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Managing Opiate Dependence.ppt

  1. 1. Managing Opiate Dependence Pharmacy Perspective Hasryn Azzuar Mohd Khairy Pharmacist Methadone Pharmacy
  2. 2. 4 OPIOIDS OPIAT BAHAN ASAS TEMPAT PENGELUARAN - Candu - Heroin - Morfin - Kodein Getah bunga popi Acetic, Anhydride, Acetone Acetic Acid (glacial) Calcium Oxide Potassium Carbonate Sadium Carbonate Sadium Hydroxide Sadium Hypoclorite Opium Alkaloid Opium Alkaloid Amerika Selatan Columbia Guatamala Mexico Asia Tenggara Burma Laos Thailand Asia Barat Afganistan Pakistan
  4. 4. Opiates vs. Opioid  Opiates—naturally occurring or semi-synthetic derivatives of opium poppy  Eg. Morphine, heroin, opium, codeine  Opioid—”opiate-like” drug; acts like an opiate, but different chemical structure  Eg. Fentanyl, meperidine, methadone, oxycodone, hydrocodone (pain medications), buprenorphine
  5. 5. What is Heroin ? • In the class of drugs known as "opiates" • Extracted from the white sap of the flowering poppy plant • Pure heroin is a white powder with a bitter taste • ‘Black Tar’ or ‘Brown Sugar’, a gooey black or brownish substance, is a less-refined form of heroin • Chemical name: diacetylmorphine
  6. 6. How is heroin used?  Injected into a vein (‘shooting’)  Inhaled as smoke through a straw (‘chasing’ or ‘chasing the dragon’)  Snorted as powder (‘sniffing’)  Injected into a muscle (‘skin popping’)  Smoked in a water pipe or standard pipe  Mixed in a marijuana joint or regular cigarette  Mixed with benzodiazepines, MDMA, ATS, or cocaine (‘speed ball’)
  7. 7. Concentration levels in the brain Source: The Brain: Understanding the Neurobiology of Addiction National Institute on Drug Abuse, NIH,
  8. 8. Immediate Effects of Heroin Use  Euphoria or the rush  Injected into a vein: euphoria in 7-8 seconds  Injected into a muscle: euphoria in 5-8 minutes  Sniffed/snorted or smoked: euphoria in 10- 15 minutes  Drowsiness or nodding  After the initial euphoria, abusers become drowsy for several hours
  9. 9.  Crashing  Physical symptoms of withdrawal may occur within a few hours after last drug is taken  Major withdrawal symptoms peak around 24 – 48 hours after the last dose of heroin and subside after about a week  Craving  Intense feeling to stop the crash and return to euphoria Continue…
  10. 10. Treatment of opiate dependence  Untreated: high morbidity and mortality  Treatment of opiate dependence is difficult  rapid or short-term solutions are ineffective for majority of opiate dependent individuals (high rate of relapse)  many opiate dependent individuals require multiple treatment attempts and/or long-term treatments  above characteristics are not different from other medical treatments of chronic diseases
  11. 11. Treatment of opiate dependence  Comprehensive treatments, combining medications with counseling, psycho-social treatments, are effective in reducing morbidity and mortality, as well as improving health, vocational, social, family, and legal functioning
  12. 12. Treatment Modalities  Pharmacotherapy  Detoxification + follow-up treatment  Maintenance with agonist or antagonist medications  Long term approach: opportunity for client to distance themselves from drug-using lifestyle  To flood the brain with safe opiates, so it stops craving for heroin (unsafe opiates)
  13. 13. Treatment Modalities  Psychosocial/behavioral treatment  Outpatient counseling  Self-help programs  Other  Residential treatments  Therapeutic communities  Religious approachs
  14. 14. Methadone  1st produced by German Chemists in early 20th century and has been used clinically since end of WW1.  Synthetic opiate without strong sedative effects.  White crytalline powder.  Widely used as a substitution therapy in the treatment of heroin addiction.
