NR 546 Week 6 Addiction Medications Table

NR 546 Week 6 Addiction Medications Table. Maintenance treatment of opioid dependence (sublingual)  Maintenance treatment of opioid dependence in patients who have achieved and sustained prolonged clinical stability on low-to-moderate doses (no more than 8 mg) of a transmucosal buprenorphine- containing product (implant)  Moderate to severe opioid use disorder in patients who have initiated treatment with a transmucosal buprenorphine-containing product, followed by dose adjustment for a minimum of 7 days (injection) Affected Neurotransmitters:  Partial agonist at mu opiate receptors  Antagonist at the kappa opioid receptor  Agonist at delta opioid receptors  Partial agonist at nociceptin Half-life: Sublingual buprenorphine: 24–42 hours Naloxone: 2–12 hours Implant: Tmax is 12 hours; time to steady state is 4 weeks Metabolism: CYP450 3A4 Notable Side Effects:  Headache, constipation, nausea  Oral hypoesthesia, glossodynia  Orthostatic hypotension  Implant specific: insertion site pain, pruritis, erythema Side Effect Pathways:  Binding at mu opioid receptors Initial Dosing Considerations:  Patients must be in a mild withdrawal state prior to starting buprenorphine  Day 1 – 8 mg  Day 2 – 12 or 16 mg  Days 3-7 – Increase in increments of 4 mg to max dose of 32 MG  Observe patient for at least 2 hours with initial dose, then have 1–2 visits in first week  Achieve the lowest dose that eliminates withdrawal symptoms and illicit opioid use  During stabilization patients should be seen once per week  During maintenance patients should be seen biweekly or monthly Specific lifespan considerations Age:  Elderly - Use with caution  Children and adolescents - Safety and efficacy have not been established Pregnancy:  Controlled studies have not been conducted in pregnant women  Buprenorphine may be Addiction Medications opioid peptide receptors Target Symptoms:  Opioid dependence preferable to methadone in pregnant women  Neonatal withdrawal has been reported following use of buprenorphine during pregnancy  Not generally recommended for use during pregnancy, especially during first trimester  Effective June 30, 2015, the US FDA requires changes to the content and format of pregnancy and lactation information in prescription drug labels, including the elimination of the pregnancy letter categories; the Pregnancy and Lactation Labeling Rule (PLLR or final rule) applies only to prescription drugs and will be phased in gradually for drugs approved on or after June 30, 2001 Breastfeeding:  Some drug is found in mother’s breast milk Recommended either to discontinue drug or bottle feed Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) Indication:  Maintenance treatment of opioid dependence  Induction of treatment for opioid dependence (Bunavail only) Half-life: Buprenorphine: 24–42 hours Naloxone: 2–12 hours Metabolism: CYP 450 3A4 Notable Side Effects:  Headache, constipation, nausea  Oral hypoesthesia, glossodynia  Orthostatic hypotension  Implant specific: insertion site pain, Initial Dosing Considerations:  Patients must be in a mild withdrawal state prior to starting buprenorphine  Day 1 - 8 mg/2 mg  Day 2 – 12 mg/3 mg or 16 Addiction Medications Affected Neurotransmitters:  Partial agonist at mu opiate receptors – Buprenorphine  Antagonist at the mu opioid receptor - Naloxone  Antagonist at the kappa opioid receptor  Agonist at delta opioid receptors  Partial agonist at nociceptin opioid peptide receptors Target Symptoms:  Opioid dependence pruritis, erythema Side Effect Pathways:  Binding at mu opioid receptors mg/4 mg  Days 3-7 - Increase in increments of 4 mg/1 mg to max dose of 32 MG/8 mg  Observe patient for at least 2 hours with initial dose, then have 1–2 visits in first week  Achieve the lowest dose that eliminates withdrawal symptoms and illicit opioid use  Stabilization (up to 2 months) and maintenance dose is generally 8 mg/2 mg up to 24 mg/6 mg  During stabilization patients should be seen once per week  During maintenance patients should be seen biweekly or monthly Specific lifespan considerations Age:  Elderly - Use with caution  Children and adolescents - Safety and efficacy have not been established Pregnancy:  Controlled studies have not been conducted in pregnant women  Buprenorphine may be preferable to methadone in pregnant women  Neonatal withdrawal has been reported following use of Addiction Medications buprenorphine during pregnancy  Extremely limited data on sublingual naloxone exposure in pregnancy  Not generally recommended for use during pregnancy, especially during first trimester  Effective June 30, 2015, the US FDA requires changes to the content and format of pregnancy and lactation information in prescription drug labels, including the elimination of the pregnancy letter categories; the Pregnancy and Lactation Labeling Rule (PLLR or final rule) applies only to prescription drugs and will be phased in gradually for drugs approved on or after June 30, 2001 Breastfeeding:  Some drug is found in mother’s breast milk  Recommended either to discontinue drug or bottle feed Methadone (Dolophine, Methadose) Indication:  Moderate-to-severe pain not responsive to nonnarcotic analgesics  Maintenance treatment of opioid addiction (heroin or other morphine-like drugs), Half-life: 15 to 55 hours Metabolism: CYP 450 3A4, 2B6, 2C19, 2C9, and 2D6 Notable Side Effects:  Dizziness  Tiredness  Sweating  Legs swelling  Rash or hives  Chest pain Initial Dosing Considerations:  Methadone is administered daily under close supervision  When used for detoxification: Patient may receive methadone when there are significant symptoms of withdrawal, in Addiction Medications in conjunction with appropriate social and medical services Affected Neurotransmitters:  Agonist of mu opiate receptors  Antagonist at the NMDA receptor  Agonist at delta opioid receptors Target Symptoms:  Moderate to severe pain  Detoxification and maintenance treatment of opioid addiction  Confusion  Arms swelling  Hallucinations  Trouble sleeping  Constipation  Nausea  Vomiting  Difficulty breathing  Sexual dysfunction Side Effect Pathways:  Acts on central and peripheral nervous system opioid receptors accordance with clinical judgment  Initially, a single oral dose of 15 - 20 mg of methadone will be sufficient to suppress withdrawal symptoms  When used for maintenance: Patients should be titrated to a dose in which symptoms are prevented for 24 hours, craving is reduced, and the euphoric effects of opioids are blocked  Most commonly, clinical stability is achieved between 80 and 120 mg/day  Only physicians working in methadone maintenance centers can prescribe methadone for maintenance, however, any physician can prescribe methadone for pain Specific lifespan considerations Age:  Elderly - pharmacokinetics of methadone have not been evaluated in the geriatric population. If used in older adults, the starting dose should be reduced with very slow gradual titration  Children and adolescents - Safety and efficacy have not been established Pregnancy: