13 - Opioid-Related Disorders

Question 1

for chronic opioid noncancer pain, keep opioid dose below _____

Answer 1

90 mg MED (morphine equivalents daily)

Question 2

When tapering opioids, what is a good taper rate to use?

Answer 2

lower dose by 5-10% every 2-4 weeks and regularly monitor

Question 3

What is the most effective tx for opioid use disorder?

Answer 3

maintenance therapy with a long acting agonist like methadone or partial agonist buprenorphine

Question 4

Why should you avoid detoxification for those in pregnancy?

Answer 4

risk of spontaneous abortion

Question 5

What can clonidine help with?

Answer 5

it decreases neuronal output of NE which can blunt the noradrenergic symptoms of withdrawal such as chills and flushing

Question 6

s/e of clonidine

Answer 6

hypotnesion

Question 7

______ is used off-label for out-patient detox

Answer 7

buprenorphine

Question 8

What is naloxone?

Answer 8

opioid antagonist

Question 9

Why is buprenorphine combined with naloxone? (Suboxone)

Answer 9

• naloxone is an opioid antagonist with no action taken orally
• it is combined with buprenorphine to prevent abuse
• if taken intranasally or injected it will induce opioid withdrawal symptoms in opioid-tolerant individuals

Question 10

Typically increase the dose of suboxone over ____ days

Answer 10

3-5

Question 11

Typically taper the dose of suboxone over ___ weeks

Answer 11

2-4

Question 12

Why is methadone seldom used in the acute setting?

Answer 12

increased risk of sedation and respiratory depression

Question 13

How can we manage nausea, diarrhea and muscle aches associated with opioid withdrawal?

Answer 13

• antiemetics (ginger over gravol bc of abuse potential)
• loperamide
• NSAIDs or espom salts

Question 14

What are the current maintenance therapies for opioid use disorder?

Answer 14

1st line = suboxone
2nd line = methadone
3rd line = slow-release morphine (off-label use)

Question 15

MOA of buprenorphine

Answer 15

partial agonist at the mu opioid receptor and an antagonist at other receptors (ex. kappa)

Question 16

MOA of methadone

Answer 16

mu opioid receptor agonist

Question 17

Min length of treatment?

Answer 17

12 months, potentially lifelong

Question 18

Why is suboxone better than methadone?

Answer 18

safer during initiation and less likely to cause DIs, erectile dysfunction, or cognitive/psychomotor impairment

Question 19

Naltrexone is usually just used for ______ treatment

Answer 19

adjunctive

Question 20

What are the symptoms of opioid toxicity/overdose?

Answer 20

respiratory depression (shallow breathing, respiratory rate < 12 breaths per minute), constricted pupils, pale/cold skin, blue fingernails and being unresponsive to shaking or pain

Question 21

How do you treat opioid toxicity/overdose?

Answer 21

• While awaiting EMS, give CPR and naloxone (NAPRA schedule 2) which is an opioid antagonist
• Repeat dose every 3-5 minutes if still unresponsive or overdose symptoms come back
• Naloxone comes as IM or IN

Question 22

How do we treat opioid use disorder in pregnant patients?

Answer 22

Buprenorphine (w/o naloxone) may be as safe and effective as methadone. Can get through SAP in Canada but if not available can just give Suboxone as withdrawal carries a great risk of harm to fetus than naloxone exposure

Methadone is ok to use

Question 23

How do we treat opioid use disorder in breast feeding?

Answer 23

Methadone is compatible ( > 100 mg/day) can increase risk of sedation and respiratory depression

Transfer of buprenorphine into breast milk is lower than methadone

Both are safe provided mom is HIV -ve