  15. 15. Pharmacological & Clinical Properties Pharmacological property Clinical implication Substitutes for heroin Prevents withdrawal Mild opiate-like effects Reduces cravings Increases treatment retention ‘blocks’ other opiates Reduces heroin use Long duration of action Daily (or alternate day) dosing Ceiling effects Greater safety profile
  16. 16. Methadone Pharmacokinetic  Onset of effects : 30 minutes  Peak effects : Approx 3 Hr  Half life (in MMT) : Approx 24 Hr  Time to reach stabilization : 3 -10 days (steady state)
  17. 17. Heroin vs methadone
  18. 18. Benefits of MMT  Reduced illicit drug use  Improved health status as a result of access to treatment (by normalization of endocrine and immune system functioning)  Decreased transmission of HIV, HCV, HBV (↓ harm)  Decreased illegal activity  Increased employment  Decreased cost to society  Decreased mortality  High treatment acceptance and good retention
  19. 19. Continue…  Long-acting oral opiate administered daily replaces short-acting drug used by injection, chasing, or smoking  Steady-state plasma levels  no “rush,” “nod” or withdrawal during maintenance  Multiple targets:  Low doses (30-40 mg daily)  prevent withdrawal  Higher doses (80-120 mg daily)  Reduce craving  Induce tolerance to street opiates  Block/attenuate pleasurable opiate effects
  20. 20. Side Effects of Methadone  CNS- Sedation, dysphoria, weakness, headache, insomnia, agitation, disorientation, and visual disturbances.  Gastrointestinal- Dry mouth, anorexia, constipation and biliary tract spasm.  Cardiovascular- Flushing, bradycardia, palpitations, faintness, and syncope.  Genitourinary- Urinary retention, anti-diuretic effect, reduced libido/potency.  Allergic- Pruritus, urticaria, edema, and, rarely, hemorrhagic urticaria.  Hematologic- Reversible thrombocytopenia has been described in a narcotics addict with chronic hepatitis.
  21. 21. Common Adverse Effects and What To Do? Side Effect Common Causes Response Drowsiness after dose •Excessive dose •Use of other CNS depressants (alcohol, BDZ) •Review and maybe reduce dose •Reduce patient’s use of other drugs Craving for heroin Insufficient dose Review and maybe increase dose
  22. 22. Continue… Side Effect Common Causes Response Constipation •Methadone •Dysfunctional diet •Other lifestyle behaviours •Advise a high fibre diet, adequate fluid intake & exercise •Pharmacotherapy of constipation if necessary Dental problems (decayed teeth, periodontal disease) •Drug induced reduced saliva volume (problem with all opioids) •Poor dental hygiene Advise enhanced dental hygiene (frequent brushing, avoid sugary foods/drinks, chew non-sugar gum)
  23. 23. Continue… Side Effect Common Causes Response Weight Gain •Fluid retention •Improved appetite •Decreased activity •Review dose and reduce patient’s salt intake •Review and change patient’s diet •Advice patient to increase exercise carefully
  24. 24. Continue… Side Effect Common Causes Response Insomnia •Excessive or insufficient dose •Timing of dose •Stimulation by other drugs (coffee, tobacco, stimulant drugs such as amphetamine or pseudoephedrine) •Review dose •Review timing of dose •Identify stimulant drugs and advise patient to avoid them •Review patient’s general sleep hygiene
  25. 25. Continue… Side Effect Common Causes Response Lowered libido •Higher doses •Psychological or social/situational problems •Review dose •Check patient’s history and advise counselling
  26. 26. Continue… Side Effect Common Causes Response Nausea/ Vomitting / Loss of Appetite • methadone • Do not take the dose while empty stomach. • Can be taken with milk if there is GI disturbance Skin Itchiness/ Urticaria • Histamine released by methadone • Review & identify the skin problem. • Symptomatic relief by antihistamine.
  27. 27. Continue… Side Effect Common Causes Response Excessive Sweating • Excessive dose of methadone • Wear thin clothes Tachycadia/ Bradycardia • Excessive dose of methadone • Refer to see doctor immediately.
  28. 28. Drug Interactions Drug Effect on Methadone Action Alcohol Increase ↑ Avoid Antiepileptics ex. PHT Decrease ↓ Increase/split Methadone dose Benzodiazepines Increase ↑ Limit/stop use BDZ Cimetidine Increase ↑ Avoid Ciprofloxacin Increase ↑ Decrease methadone dose Efavirenz Decrease ↓ Increase/ split Methadone dose Fluoxetine Increase ↑ Change SSRI
  29. 29. Drug Effect on Methadone Action Fluvoxamine Increase ↑ Change SSRI Nicotine Decrease ↓ Advise stop smoking Rifampicin Decrease ↓ Increase/ split Methadone dose SLN (Stavudine+ Lamivudine + Nevirapine ) Decrease ↓ Increase/ split Methadone dose Tricyclic Antidepressants Increase ↑ Avoid Urine Acidifier (Ascorbic acid) Decrease ↓ Avoid Urine alkaliniser (NaHCO3) Increase ↑ Avoid Zidovudine None (Incr. AZT Decrease AZT
  30. 30. MMT for Special Cases  Pregnancy & Lactating Mother :  Safe for both & enable stabilisation of drug use & lifestyle  Reduces & eliminates illicit opioid drug use & can help stabilize the in utero environment.  Does not increase the risk of congenital abnormalities, premature delivery & reduced weight in the fetus.  Babies born may experience “fetal abstinence syndrome” (FAS) which can be relieved by symptomatic Tx eg. Phenobarbitone for asthma.  Methadone is classed as Pregnancy Category C drug because of potential risk of respiratory depression in neonates (not significant).
