Remplacement de l'héroïne par la buprénorphine

Qu'est-ce que l'héroïnomanie ?

If you are addicted to heroin it means that you develop withdrawal symptoms within a day or so of the last dose. These symptoms are listed in the separate leaflet called Medicines for Drug Dependence. If you are addicted to heroin you need a regular dose to feel 'normal'.

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Traitement et médicaments

Que peut-on attendre d'une consultation en pharmacie ?

Pharmacy First est un service qui vous encourage à contacter votre pharmacien avant de prendre rendez-vous avec un médecin pour des problèmes de santé mineurs. Bien que les pharmaciens ne puissent pas diagnostiquer ou traiter tous les problèmes de santé, ils sont formés pour prendre en charge une série de maladies mineures et fournir des conseils d'experts. Mais que se passe-t-il lors d'une consultation en pharmacie ? Nous avons demandé à un expert de nous expliquer le processus.

par Victoria Raw

Traitement et médicaments

Antibiotiques

Les antibiotiques sont un groupe de médicaments utilisés pour traiter les infections causées par des bactéries et certains parasites. Les antibiotiques ne sont pas efficaces contre les infections causées par des virus, comme le rhume ou la grippe. Les antibiotiques ne doivent être prescrits qu'en cas d'infections bactériennes graves ou d'infections bactériennes chez les personnes ayant des problèmes de système immunitaire, car de nombreuses infections guérissent d'elles-mêmes. L'utilisation correcte des antibiotiques est absolument essentielle pour contribuer à réduire la résistance aux antibiotiques. Les bactéries deviennent résistantes aux antibiotiques avec le temps, ce qui les rend moins efficaces. L'Organisation mondiale de la santé (OMS) affirme que "le monde doit de toute urgence changer la manière dont il prescrit et utilise les antibiotiques", car la résistance aux antibiotiques est une menace mondiale majeure.

par le Dr Philippa Vincent, MRCGP

What is buprenorphine?

Buprenorphine is an opioid drug that is similar to heroin. It can be prescribed. If you take buprenorphine, you are unlikely to develop withdrawal symptoms if you stop heroin (or the withdrawal symptoms are much less severe). It also helps to reduce cravings for heroin. The drug most commonly prescribed as a substitute for heroin is methadone. On average, methadone tends to work better than buprenorphine in helping people to keep off heroin. However, buprenorphine is still a good treatment and some people prefer it because:

• They feel more 'clear-headed' with buprenorphine than with methadone.

• They have difficulties using methadone.

• They may be on other medication which interacts with methadone.

• Buprenorphine is possibly safer if taken in overdose than methadone.

If you take buprenorphine (or methadone) under supervision from a doctor instead of street heroin, you are:

• Ils ont plus de chances de pouvoir s'éloigner de la "scène de la drogue" de la rue.

• Il est probable que vous vous sentiez mieux dans votre peau.

• Plus de chances d'être en mesure d'arrêter définitivement la drogue.

Who prescribes buprenorphine, and when?

Many GPs will refer you to a community drug team to be assessed. Following assessment, the community drug team may prescribe buprenorphine. Some GPs work in a 'shared care' arrangement and will prescribe whatever is recommended for you by a community drug team. Some GPs who are specially trained may assess and prescribe buprenorphine without the need for referral.

Assessment
This usually includes:

• Prendre des renseignements sur votre état de santé et votre situation sociale.

• Taking details of your past and current drug taking and whether buprenorphine is needed or appropriate.

• Un examen.

• Un test d'urine (ou un prélèvement buccal) pour confirmer les drogues que vous prenez.

• Une évaluation de ce dont vous pensez avoir besoin à l'heure actuelle.

Si vous vous êtes injecté des drogues telles que l'héroïne, il est également courant de conseiller :

• Une analyse de sang qui comprend un test de dépistage du VIH, un contrôle de la santé du foie (tests de la fonction hépatique) et un contrôle de l'hépatite B et de l'hépatite C.

• Vaccination contre l'hépatite A, l'hépatite B et le tétanos (si l'on n'a pas été vacciné auparavant).

• Le cas échéant, une vaccination contre l'hépatite B pour votre partenaire et vos enfants.

