Heroin/Opioid misuse Flashcards
Definition of opioid abuse?
Continuous opioid use despite physical, psychological or social harm to the user
What are examples of opioids?
Heroin, morphine, methadone, buprenorphine
What are the main effects of opioid?
Analgesia Euphoric effect (the main reason why it is abused)
By which routes can opioids be taken?
IV, SC, intranasally, smoked
What are characteristic features of opioid dependence?
- Drug craving / compulsion to take substance
- Maladaptive behaviour focused on obtaining opioids at any cost
- Difficulty in controlling use
- Physiological withdrawal state
- Tolerance (need increased dose for same effect)
- Neglect of alternative pleasures and interests
- Persistence of use despite harm to themselves or others
What are the three major symptoms of opioid overdose?
- pinpoint pupils
- unconsciousness
- respiratory depression
What are symptoms of acute opioid withdrawal?
- Sweating
- Watering eyes
- Rhinorrhoea and coughing
- Yawning
- Feeling hot/cold
- Anorexia
- Abdominal cramps
- Nausea, vomiting and diarrhoea
- Tremor
- Goosebumps
- Tachycardia and HTN
- Insomnia, restlessness, anxiety and irritability
- Generalised aches and pains
- Dilated pupils
- Increased bowel sounds
How soon can acute heroin withdrawal symptoms start to improve?
after 5 days
How soon can methadone withdrawal symptoms start to ease?
10-12 days
How long can opioid cravings last for after withdrawal?
Up to 6 months
What health complications are there with opioid dependence?
- Death overdose, suicide accidents, health-related complications
- Skin infection at injection sites (can be serious e.g. necrotising fasciitis)
- Sepsis
- Infective endocarditis
- HIV infection
- Hepatitis A, B, C infection
- TB
- Venous and arterial thromboses (due to poor injecting techniques)
- Poor nutrition and dental disease
What social complications can occur with opioid dependence?
- Crime
- Relationship problems
- Child protection issues
- Homelessness and deprivation
- Working in sex industry
What psychological complication scan occur with opioid dependence?
- Craving
- Guilt
- Anxiety
- Cognitive impairment and memory loss
How may opioid dependence present in primary care?
- Direct request for help with their dependence
- Medical complication due to their dependence
- Clinical signs of opioid intoxication or withdrawal
- Social problems including forensic history
- Disclosing their opioid abuse whilst presenting for another problem
How would you assess for current opioid drug use?
Drug testing:
- Screening test - immunoassay and dipstick (these are quick, easy and cheap)
- confirmatory tests - gas or liquid chromatography and mass spectrometry
- oral fluid testing ( however, this only detects drug use in past 24-48 hours)
- hair testing - can detect drug use over past few months ( but can’t tell between continuous and sporadic use)
Which risks need to be assessed in opioid drug users?
Overdose risk Polydrug and alcohol misuse Unsafe injecting practices Unsafe sexual practices Risk of self harm or harm to others Risk to dependent children
What needs to be looked at in order to assess social functioning?
- partners, family, support
- housing
- education/employment
- domestic violence
- Benefits and financial problems
- childcare issues - pregnancy, parenting and child protection
What should be assessed in opioid users?
current drug use risk ( to self and others) Social functioning criminal involvement and offending physical and psychological health
What is the treatment of opioid intoxication?
1) ABCDE
2) Naloxone (is. pure opioid antagonist to reverse opioid intoxication) (route: IV best, IM or SC if venous access difficult)
3) supportive measures - maintain airway, ventilation, IV fluids
What is the treatment of opioid dependence?
detoxification
induction and maintenance substitute prescribing
How long does it take to lose tolerance to methadone?
3 days
If someone stopped taking methadone and wanted to restart it after 3 or more days what would you do?
Prescribe them a lower dose than before to reduce risk of overdose
what are the two main treatment options for heroin detox?
Methadone
Buprenoprhine
What else should be delivered alongside the medication during detox?
Psychological interventions - CBT
keyworker support
When an opioid user asks for detox, what has to be considered when assessing suitability?
- Patient COMMITTED and fully informed??
- Does patient understand the physical and psychological aspects of withdrawal and how they can be managed?
- Understand increased risk of overdose and death if use illicit drug whilst on detox medication
- High risk of relapse been explained?
- Adequate social support available post detox??
What are the aims of pharmacological treatment for opioid detoxification?
- Reduce or prevent withdrawal symptoms
- Provide opportunity to stabilise drug intake whilst breaking with illicit drug use and associated unhealthy risk behaviours
Which medication is first line for opioid detox (despite them both appearing to be equally effective)?
methadone
What does treatment with a. drug substitute help protect against?
Risk of overdose
Bloods-borne infection
Risk of offending
With methadone - when is the risk highest for overdose?
On induction and during the first 2 weeks of treatment
What increases the risk of overdose when on methadone for detoxification?
o Low opioid tolerance o Other CNS Depressants e.g. alcohol, benzos o Initial dose is too high o Slow methadone clearance o Polysubstance abuse
How do you reduce the risk of toxicity with methadone?
- Identifying high-risk patients
- Avoid starting the patient on too a low a dose
- avoid rapid increases of dose
- explain and educate patients and careers on the early signs of overdose
Why does buprenorphine have reduced risk of overdose during induction of the medication for detoxification?
As it has mixed agonist and antagonist properties at opioid receptors, so an increased dose does not produce more intense opioid effects
What are downsides with using buprenorphine for opioid detox?
- May interact with any HIV medications
- More risk of misuse than methadone
What pharmacological medications can be used to treat any withdrawal symptoms that may be experienced?
- Antidiarrhoeals (Loperamide) for diarrhoea
- Metoclopramide, Prochlorperazine for nausea, vomiting and stomach cramps
- Mebeverine for stomach cramps
- Diazepam or Zopiclone for agitation, anxiety and insomnia
- Paracetamol and NSAIDs for muscle pains and headaches
What medication can be prescribed to prevent replaces of opioid use?
Naloxone