  31. 31. Management in Pregnancy  Pregnant women should be maintained on an adequate dose/ current dose of methadone to achieve stability.  Opioid withdrawal at 1st trimester -- ↑ risk of miscarriage; 3rd trimester – risk of fetal distress & death.  The bioavailability of methadone is decreased in the later stage of pregnancy due to increased plasma volume, an increase in plasma proteins which bind methadone & placental metabolism of methadone.  may divide the daily dose & increase the dose in the 3rd trimester.
  32. 32. Management in Breastfeeding  Breast milk contains only small amount of methadone & mothers can be encouraged to breastfeed of methadone dose provided that they are not using other drugs.  Breastfeeding may reduce the severity of the neonatal withdrawal syndrome.  Women receiving high doses of methadone should be advised to wean their babies slowly to avoid withdrawal in the infant.
  33. 33. Management in HIV Patients  HIV positive patients must have access to specialist HIV medical care  In general, these patients are able to comply with the requirements and conditions of the program  Doses must be monitored due to interactions between methadone and HIV medications and the effects of related illnesses  Higher doses may be necessary if HIV medications increase methadone metabolism.
  34. 34. Management in Hep B Patients  Recommend Hepatitis B vaccinations to all clients on the methadone program who are found to have no immunity to the hepatitis B virus  Clients who are acutely infected or who are chronic carriers of hepatitis B should be referred to a specialist
  35. 35. Management in Hep C Patients  A high percentage of clients - Hepatitis C antibody positive  Hep. C positive + 3 normal serum ALT and AST over 6 months , LFT’s repeated at 6 monthly intervals  Hep. C positive + 3 abnormal serum AST and ALT over 6 months, referral for specialist care is indicated
  36. 36. Self Care for MMT Patients  Do not give Methadone to other people because it is extremely dangerous & may cause toxicity or unwanted effects.  Do not inject Methadone as it may cause dangerous complications.  Advice patients to see dentist for dental check up at least 2 times per year.  Increase fluids (water) intake.  Do more exercise.  Eat balance diet with high fibre food.  Involved in religious activities to seek for peace & enhance confidence & motivations
  37. 37. When should we stop treatment? Chronic condition needs long term treatment Premature cessation of treatment usually results in relapse to dependent heroin use Consider ending treatment when  no illicit drug use for months / years  stable social environment  stable medical / psychiatric conditions  patient has a life that does not revolve around drugs  patient informed consent
  38. 38. Services
  39. 39. SPUB
  40. 40. Prescription
  41. 41. M1M (Methadone 1 Malaysia)
  42. 42. M1M (Methadone 1 Malaysia)
  43. 43. Problems We Are Facing  Aggressive Patients  Divertion of Methadone  Bring another bottle (not TA bottle)  Cheating
  44. 44. KECICIRAN RTG METHADONE  Pesakit tidak hadir untuk rawatan RTG Methadone di pusat rawatan lebih daripada 14 hari berturut-turut.
  45. 45. FAKTOR PENYEBAB KECICIRAN RAWATAN  Tidak dapat dikesan/ dihubungi (TDK)  Ditahan polis/ lokap  Masuk penjara  Masalah kewangan  Lokasi jarak  Masa rawatan kurang sesuai
  46. 46.  Duration of treatment  Dose of medication  Quality of therapeutic relationship  Regular review, supervision & monitoring  Psychosocial supports for the patient  Motivation / goals of clients Principles of Effective Maintenance Treatment
