as HIV prevention among IDUs: Developing countries

1. OpioidSubstitution Treatment as HIV prevention among IDUs: Developing countries WORKSHOP Monday, 23 July, 2012

2. Let’s try to know each other… • I am… Dr. AtulAmbekar (MD, Psychiatry) Associate Professor National Drug Dependence Treatment Centre, AIIMS, New Delhi Member: Reference group to UN on HIV and IDU

3. Contents

4. Contents

5. Terminology Part 1: OST

6. What’s in a name? • Agonist maintenance treatment • Agonist substitution treatment • Oral maintenance treatment • Oral substitution treatment (OST) • Buprenorphine / Methadone maintenance treatment • Buprenorphine / Methadone substitution treatment • Medication Assisted Treatment (MAT) Part 1: OST

7. Opioids Part 1: OST

8. Opiate / Opioid : What’s the Difference? Opiate • A term that refers to drugs or medications that are derived from the opium poppy, such as heroin, morphine, codeine. Opioid • A more general term that includes opiates as well as the synthetic drugs or medications, such as buprenorphine, methadone, meperidine, pentazocine —that produce analgesia and other effects similar to morphine. Part 1: OST

9. Opium Part 1: OST

10. Heroin (Smack) Street Names: Brown Sugar White Sugar Part 1: OST

11. Heroin: ‘chased’ or injected Part 1: OST

12. Agonist Partial Agonist Antagonist Morphine-like effect (e.g., heroin) Maximum effect is less than a full agonist (e.g., buprenorphine) No effect in absence of an opiate or opiate dependence (e.g., naloxone, naltrexone) What’s What? Agonists, Partial Agonists, and Antagonists Part 1: OST

13. Understanding ‘agonists’ Part 1: OST

14. Opioid Agonists Site of action of Opioids Part 1: OST

15. Opioid Agonists Opium (morphine) Part 1: OST

16. Opioid Agonists Heroin Part 1: OST

17. Opioid Agonists Buprenorphine Part 1: OST

18. NALTREXONE Opioid Antagonists Part 1: OST

19. NALTREXONE Opioid Antagonists Heroin Opium Buprenorphine Part 1: OST

20. Opioid Agonists • Semisynthetics: Derived from chemicals in opium -Diacetylmorphine – Heroin - Hydromorphone • Oxycodone • Natural derivatives of opium poppy - Opium - Morphine - Codeine • Synthetics • Propoxyphene • Methadone • Levo-alpha-acetylmethadol • Buprenorphine • Pentazocine Part 1: OST

21. Opioid Agonists • Semisynthetics: Derived from chemicals in opium -Diacetylmorphine – Heroin - Hydromorphone • Oxycodone • Natural derivatives of opium poppy - Opium - Morphine - Codeine • Synthetics • Propoxyphene • Methadone • Levo-alpha-acetylmethadol • Buprenorphine • Pentazocine CAN BE / ARE INJECTED Part 1: OST

22. Opioids: Acute effects Psychological effects The effects differ widely between new and chronic (dependent) users • Dependent users • short lived in-tense experience – “rush”. • A state of profound euphoria. • a dreamlike state lasting longer • New users • who is not in pain  an unpleasant reaction. • Who has pain or anxiety  some relief Part 1: OST

23. Opioid Withdrawal SyndromeAcute SymptomsHOURS to DAYS • Opening of all holes ! • Pupillary dilation • Lacrimation (watery eyes) • Rhinorrhea (runny nose) • Yawning, sweating, chills, gooseflesh • Stomach cramps, diarrhea, vomiting • Aches and Pains, Muscle spasms (“kicking”) • Restlessness, anxiety, irritability Part 1: OST

24. Opioid Withdrawal SyndromeProtracted withdrawals WEEKS to MONTHS Opioid Withdrawal SyndromeProtracted Symptoms • Deep muscle aches and pains • Insomnia, disturbed sleep • Poor appetite • Premature ejaculation, Reduced libido, impotence, anorgasmia • Depressed mood, anhedonia • Drug craving Part 1: OST

