23 - Prescribing psychotropic medications in patie

Prescribing psychotropic medications in patients with opiate dependence

Addictions and substance misuse CHAPTER 4 Prescribing psychotropic medications in patients with opiate dependence General psychiatrists often see and treat patients with addictions and psychiatric comorbidity. Prescribing guidelines regarding the treatment of comorbid psychiatric conditions pharmacologically can be found in the British Association of Psychopharmacology guidelines for substance misuse.79 Some general guidance is as follows: ■ ■Prescribers should be cautious about prescribing sedating medications because of the increased risk of respiratory depression. For example, pregabalin greatly increases the risk of overdose death.37,80 Pregabalin and olanzapine also appear to have an abuse liability in the opioid-­dependent population.81,82 ■ ■Patients with opiate dependence suffer disproportionately from depression – about half of those entering treatment will meet the criteria for depression. They may require 20–50% higher doses of methadone than non-­depressed patients to stabilise83 but stabilisation may afford remission in a majority of cases.84 There is limited clinical trial evidence of low to moderate quality regarding antidepressant use in opioid dependence which suggests that it is of limited benefit for either mood or drug use.79,84 Positive studies have largely been those using medication with varied pharmacology such as tricyclic antidepressants (TCAs).84 However, TCAs are not recommended in people with comorbid substance misuse because of their cardiotoxicity,79 although lofepramine can probably be used if available.85 The recommended approach to ­treatment of depression based on the evidence includes stabilising the patient on OST first, then if depression persists trying an SSRI because of their relative safety, but considering mixed pharmacology antidepressants as a second-­line should the patient fail to respond.84 Sertraline is probably the drug of choice in OST-­treated patients as it has limited interaction potential. Table 4.18  Treatment of withdrawal symptoms in people taking opioids. Adapted from Department of Health and Social Care (2017).8 Symptom Treatment Diarrhoea Loperamide 4mg then 2mg after each loose stool; maximum 16mg daily for up to 5 days Nausea, vomiting Metoclopramide 10mg tds for a maximum of 5 days or prochlorperazine 5mg tds or 12.5mg IM bd Abdominal cramps Mebeverine 135mg tds Agitation, anxiety and insomnia Diazepam up to 5–10mg tds when required or zopiclone 7.5mg nocte for patients with a history of benzodiazepine dependence Muscular pains and headaches Paracetamol, aspirin or non-­steroidal anti-­inflammatories Topical rubefacients can be helpful in relieving muscle aches from methadone withdrawal.