  47. 47. How far is far, how high is high? We will never know until we try. The door to success is the one marked “PUSH”…… Persevere Until Success Happens
  48. 48. Thank you…
  49. 49. Hasryn Azzuar Mohd Khairy Pegawai Farmasi Y/M Farmasi RTG Methadone HKL Kepentingan ‘Compliance’ (Kepatuhan) Terhadap Rawatan Terapi Gantian Methadone
  50. 50.  Di dalam bidang perubatan, ‘compliance’/kepatuhan bermaksud sejauh mana seseorang pesakit itu mengikut dengan betul rawatan atau nasihat-nasihat perubatan yang telah diberikan.  Ketidakpatuhan pada rawatan adalah suatu halangan utama dalam memberikan penjagaan kesihatan yang berkesan kepada pesakit.  Kepatuhan = Bil dos yang diambil x Apa itu 'Compliance'
  51. 51. Kerjasama Pelbagai Pihak Dalam Menjayakan RTG Methadone
  52. 52. Mengapa RTG Methadone?  Semejak 40 tahun lalu, methadone telah membantu jutaan penagih meninggalkan ketidakstabilan hidup yang dialami ketika bergelumang dgn dadah.  ↓ penularan penyakit bawaan darah (HIV & Hepatitis)  ↑ tahap kesihatan  √ pekerjaan stabil  Belajar semula  Diterima keluarga semula  √ kehidupan sosial  Keyakinan diri (feel good about themselves)
  53. 53.  ↓ penggunaan dadah jalanan  ↓ jenayah  ↓Beban masyarakat dan negara  ↓ Kematian  Penerimaan terhadap rawatan yang bagus Mengapa RTG Methadone? Bantu AADK capai ‘Negara Bebas Dadah 2015’ ☺
  54. 54.  Keselamatan Pesakit  Kayu Pengukur Kejayaan  Retention Rate (WHO Standard - 65% retention rate selepas satu tahun rawatan)  Peningkatan Kualiti Hidup (QOL)  Disiplin Kepentingan 'Compliance'
  55. 55.  Staf – galak pesakit untuk berhenti ambil dadah lain supaya tidak ganggu rawatan → kepatuhan kepada rawatan.  Heroine  Morphine  Syabu/’ice’  Alkohol  Ganja  Ubat Tidur  Komplian – penting dalam pemulihan  Elak ‘relapse’  Mengawal fungsi otak  Tidak komplian – regimen methadone akan gagal → ↑ kos keseluruhan penjagaan
  57. 57.  Methadone – Hanya perlu ambil sekali sehari.  Methadone - Long-acting oral opiate (berada dalam badan lebih lama) → elak suntik,’chase’ / hisap heroine/opiat Kenapa Perlu Ambil Dos Secara Harian?
  58. 58. Heroin vs Methadone
  59. 59. Concentration levels in the brain Source: The Brain: Understanding the Neurobiology of Addiction National Institute on Drug Abuse, NIH,
  60. 60.  Seeloknya diminum pada waktu PAGI  Dalam proses induksi methadone ‘overdose’ selalu berlaku semasa di rumah bila tidur  Administrasi methadone pada waktu pagi akan pastikan tahap methadone optimum berlaku semasa pesakit berjaga & org lain masih ada jika overdose berlaku. Kenapa perlu ambil pada waktu yang sepatutnya?
  61. 61.  Minum methadone pada waktu yang sama setiap hari  Untuk mencapai konsentrasi methadone dalam badan yang selamat (underdose/overdose)  ≈ setiap 24 jam ± 1 jam  Bagi pesakit yang mempunyai dos dua kali sehari  Minum dos malam yang dibawa balik pada waktu sama yang ditetapkan setiap hari.  Habiskan isi kandungan DBB (JANGAN dibahagi2kan) Kenapa perlu ambil pada waktu yang sepatutnya?
  62. 62.  Pesakit yang mempunyai Dos Bawa Balik (DBB)  Perlu minum seperti yang tertulis pada label  Minum sekaligus (habiskan isi kandungan botol)  Tidak boleh dibahagi-bahagikan  Perlu disimpan dengan selamat dan betul Kenapa perlu ambil pada waktu yang sepatutnya?
  63. 63.  Methadone ada banyak interaksi dengan ubat2an lain dan makanan  Diproses di hati  Ubat-ubatan lain boleh menyebabkan  ↑ konsentrasi methadone dalam darah – kesan sampingan  ↓ konsentrasi methadone dalam darah - gian Saya ada makan ubat2an lain…
  64. 64. Ubat-ubatan  Alkohol  Ubat Gastrik  Ubat tidur  Ubat sawan  Antibiotik  Ubat HIV  Ubat TB  Nikotin (Rokok/Patch)  Vitamin C  Buah – buahan masam  Minuman/makanan berkaffein  Kopi  Teh  Coca- cola/pepsi dll Contoh bahan-bahan yang berinteraksi dengan Methadone Makanan