25. Treatment of opioid dependence • Drug Dependence is a chronic, relapsing disorder • Should be seen as a ‘chronic non-communicable disease’ Part 1: OST

26. Treatment of opioid dependence Part 1: OST

27. Detoxification • Treatment of withdrawal symptoms • Short-term • Associated with very high rates of relapse …hence the need of long-term treatment… Part 1: OST

28. Philosophy of Agonist Substitution Part 1: OST

29. What kind of medications are suitable for agonist maintenance? • Ability to control withdrawal symptoms • Should reduce desire to take illicit drugs • Minimum side-effects • Easy to administer • Low euphoria – low dependence potential • Economical, Easily available • Long acting (so that frequent dosing is not required) Part 1: OST

30. Medications suitable for agonist maintenance • Methadone • Buprenorphine • LAAM • Slow-Release Oral Morphine • ? opium Part 1: OST

31. Comparing OST and Heroin Part 1: OST

32. Heroin vs. OST INTOXICATION Opiate Effect WITHDRAWAL  Time  Part 1: OST

33. Effectiveness of OST Part 1: OST

34. Why is OST relevant for HIV associated with IDU? • IDU: Known risk factor of HIV • In some countries, MAJOR route of transmission • Vulnerable for EXPLOSIVE epidemics of HIV • Can affect even the bridge populations through sexual networks • Opioids are the drugs preferred by IDUs in many countries Part 1: OST

35. Wives and girlfriends of clients Wives and girlfriends of Substance users Clients of FSWs Female Sex Workers HIV Generalized HIV epidemic Husbands and boyfriends of FSWs DRUG USE AND HIV/AIDS Substance Users IDUs RISK RINGS

36. OST: current global status • Both Buprenorphine and Methadone • Approved by US FDA • Endorsed by the UN system • Listed as ‘essential medications’ by WHO • Are being used in a number of countries Part 1: OST

37. OST: current global status Part 1: OST

38. OST: current global status Part 1: OST

39. Myths about substitution treatment Part 1: OST

40. MYTH #1: Patients are stilladdicted FACT: It is true that a person on OST upon missing a dose will experience Withdrawl symptoms. However concept of Addiction or Dependence Syndrom is much broader. • Physical dependence on a medication for treatment of a medical problem does not mean the person is engaging in pathologic use and other behaviors. Part 1: OST

41. MYTH #2: OST is simply a substitute for illegal drugs FACT: Buprenorphine / Methadone are replacement medications; not simply a substitute • legally prescribed medications, not illegally obtained. • Medication taken through safe route of administration. • OST allows the person to function normally. Part 1: OST

42. MYTH #3: Providing medication alone is sufficient treatment for opioid addiction FACT:OST Medication is an important treatment option. However, the complete treatment package must include other elements, as well. • Combining pharmacotherapy with counseling and other ancillary services increases the likelihood of success. Part 1: OST

43. Myth # 4: OST is a “cure” for addiction FACT • It is not a cure • It is a treatment modality that helps in repairing the damage caused by opioid dependence Part 1: OST

44. Contents Any Questions ?

45. Contents

46. what is buprenorphine? Pharmacology Part 2: Buprenorphine

47. Buprenorphine • Semi-synthetic • 25-40 times more potent than morphine • Action: • Partial agonist at mu receptor • Antagonist at kappa receptor • Can be given alternate day Part 2: Buprenorphine

48. Pharmacokinetics • Bioavailability (amount reaching blood) • By oral route = 15 percent • Sublingually = 51 percent • Metabolized in liver • Duration of action (0.3 mg): • i.v route: lasts 3 hrs • sublingual route: lasts 6-8 hrs • Elimination half-life (sublingual)- 27.2 hours Part 2: Buprenorphine

49. Implementing Buprenorphine Substitution Treatment Part 2: Buprenorphine

50. Implementing OST:Some Important steps … Recruitment of clients Assessment: (History, examination, motivation) Discussion: (education of patient) Informed consent Careful monitoring Part 2: Buprenorphine