Dependence: Drugs (Opiates) Flashcards
Define
Opiate (derived from poppy seeds, Papaver somniferum) types:
- Heroin (aka: brown, smack, horse, gear, H, skag)
- Morphine, diamorphine
- Pethidine
- Codeine, dihydrocodeine
- Heroin profile (µ (mu) opiate agonist -> immediate euphoria, diminished pain sensation, feelings of detachment):
- Administration routes (often starts with smoking and progresses to IV to skin popping)
- Smoking (‘chasing the dragon’)
- Sniffing (‘snorting’)
- Oral
- IV (‘mainlining’) – many complications… see right (abscess, cellulitis, DVT, emboli, septicaemia, HCV)
- IM or SC (‘skin popping’)
- HCV is the most serious infection
Symptoms and signs
Intoxication
- ‘Pinpoint pupils’
- Itching and scratching
- Sedation
- Somnolence
- Lower blood pressure
- Slower pulse
- Hypoventilation
- Overdose
- Miosis
- Respiratory depression
- Altered mental status
ANTIDOTE: Naloxone (opioid antagonist)
WARNING: after giving naloxone, patients may be plunged into withdrawal
Acute Withdrawal Syndrom
- Craving
- Yawning, sneezing, cool and clammy skin
- Dilated pupils, cough
- Abdominal cramps, N+V
- ‘The Runs’- diarrhoea, vomiting, lacrimation, rhinorrhoea
- Piloerection -> gooseflesh
- Tremor, sleep disorder (insomnia), restlessness, anxiety, irritability, hypertension
- Dysphoria
- Starts: 6 hours after injection
Peak: 36-48 hours
Improves by 1 week - WILL NOT KILL JUST NOT NICE
Complications
- Psychiatric: overdoses, depression, psychosis
- Forensic: past custodial sentences, probation, community service
- Social: family problems, unemployment, accommodation issues, financial problems
- Poor nutrition, dental caries, signs of neglect, needle tracks,
- Local complications: skin abscesses, cellulitis, DVT, emboli
Systemic complications: Septicaemia, Infective endocarditis, blood-borne infections (Hep B/C and HIV - Hep C is most common), Increased risk of overdose
Investigations
Physical exam, bedside/basic obs, biochemical, imaging:
o Physical examination (establish baseline physical state)
o Urine drugs screen (2 days in the urine)
o U&E (features of malnutrition)
o FBC (anaemia due to malnutrition or signs of infection)
o LFTs (may impact medication dosing)
o Blood borne infections (RPR, hepatitis serology, HIV test)
Management
Similar to alcohol regime – triage to admit and treat – MDT APPROACH:
General recommendations:
- Appoint a key worker (single point of contact) and develop a care plan:
- Agreed treatment and recovery goals
- Specific, clear, action to be taken to achieve those goals
- Clarity about who is taking the actions
- Monitoring of progress
Harm reduction (pragmatic approach) – complete abstinence unlikely, be pragmatic:
- Needle-exchanges for IVDUs
- Offer vaccinations and testing for blood-borne pathogens
- Health education (i.e. sleep hygiene, support groups *, diet, etc.)
· * SMART recovery
· * Narcotics Anonymous
Pathophysiology of withdrawal = ‘noradrenergic storm’
- Discuss if they want to undergo an Opioid Substitution Therapy (OST) ‘withdrawal’ or ‘maintenance’ regimen:
1st -> maintenance – the goal = stabilise lifestyle and reduce harm
2nd -> detoxification – the goal = detoxification and abstinence
· Maintenance on OST is required before you start on detoxification
Opioid Substitution Therapy (admission may be necessary):
- 1st -> OST given in controlled environment (for 3-6m)
- 2nd -> if suitable -> ‘take-home’ some medications
Maintenance:
- 1st line: methadone (liquid) or buprenorphine (sublingual) patient preference
- If still using heroin -> low-dose methadone
- If wanting to stop heroin completely -> high-dose methadone OR buprenorphine
- Offer naloxone to take home with them and training on when/how to use it
Detoxification – must be committed to stopping (committed, fully aware, stable environment):
- Must be on a stable OST maintenance before you start detoxification
- Lasts 12w as an outpatient (can be inpatient if deemed appropriate)
- nform them they will lose tolerance so if they start again, they should take a lot less
· 1st line: methadone (liquid) or buprenorphine (sublingual)
o Offer naloxone to take home with them and training on when/how to use it
· 2nd line: lofexidine (alpha-2 agonist) – indications: rapid detox, mild dependence, preference
Withdrawal symptom medications:
- Clonidine or lofexidine (alpha-2 agonist)
- Anti-diarrheals (loperamide), anti-emetics (metoclopramide), etc.
- Ultra-rapid detoxing regimens do exist but are not pleasant and not routinely offered (using naloxone)
- Follow-up care (with the Drugs and Alcohol Service) – for at least 6 months:
- Look for signs of withdrawal Check other drug use (urine drug screens)
- ECG (QTc) for those on methadone CBT (to reduce relapse chance)
- Contingency management (through frequent screenings à less frequent screenings as time goes on):
· Incentives for -ve drug test results
· Urinalysis preferred