  65. 65.  Dadah jalanan : alkohol, heroine, ice, ganja, ubat tidur, ecstasy → boleh sebabkan overdose jika dicampur bersama Methadone.  Simptom2 Overdose  Pengecilan Anak Mata  Loya / Muntah  Pening-pening  Mengantuk  Pergerakan tidak stabil / Percakapan tak jelas  Berdengkur  Pernafasan cetek  Berbuih di mulut Selain itu…
  66. 66. KESAN SAMPINGAN KESAN SAMPINGAN FAKTOR PENYEBAB TINDAKAN Mengantuk selepas pendosan Gian kepada heroin Dos berlebihan/ Penggunaan dadah depresi Dos tidak mencukupi Elakkan dari memandu kenderan/ mengendalikan mesin sekurang-kurangnya dalam masa 2 minggu pertama Beritahu doktor
  67. 67. KESAN SAMPINGAN KESAN SAMPING FAKTOR PENYEBAB TINDAKAN Sembelit Gangguan tidur/ Insomnia Masalah gigi Metadon Terlebih/ Kurang dos Metadon Banyakkan ambil buah,sayur berserat tinggi Kesan dadah/ bahan lain (kopi,rokok) Buat senaman ringan Kerap memberus gigi,elakkan mengambil makanan/minuman bergula,kunyah gula getah
  68. 68. KESAN SAMPINGAN KESAN SAMPING FAKTOR PENYEBAB TINDAKAN Berpeluh berlebihan Kadar denyutan jantung laju/perlahan Pengurangan fungsi sex Dos berlebihan Dos berlebihan Dos yang tinggi Pakai pakaian yang tidak terlalu tebal. Segera berjumpa doktor Beritahu doktor
  69. 69. INTERAKSI METHADONE  Campuran sebarang dadah lain dengan metadon amat berbahaya.  Boleh menyebabkan gejala mengantuk, lali dan tidak sedarkan diri
  70. 70. Bahan/ Dadah Kesan ke atas Metadon Cara mengatasi Efavirenz Nikotin Rifampicin Urine acidifiers cth. asid askorbik Mungkin perlu tingkatkan dos metadon ataupun split dose Nasihatkan pesakit berhenti merokok Tingkatkan dos Metadon/split dos Elakkan INTERAKSI METHADONE
  71. 71. Bahan/ Dadah Kesan ke atas Metadon Cara mengatasi Zidovudin Benzodiazepine Alkohol Tiada ( mungkin meningkatkan paras zidovudin ) Kurangkan dos zidovudin Hadkan penggunaan benzodiazepine Elakkan INTERAKSI METHADONE
  72. 72.  Mengandungi Burprenorphine + Naloxone  Apakah itu buprenorphine? Adakah ia lebih baik dari methadone?  Buprenorphine ialah ubat yang berpotensi utk sesetengah penagih opioid. Ia seakan methadone, dimana ia menghalang kesan opioid lain seperti heroine, morphine dan methadone.  Tetapi mempunyai kesan yang kurang dari methadone  Bahaya jika diambil bersama methadone → sebabkan gian teruk. Suboxone?
  73. 73.  Pesakit suka campur  Bila rasa gian, pesakit salahkan methadone
  74. 74. Rawatan Terapi Gantian Dengan Methadone Hasryn Azzuar Mohd Khairy Pegawai Farmasi, Hospital Kuala Lumpur
  75. 75. Kenapa ambil Methadone?
  76. 76. Ketagihan Dadah  Ketagihan dadah adalah satu penyakit yang kompleks dan kronik (berpanjangan)  SAMA seperti penyakit kencing manis dan darah tinggi  Ketagihan – suatu penyakit otak
  77. 77. Apa perbezaan ketagihan dengan penyakit kronik lain Ketagihan Diabetes Melibatkan faktor biologi badan Ya Ya Rawatan Ubat - ubatan Ya (Methadone) Ya (Ubat-ubatan anti- diabetes) Implikasi jika tidak mengikut rawatan Simptom gian, penggunaan dadah haram Peningkatan gula dalam darah Komplikasi jika tidak dirawat HIV, Hep B & C, Penyakit-penyakit psikiatri, jenayah Kegagalan organ-organ penting dalam badan
  78. 78.  Kajian saintifik menggunakan tikus menunjukkan  Tikus yang diberi heroine akan menunjukkan kesan ketagihan  Tikus akan menekan butang secara kerap untuk mendapatkan heroine seterusnya  Ketagihan mempunyai sifat galakan berulangan (self- reinforcing property)
  79. 79. Penagih juga perlu dirawat sama seperti orang yang berpenyakit!!!
  80. 80. Jadi, apa itu methadone?
