1.
Managing Opiate
Dependence
Pharmacy Perspective
Hasryn Azzuar Mohd Khairy
Pharmacist
Methadone Pharmacy

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

3.
NAMPAK CANTIK TAPI MEMBUNUH.

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.
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.
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.
Concentration levels in the brain
Source: The Brain: Understanding the Neurobiology of Addiction National Institute on Drug Abuse, NIH,

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.
 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.
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.
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.
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.
Treatment Modalities
 Psychosocial/behavioral treatment
 Outpatient counseling
 Self-help programs
 Other
 Residential treatments
 Therapeutic communities
 Religious approachs

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.
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.
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.
Heroin vs methadone

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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Services

39.
SPUB

40.
Prescription

41.
M1M (Methadone 1 Malaysia)

42.
M1M (Methadone 1 Malaysia)

43.
Problems We Are Facing
 Aggressive Patients
 Divertion of Methadone
 Bring another bottle (not TA bottle)
 Cheating

44.
KECICIRAN RTG METHADONE
 Pesakit tidak hadir untuk rawatan RTG Methadone di
pusat rawatan lebih daripada 14 hari berturut-turut.

45.
FAKTOR PENYEBAB KECICIRAN
RAWATAN
 Tidak dapat dikesan/ dihubungi (TDK)
 Ditahan polis/ lokap
 Masuk penjara
 Masalah kewangan
 Lokasi jarak
 Masa rawatan kurang sesuai

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.
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.
Thank you…

49.
Hasryn Azzuar Mohd Khairy
Pegawai Farmasi Y/M Farmasi RTG Methadone HKL
hasryn@moh.gov.my
Kepentingan ‘Compliance’
(Kepatuhan) Terhadap
Rawatan Terapi Gantian
Methadone

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.
Kerjasama Pelbagai Pihak Dalam Menjayakan RTG Methadone

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.
 ↓ 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.
 Keselamatan Pesakit
 Kayu Pengukur Kejayaan
 Retention Rate (WHO Standard - 65% retention
rate selepas satu tahun rawatan)
 Peningkatan Kualiti Hidup (QOL)
 Disiplin
Kepentingan 'Compliance'

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

56.
PENTING BAGI ANDA
MENGETAHUI TUJUAN RTG
METHADONE SUPAYA ANDA
DAPAT MEMBANTU PENAGIH

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.
Heroin vs Methadone

59.
Concentration levels in the brain
Source: The Brain: Understanding the Neurobiology of Addiction National Institute on Drug Abuse, NIH,

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.
 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.
 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.
 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.
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.
 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.
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.
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.
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.
INTERAKSI METHADONE
 Campuran sebarang dadah lain dengan
metadon amat berbahaya.
 Boleh menyebabkan gejala mengantuk,
lali dan tidak sedarkan diri

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.
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.
 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.
 Pesakit suka campur
 Bila rasa gian, pesakit salahkan methadone

74.
Rawatan Terapi Gantian
Dengan Methadone
Hasryn Azzuar Mohd Khairy
Pegawai Farmasi, Hospital Kuala Lumpur

75.
Kenapa ambil
Methadone?

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.
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.
 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.
Penagih juga perlu dirawat sama
seperti orang yang berpenyakit!!!

80.
Jadi, apa itu methadone?

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.
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.
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.
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.
 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.
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.
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.
 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.
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.
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.
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.
 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.
 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.
 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.
Kesan – kesan yang tidak
diingini
 Boleh berlaku pada permulaan rawatan
 Sesetengah simptom yang dialami mungkin
disebabkan oleh kesan sampingan Metadon

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

97.
Kesan sampingan
PENGURANGAN
FUNGSI SEKS
MULUT KERING
SEMBELIT
HILANG SELERA
MAKAN
KULIT LEBAM
&
GATAL
SAKIT
OTOT
&
SENDI
BERPELUH
BERLEBIHAN
MENGANTUK
KESAN
SAMPINGAN
METADONE

98.
Mengantuk
(nodding off)
koma
Pernafasan
Singkat
(hypoventilation
pening
loya
TERLEBIH
DOS

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.
 Minum sekurang-kurangnya 2 liter air sehari
 Banyakkan senaman
 Makan makanan seimbang
 Jaga kebersihan diri
 Banyakkan aktiviti keagamaan untuk mencari
ketenangan diri

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.
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.
Elakkan / kurangkan …
 Alkohol
 Buah – buah masam
 Vitamin C
 Minuman berkaffein (kopi, teh, coke)
 Merokok
 Ubat tidur

104.
Outline
 Missed Dose
 Vomited Dose
 Take Away Dose
 Storage of Methadone
 Overdose
 Underdose

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.
 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.
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.
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.
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.
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.
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.
 Steps to be taken
 Obtain new prescription for replacement dose
 Replace full dose of methadone
 Call cleaner to clean up

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.
“ 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.
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.
Take-AwayDoses(2)
 Take away doses
Dosage of methadone To add water
≤ 25mg Up to 50mL
> 25mg Up to 100mL

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

118.
Take-AwayDoses(4)
WEEKLY TA
DEATH / BIRTH
FESTIVE SEASONS
FASTING MONTH

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.
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.
Take-AwayDoses(7)
 3/7 of TAs
 After being 6/52 into the programme
 Patients who are celebrating
 Pharmacist
Festive Seasons

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.
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.
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.
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.
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.
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.
OverDoses(5)
 Things that cant be done when patient has
overdose
 Force patient to vomit
 Take a cold shower
 Injecting salt water

129.
OverDoses(6)
 Treatment
 IV Naloxone 0.4-2mg every 2-3 minutes
according to patient’s need

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

131.
SEKIRANYA TERBUKTI MASIH
TERLIBAT DALAM
PENYALAHGUNAAN DADAH
TETAP
TIDAK AKAN TERLEPAS DARI
TINDAKAN UNDANG-UNDANG

132.
MMT Patients’ Outcome
When We Were Addicts
Now … We can already function like
normal

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.
Terima Kasih
Ingin berkongsi cerita?
Ingin bertanya soalan?

135.
SEKIAN TERIMA KASIH
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