Home' Australian Pharmacist : Australian Pharmacist November 2012 Contents Australian Pharmacist November 2012 I ©Pharmaceutical Society of Australia Ltd. 899
Continuing Professional Development
EVIDENCE IN PATIENT CARE
1. Which of the follow cases may meet
DSM criteria for opioid dependence?
a) A patient who experiences
constipation, sedation and miosis
following dosing, and who is also
taking temazepam 10 mg at night for
b) A patient who reports withdrawal
symptoms when he reduces his dose of
oxycontin from 80 mg twice daily to 60
mg twice daily.
c) A patient who has needed to increase
their dose of Panadeine Forte several
times over the past 12 months. The
patient has begun spending a lot of
time seeing doctors to get enough
Panadeine Forte and has been given
a warning at work due to being
intoxicated/sedated on the job.
d) A patient who reports severe
withdrawal symptoms when she
doesn't take her tramadol dose.
e) A patient who has been prescribed
antidepressants for her mood, who has
begun injecting heroin once or twice a
week in the past three months. Before
initiating heroin injection, she had
smoked heroin on the weekends for a
2. Common comorbidities in
pharmacotherapy clients in Australia
include which of the following?
a) Obesity and neuropathy.
b) Hepatitis C and diabetes.
c) Depression and HIV.
d) Depression and liver disease.
e) Hepatitis C and HIV.
3. Which induction scenario would be
outside the current guidelines?
a) Methadone 20 mg on day 1, increasing
to 25 mg on day 4 after review.
b) Methadone 40 mg on day 1, increasing
by 10 mg each day until they are taking
c) Buprenorphine--naloxone 8 mg on day
d) Buprenorphine--naloxone 4 mg on
day 1, increasing to 6 mg on day 2 in
a patient using diazepam 5 mg three
e) Methadone 30 mg daily: may increase
by 2.5 mg on day 3 after review.
4. Which statement is CORRECT
regarding using OST for
pharmaceutical opioid dependence?
a) Methadone and buprenorphine are
currently licensed only for heroin
dependence only in Australia.
b) People dependent on pharmaceutical
opioids such as codeine are likely to
need lower doses of buprenorphine.
c) People dependent on pharmaceutical
opioids generally do well with shorter
periods of treatment.
d) Methadone is more effective than
buprenorphine for people dependent
on pharmaceutical for pain treatment.
e) Methadone and buprenorphine
are indicated in Australia for
pharmaceutical opioid dependence,
though patients' own perceptions
around treatment can be a barrier to
5. A patient presents in the morning
for their regular methadone dose
and you observe that they have
slurred speech, seem unstable on
their feet, and smell of alcohol.
Which of the following approaches is
a) Supply a take-away dose with
instructions to take later on this
evening after the effects of alcohol
have worn off.
b) Administer half their dose now and
review the patient yourself before
giving the other half this afternoon.
c) Administer a dose of buprenorphine
instead as there is less risk of
respiratory depression with
d) If this is the first time this has
happened, administer the dose as
normal, and warn the patient of the
risks of taking methadone and other
e) Ask the patient to return later when
they are not intoxicated to assess them
for safety to dose, and contact the
prescriber to inform them.
contact with the patient, knowledge of
other medications used, noting when they
present while intoxicated, or concerns
In 2011 a new formulation of
buprenorphine--naloxone film was released
in Australia. The two primary differences
with the film compared to the sublingual
tablet formulations are:
1. adhesion to the sublingual or buccal
membranes resulting in a formulation
that is easier to supervise compared
with the slower dissolution times of the
2. child proof packaging.
Results of a randomised controlled trial
that examined switching patients from the
sublingual tablet to the film product found
no significant differences in patient ratings
of medication effect or dose requirements,
though shorter dispensing times were
identified with the new film product.55
Extended release naltrexone
Internationally there are several new
products available or under development
for opioid dependence. These include an
extended release naltrexone injection,
Vivitrol, licensed in the US for both alcohol
dependence and opioid dependence.56
This product aims to counter poor
compliance with the oral naltrexone
products. It is not available in Australia yet.
The 380 mg extended release naltrexone
injection is administered as a gluteal
injection administered every four weeks.
Research is continuing with a
buprenorphine implant that delivers
buprenorphine over a six month period.
Clinical trials have found that the
implants are as effective as sublingual
buprenorphine--naloxone56 and superior
to placebo treatment. An implantable
product would represent opportunity for
improved compliance and reduce concerns
about diversion of buprenorphine. It is not
available in Australia yet.
New guidelines in 2013
New national guidelines for methadone
and buprenorphine are currently being
developed and are due to be released in the
first half of 2013. Areas under review include
supervision requirements with Suboxone for
low risk patients groups.
References available on request
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