  81. 81. Methadone  Ditemui pada zaman perang dunia pertama (1940)  Mula digunakan sebagai ubat penahan sakit  Didapati mempunyai ciri-ciri untuk memulihkan penagih  Dadah sintetik dari jenis opiat
  82. 82. Keberkesanan Methadone  Menutup rangsangan Heroin dan dadah lain pada otak  Kurangkan kesan gian  Kesan drastik: 30 minit  Kesan kemuncak: 3 jam  Jangka Hayat : 24 jam  Masa penstabilan : 3-10 hari
  83. 83. Apa itu Rawatan Terapi Gantian Dengan Methadone  Pada awal 1960an – 2 orang doktor dari New York telah mendapati jika methadone diambil secara harian dan ditambah dengan khidmat sokongan, ia adalah kaedah yang efektif untuk merawat ketagihan terhadap dadah opiat
  84. 84. Apa itu Rawatan Terapi Gantian Dengan Methadone (2)  Methadone ini digunakan sebagai kaedah mengurangkan mudarat bagi membendung risiko penularan penyakit berjangkit yang berkaitan dengan perkongsian jarum  Dos methadone yang betul TIDAK akan menyebabkan pesakit “high” atau “lalok” – mereka boleh menjalani kehidupan seperti normal
  85. 85.  Walaubagaimanapun, Methadone masih boleh disalah guna, jadi rawatan ini mesti dipantau dan diselia dengan perhatian dari pelbagai pihak (pegawai farmasi, doktor, pihak AADK, kaunselor dan AHLI KELUARGA)
  86. 86. Soalan cepu emas !!!  Berapa lama nak minum?  Gian lagi teruk bila nak berhenti?  Minum methadone boleh mati!  Minum methadone tak boleh berhenti!  Sy adjust dose sendiri so lagi senang berhenti…
  87. 87. Berapa lama nak minum?  Jangka masa rawatan adalah berbeza bergantung kepada penggunaan heroin sebelum ini  Pemerhatian, lebih lama mengambil methadone, lebih baik peluang untuk pulih sepenuhnya dari ketagihan  Pengambilan dalam masa yang singkat – kebarangkalian tinggi untuk ‘jatuh’ semula.
  88. 88.  Ketagihan – sakit otak kronik  Sama macam diabetes – perlu komitmen sepanjang hayat, proses yg berterusan  Lebih lama lagi bagus – lepas 1 tahun 80% pengurangan pengambilan dadah  Pulih sepenuhnya – makan masa bulan/tahun  Methadone – titik permulaan proses pemulihan, selebihnya dan berapa lama bergantung pada pesakit itu sendiri. Berapa lama nak minum?
  89. 89. Berapa dos yang sesuai untuk saya?  Jangan bandingkan dos anda dengan orang lain  Dos methadone anda adalah unik bagi setiap individu  Dos penstabilan 60 – 120mg  Anda mungkin perlu lebih atau kurang dari dos tersebut untuk stabil
  90. 90. Faedah Rawatan Terapi Gantian Dengan Methadone  Diberi secara oral, bukan secara suntikan. Oleh itu dapat mengurangkan risiko jangkitan hepatitis B dan C serta jangkitan HIV.  Mengurangkan kebergantungan opioid.  Mengurangkan kesan pengunduran (withdrawal).  Membantu mengurangkan kesan psikologi dan emosi semasa proses pengunduran.  Pendosan sekali sehari . Dengan itu, meningkatkan komplians pesakit.  Selamat digunakan oleh ibu yang mengandung dan menyusukan anak.  Membantu meningkatkan status sosial dan peluang pekerjaan
  91. 91. Pendispensan Methadone Screening of Methadone Prescription Patient Drinking their ‘DOT’ Dose Make sure patient throw away their cup(s) into the designated bins. Patient rinses their cup to make sure there are no more medication left and also to make sure they drink and swallow their dose.
  92. 92.  Kajian – gian methadone tidak seteruk heroine/morphine  Jika diberhentikan dengan prosedur yang betul tidak akan rasa gian dan senang untuk berhenti  Jika diberhentikan secara ‘cold turkey’ – rasa tidak selesa akan ada lebih lama kerana methadone berada lebih lama dalam badan Methadone lagi susah nak berhenti…Gian lagi teruk…
  93. 93.  Sejak diperkenalkan (2005) – tiada kes kematian yang disebabkan oleh RTG Methadone  Semua ubat ada kesan sampingan  Jika dipantau oleh ahli professional kesihatan – terapi yang selamat (terdapat rawatan yg lebih bahaya dari RTG Methadone)  Pada dos yang selamat – pesakit tidak rasa ‘high’ dan boleh berfungsi seperti normal. Minum Methadone boleh mati!!!
