readings Standard: BrAL<0.35mg/L Controlled drinking? Detox & Disulfiram Mixed results

  19. Benzodiazepines Policy: no benzodiazepine maintenance prescribing Standard: Linear reduction Un prescribed use can be life threatening However not all patients with positive urines show clinically significant effects

  20. Street heroin In general present during initiation and stabilisation stage In general stops at end of stabilisation If street heroin use continues treatment plan review

  21. Crack cocaine No policy in place yet In general no complications during monitoring But has therapeutic implications, and physical implications (DVT) Continued use will lead to treatment review

  22. Treatment interruptions Planned Unplanned Intermittent

  23. Planned Treatment interruption E.g. Travel, hospital* All prescribed medication is converted to oral methadone (concentrate or mixture) Use standard conversion scale Ceiling for higher doses * In general hospital will take over prescribing!

  24. Unplanned Treatment interruption • E.g. Prison, no show • Continuation of prescribing after no show depending on time missed • < 3 days → monitor or reduce dose (standard table) • > 3 days → formal assessment, continuation depends on circumstances & total time lapsed

  25. Intermittent interruption No medication (oral and injectable) due to intoxication No injectable but oral due to unsuccessful injecting If happens frequently review treatment

  26. Co morbidity Supervising additional medication can be very useful Use daily attendance to your advantage but do not take over all responsibility Example: ask patient to bring in medication and take in supervised clinic

  27. Thank You

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