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Little gems: how hot are you on heroin misuse?

Test your knowledge for the nMRCGP with this little GEM from GPnotebook

Test your knowledge for the nMRCGP with this little GEM from GPnotebook

Q A 20-year-old male heroin addict has presented for the first time this afternoon. What are important aspects to consider for this first consultation?

A It is important to:

• obtain an adequate drug history: type of drug, injected or taken by other route; length of drug abuse; effects of withdrawal; how the patient supports his habit

• take measures to limit harm – does the patient practise safe sex?– does the patient share needles/use 'shared' needles?– does the patient use a needle exchange scheme/counselling agency?– what family support is available?

• agree a contract with the patient – agree what is expected from the patient, what treatment is offered by the practice, the keeping of appointments, and so on – if the patient is referred for treatment, then agreement is still required about future contacts with the practice

• register with regional drug misuse database/notification of addicts

• refer if specialised treatment is not available from the practice

Q This man was referred to the community drug team and is to start subutex. What's that?

A Subutex is the proprietary name for a preparation of sublingual buprenorphine used to treat opioid dependence.

Buprenorphine is a semi-synthetic opioid derived from the morphine alkaloid thebaine. Buprenorphine:

• is a mixed agonist-antagonist and its primary action is as a partial opiate agonist

• produces opioid responses while also reducing the effect of additional heroin, methadone or morphine

• has low intrinsic agonist activity, only partially activating mu opioid receptors, and consequently high buprenorphine doses produce a milder, less euphoric and less sedating effect than high doses of other opioids such as heroin, methadone or morphine; but it exerts sufficient opiate effects to prevent or alleviate opioid withdrawal, including craving.

Q Is buprenorphine a more effective maintenance treatment than methadone?

A Cochrane evaluated the effects of buprenorphine maintenance against placebo and methadone maintenance in retaining patients in treatment and in suppressing illicit drug use. The meta-analysis found that:

• Buprenorphine is an effective intervention for use in the maintenance treatment of heroin dependence, but it is not more effective than methadone at adequate dosages.

• Buprenorphine is not significantly different from methadone in the impact on other substance use (such as cocaine, benzodiazepines, alcohol).

Q With similar outcomes, the choice between methadone and buprenorphine should be informed by other factors. What other factors may suggest use of buprenorphine over methadone?

A There's limited evidence of the superiority of either medication for particular subgroups, and the decision should be made in consultation with each patient after consideration of their relative merits

There appears to be increasing consensus among clinicians experienced in choosing both buprenorphine and methadone that:

• Buprenorphine may be better suited to those who wish to cease using heroin completely, as the blockade effects of even moderate dose buprenorphine interfere with the subjective effects of additional heroin use; in contrast, although high-dose methadone treatment is also suited to those who wish to stop using heroin, those patients who wish to continue to use heroin may prefer low-dose methadone treatment

• Withdrawal from buprenorphine appears to be easier than from methadone, and as such may be preferred for those considering a detoxification programme.

• The transition from buprenorphine to naltrexone can be accomplished much earlier than the transition from methadone to naltrexone, so those considering naltrexone treatment after detoxification may be better suited to buprenorphine

• Buprenorphine is less affected by interactions with hepatic enzyme inducers/inhibitors (anticonvulsants, rifampicin, ribavirin)

• Buprenorphine is less sedating than methadone; this may be positive or negative for different patients

This fortnightly series is based on GPnotebook Educational Modules (GEMs). The full version is available via GPnotebook Plus, a service free to UK medics at

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