  94. 94.  Jika tidak patuh pada rawatan – PASTI tidak boleh berhenti  Maklumkan doktor/pegawai farmasi jika ingin berhenti  Ada cara yang betul untuk berhenti tanpa merasa apa-apa/sedikit kesan yang tidak menyenagkan Minum Methadone tak boleh berhenti? Saya 'adjust' sendiri dos saya…
  95. 95. Kesan – kesan yang tidak diingini  Boleh berlaku pada permulaan rawatan  Sesetengah simptom yang dialami mungkin disebabkan oleh kesan sampingan Metadon
  96. 96. Kesan – kesan yang tidak diingini  Juga boleh berlaku sekiranya dos metadon yang diambil adalah terlalu tinggi atau rendah  Kebanyakan orang yang pernah mengambil heroin akan mengalami kesan sampingan dengan Metadon yang minimal
  98. 98. Mengantuk (nodding off) koma Pernafasan Singkat (hypoventilation pening loya TERLEBIH DOS
  99. 99. Penjagaan Diri Pesakit  Jangan berikan metadon kepada orang lain  Jangan menyuntik metadon kerana ianya boleh menyebabkan komplikasi yang membahayakan  Sila berjumpa dengan doktor gigi anda sekurang- kurangnya 2 kali setahun
  100. 100.  Minum sekurang-kurangnya 2 liter air sehari  Banyakkan senaman  Makan makanan seimbang  Jaga kebersihan diri  Banyakkan aktiviti keagamaan untuk mencari ketenangan diri
  101. 101. Pengambilan Alkohol  Dinasihatkan tidak mengambil alkohol.  Terlebih dos alkohol mengganggu rawatan methadone  Boleh menyebabkan terlebih dose jika diambil bersama  Jika berbau alkohol atau mabuk, dos methadone akan ditangguhkan
  102. 102. Interaksi Methadone dan Ubat-ubatan  Campuran sebarang dadah lain dengan metadon amat berbahaya  Boleh menyebabkan gejala mengantuk, lali dan tidak sedarkan diri dan kematian  Sila beritahu dengan pegawai farmasi, doktor jika anda mengambil sebarang ubat lain!!!
  103. 103. Elakkan / kurangkan …  Alkohol  Buah – buah masam  Vitamin C  Minuman berkaffein (kopi, teh, coke)  Merokok  Ubat tidur
  104. 104. Outline  Missed Dose  Vomited Dose  Take Away Dose  Storage of Methadone  Overdose  Underdose
  105. 105. MissedDose  When patient miss their methadone doses, they may use other drugs (i.e. Alcohol / Benzo)  When missed 3 or more days, tolerance to opioids may be reduced – increase risk of overdose when methadone is reintroduced  Patient should be assessed for signs of intoxication & withdrawal  If dose has not been collected for 3/more days, dose should be withheld or reduced – Dr’s review
  106. 106.  If a patient misses their dose : One Day No changes in dose Two Days If no evidence of intoxication, administer normal dose Three Days Administer half dose in discussion with the prescriber Four Days Patient must see prescriber. Recommence at 40mg or half dose whichever is lower Five Days or more Regard as a new induction
  107. 107. Scenario1  Mr ESS has drank methadone 120mg on 25/10/2013, he came again on 28/10/2013 for his next dose. After that, he only came again on 1/12/2013 because he claimed that he was being arrested by the police. What should you do? a) On 28/10/2013? b) On 1/12/2013?
  108. 108. Whatshouldyoudo? a) Continue 120mg. b) Obtain letter of release (if available as proof). Refer prescriber before continuing patient’s methadone treatment, regard as new case.
  109. 109. VomitedDose  If patient has vomited after dose has given, steps for replacement dose should be taken  A new prescription is needed for the replacement dose
  110. 110. Less than 15 minutes after dosing Replace whole dose In between 15 – 30 minutes after dosing Replace 50% of dose After 30 minutes of dosing No replacement dose VomitedDose(2)
  111. 111. Scenario2  Miss AF drank her methadone dose at 1030am, 30 seconds after drinking she vomited at the waiting area of your pharmacy. What should you do?