• Sur les dangers de l'injection, sur les dangers de l'utilisation d'aiguilles et de seringues partagées et sur d'autres moyens de réduire les risques pour soi-même.

Starting off with buprenorphine

Buprenorphine is usually started some time after assessment when the results of the urine test are back. An initial dose is chosen, depending on current usage of heroin (or methadone).

Taking buprenorphine

Buprenorphine is a tablet which you put under your tongue. The tablet dissolves over 3-7 minutes and is absorbed straight into the bloodstream from your mouth. (The tablets do not work if you swallow them into the stomach.) It is usually prescribed as a once-daily dose. You will usually be asked to take it under the supervision of the pharmacist who dispenses the buprenorphine to you. This means there can be no doubt about how much you take at each dose. This supervision may be relaxed after a few months if you are taking a regular maintenance dose. The taste of buprenorphine can be quite bitter.

The first dose

The timing of the first dose is important.

• If you are taking heroin - you take the first dose of buprenorphine at least eight hours after taking your last dose of heroin.

• If you are taking methadone - you take the first dose of buprenorphine between 24 and 36 hours after your last dose of methadone.

The reason for these timings is because, for buprenorphine to work well, you need to take it when your body has low levels of heroin or methadone. So, the aim is to take the first dose only when you feel some withdrawal symptoms starting. This tends to be about eight hours after the last dose of heroin and longer after the last dose of methadone. If you take buprenorphine sooner, it can actually cause withdrawal symptoms suddenly to develop.

Getting to the right dose

The initial dose will usually need to be increased. You will usually be given a higher dose on the second and third days, by which time you should not be feeling any withdrawal symptoms. It is very important that you do not take any heroin or methadone during this time, as this will cause you to feel ill - as though you are withdrawing. Your dose may need to be increased again to prevent symptoms of craving but most people feel they have the correct dose within the first week.

Maintien et arrêt ("désintoxication")

Once established on a regular dose, most people stay on buprenorphine for a long period of time or even long-term. This is called maintenance and helps you to keep off street drugs. Some people gradually reduce the dose and come off it. This is called detoxification, or 'detox'. However, it usually takes several months and sometimes years, before most people are ready to consider 'detox'. It is often safer to stay on buprenorphine than to 'detox' before you are ready.

Buprenorphine-naloxone

Buprenorphine has been combined with another medicine called naloxone (brand name Suboxone®). It has been produced in the form of a tablet which is dissolved under the tongue. Naloxone blocks the action of buprenorphine and the effect of the combination is that, if a person is tempted to take more than the recommended dose (particularly if they crush the tablet and try to inject it), they will start to have withdrawal effects.

Some other points about taking buprenorphine

• Some people feel uncomfortable during the first 2 to 3 days. Do not be tempted to take heroin on top.

• Some other medicines may interfere with buprenorphine - for example, some antidepressants. Tell the doctor who prescribes buprenorphine if you are taking any other medicines. However, most prescribed medicines can be taken in the normal way.

• You are more likely to succeed in staying off heroin if you have support and counselling in addition to taking buprenorphine or methadone. This may be from a local drug community team (or similar). Self-help groups or other agencies may also be of help. It is much harder to 'do it alone' - so do go for counselling and help if it is available in your area.

• You will be asked to give a urine sample from time to time by the prescribing doctor.

• Other street drugs such as benzodiazepines ('benzos') and alcohol can also affect buprenorphine. So, it is best not to take any other drugs, and don't drink too much alcohol.

• Driving. If you use heroin or other opiates such as buprenorphine, you should inform the Driver and Vehicle Licensing Agency (DVLA). You are likely to be banned from driving. However, if you are on a supervised buprenorphine programme, you may be allowed to drive again subject to an annual review.

• Pregnancy. If you become pregnant you should not suddenly stop your buprenorphine withdrawal programme. It is riskier to stop buprenorphine suddenly than to continue on your regular dose. Discuss the situation with your doctor. If you are taking buprenorphine combined with naloxone, you may be advised to switch to buprenorphine without naloxone. Studies suggest it is safer to continue with buprenorphine until the baby is born. However, if you want to stop it during pregnancy, the risk of withdrawal problems is lowest in the 3-6 months (the second trimester).

• Keep buprenorphine and any other drugs out of reach of children.