  112. 112.  Steps to be taken  Obtain new prescription for replacement dose  Replace full dose of methadone  Call cleaner to clean up
  113. 113. Scenario3 • “Encik, saya muntah la, baru je, saya nak minum lagi la encik, kalau tak minum saya gigil-gigil la encik…tolonglah…” What should you do? On what basis can you give or cannot give…
  114. 114. “ Encik, duduk dulu…”  Calm patient down  Check the time when patient drank on that particular day from the prescription  Ensure patient is not lying  Do not prejudge (patient might be genuine)  Consume methadone after food Less than 15 minutes after dosing Replace whole dose In between 15 – 30 minutes after dosing Replace 50% of dose After 30 minutes of dosing No replacement dose
  115. 115. Take-AwayDoses  Take away doses are allowed  When patient are stable 6 week into the program  Through observation on stability & misuse, urine  Review notes on evaluation for TA doses should be kept clearly in the clinical notes  Pt’s stability indicator (i.e. urine, behaviour)  No contraindication towards treatment  Other usage of psychoactive agents (if any)
  116. 116. Take-AwayDoses(2)  Take away doses Dosage of methadone To add water ≤ 25mg Up to 50mL > 25mg Up to 100mL
  117. 117. Take-AwayDoses(3)  Prepare complete label for the bottle Methadone ……mg Minum pada…(tarikh)…(masa) Nama …………………………………………. No Pendaftaran…………………………… Tarikh Dibekal…………………………….. AMARAN JAUHI DARI KANAK-KANAK Nama pusat rawatan RTG, Alamat, Telefon Perlu diambil / ditelan oleh penama yang tercatat pada label di atas pada hari yang telah dinyatakan Boleh menyebabkan kemudaratan / kematian Jikalau diambil oleh orang lain In front of bottle Back of bottle
  119. 119. Take-AwayDoses(5)  Only 3/7 per week  After being 6/52 into the program  Dr’s approval (1st time)  Specific day must be assigned  Defaulters – withhold TA 1/12 (subject to Dr’s evaluation) Weekly TAs
  120. 120. Take-AwayDoses(6)  Death/birth of family members  Can be given up to 3/7  Submit death cert/birth cert (compulsory)  Pharmacist Death / Birth
  121. 121. Take-AwayDoses(7)  3/7 of TAs  After being 6/52 into the programme  Patients who are celebrating  Pharmacist Festive Seasons
  122. 122. Take-AwayDoses(8)  1/7 ONLY given at a time  1st dose given 1 day before fasting month  Very high possibility for misuse  Further discussion???  Standard guideline??? Fasting Month
  123. 123. Storageof Methadone  Storage of take away doses  In a safe place ( cabinet or locked drawer)  Away from children  Room temperature ( not in fridge)  Cool dry place
  124. 124. OverDoses  Overdose happens when a drug is taken excessively or in combination with other agent(s)  Very dangerous, fatal  In Australia, death following methadone induction often occurs at home during sleep  Administration of methadone in the morning ensure peak methadone concentrations occur when patients are normally awake & other people may be around if overdose should occur
  125. 125. OverDoses(2)  Symptoms  Pinpoint pupils  Nausea  Dizziness  Feeling intoxicated  Sedation/ Nodding off  Unsteady gait, slurred speech  Snoring  Hypotension  Slow pulse (Bradycardia)  Shallow breathing (hypoventilation)  Frothing at the mouth (pulmonary oedema)  Coma
  126. 126. OverDoses(3)  Depressants (act by reducing nervous system activity to a dangerous level where pt stops breathing)  Heroine  Morphine  Methadone  Sleeping pills  Alcohol  Benzodiazepines  Stimulants (Increases body activity & can cause the increase in blood pressure, heart rate & body temperature)  Amphetamines  Ecstasy  Caffeine  Nicotine
  127. 127. OverDoses(4)  Overdose can happen easily either to an experienced or new addicts  Factors that affect the effects of drugs on individuals  Tolerance  Amount of drugs  Drug combination(s)  Route of administration
  128. 128. OverDoses(5)  Things that cant be done when patient has overdose  Force patient to vomit  Take a cold shower  Injecting salt water
  129. 129. OverDoses(6)  Treatment  IV Naloxone 0.4-2mg every 2-3 minutes according to patient’s need
  130. 130. Underdose  Happens between few minutes or days after stopping or reducing dose of opioids  Important to identify to retain patient in the programme  Symptoms  Dysphoria  Nausea & vomiting  Muscle aches  Runny nose , watery eyes  Pupillary dilatation  Diarrhea  Excessive yawning (sangap)  Fever  Insomnia
  132. 132. MMT Patients’ Outcome When We Were Addicts Now … We can already function like normal
  133. 133. Real Quotes From MMT Patients “You all are really doing a very noble job helping these addicts” – patient’s brother “Terima kasih la kat kerajaan sebab sudi tolong orang macam kami,akak je yang tak jemu tengok muka kitorang (penagih) ni” - pesakit “Dulu 24 jam saya keje nak cari duit, sebab ‘barang’ punya hal, sekarang dah minum metahdone, satu kerja je cukup boleh jimat dan saya pun dah boleh jaga mak bapak saya. Hari-hari saya jenguk diorang” -pesakit  Saya nak pegi hantar anak saya pegi sekolah ni, tulah minum methadone dulu” –pesakit “Boleh tak saya nak schedule kan balik take away saya, nak pegi Singapore keje, ni flight itenary saya” – pesakit “Saya sekarang dah keje dah, driver Dato’ ********* *****” – pesakit “You are really giving them (addicts) a second chance in life” – patient’s family member
  134. 134. Terima Kasih Ingin berkongsi cerita? Ingin bertanya soalan?
  135. 135. SEKIAN TERIMA KASIH Jika anda ingin mendapatkan maklumat atau belajar dengan lebih lanjut cara-cara mengendalikan klien anda, sila lawati atau berhubung terus dengan saya ;)