Opioid Addiction Flashcards
Is physical dependence/tolerance to opioids necessary/sufficient for diagnosis of opioid use disorder?
no
Criteria for Substance Use Disorder
- taking larger amounts or longer than intended
- attempt to quit or control use
- much time spent using or recovering
- cravings
- inability to meet responsibilities at home, school, employment
- interpersonal/relationship problems
- give up or cut back pleasurable activities to use
- place oneself in danger d/t use
- use resulting in physical or psychological illness/harm
- tolerance to effect of substance
- withdrawal sx when using or using less
Mild/Mod/Severe?
Mild 2-3
Mod 4-5
Severe 6+
What are 3 specific findings of opioid withdrawal?
Piloerection
Mydriasis
Yawning
What are other sx of opioid withdrawal?
- GI: cramps, diarrhea, N/V
- Flu-like: lacrimation, rhinorrhea, diaphoresis, shivering, piloerection, sneezing, myalgia, arthralgia, muscle cramps
- Sympathic/CNS arousal: mydriasis, HTN, tachycardia, anxiety, irritabiltiy, insomnia, agitation, restlessness, tremor, low grade fever
- Other: yawning, opioid craving
What does COWs stand for?
Chronic Opioid Withdrawal Scale
What is COWs used for?
- Severity tool
- NOT diagnostic tool
*Must have diagnosis of opioid withdrawal before using tool
Can methadone be administered in inpatient setting?
Yes, IF pt is admitted for a condition other than opioid use withdrawal
Inpatient Goal of mgmt of acute opioid withdrawal?
- focus on acute medical problem requiring hospitilization
- decrease leaving against medical advice
- facilitate open discussion about addiction
- improve pt/provider relationship
- help facilitate referral to substance us disorder tx after hospitlization
What are NOT the goal of inpatient mgmt of acute opioid withdrawal?
To cure addiction or eliminate cravings
Full agonist?
Morphine
Oxycodone
Methadone
Partial agonist?
Buprenorphine
Antagonist?
Naloxone
Naltrexone
Methadone (class, onset, duration, dosing)
Full opioid agonist
Full SYNTHETIC opioid
Onset: 30-60min
Duration: highly variable; tx pain before addiction
Dosing: 20-40mg
Buprenorphine
- PARTIAL AGONIST
- Mono therapy = safe in pregnancy
- Good SL and IV bioavailability
- HIGH AFFINITY for opioid receptor
- “ceiling effect”
What is the ceiling effect of Buprenorphine?
Effect of buprenorphine plateau and will ONLY provide withdrawal relief and pain relief
It will NOT provide euphoria, respiratory depression or death
What do you want to make sure before admin buprenorphine?
Pt is in withdrawal or has not been using opioids
*want to avoid going from full agonist –> partial agonist
What is suboxone?
- Buprenorphine + Naloxone
- Naloxone has good IV bioavailability
- burprenorphine doing affect
What is the purpose of combining nalaoxone w/ buprenorphine?
- Nalaxone is there so if a pt decides to melt, crush, mix suboxone, they will get the naloxone component when they inject it via IV
- reduces street value and misuse potential
What is naloxone?
- Full antagonist w/ strong affinity to receptor
- Reverses opioid OD by displacing opioid agonist (heroin) from receptor
- will induce withdrawal sx if opioid remain on receptor when given
- BLOCKS opioid receptor
What is naltrexone?
- Pure opioid antagonist
- comes PO and IM (Vivitrol)
Can pt be admin Vivitrol if they’re still taking opioids?
No. Must be opioid free for minimum 7-10days before tx
What are some “comfort meds” when treating opioid withdrawal?
- Clonidine (hyperadrenergic state)
- NSAIDs (muscle cramps/pain)
- Benzos (insomnia)
- Dicyclomine (abd cramps)
- Bismuth subsalicylate or other anti-diarrheals
Goals of maintenance therapy?
- alleviate withdrawal
- eliminate drug craving & opioid use
- opioid blockade
- normalize brain reward pathways & behavior
Need higher dose of methadone or buprenorphine to achieve 2->4
How does an opioid agonist like methadone and buprenorphine, tx opioid use disorder?
It keeps pt in normal phase (no euphora, no withdrawal) long enough till their BEHAVIOR changes and their dopaminergic system rewires itself to have normal life again.
Then slowly start removing the methadone or buprenorphine slowly over time
Methadone Maintenance involves…?
- pt have to go to methadone clinic EVERYDAY
- daily nursing assessment
- weekly individual and/or group counseling
- random supervised drug testing
- psychiatric services
- medical services
- methadone dosing
Benefit of Methadone
- increase overall survival
- increase tx retention
- increase employment
- decrease illicit opioid use
- decrease criminal activity
- improved birth outcomes
Methadone Maintenance Limitation
- Highly regulated
- Limited access
- Inconvenient and highly punitive
- Mixes stable & unstable pt
- Lack of privacy
- No ability to “graduate” from program
- Stigma
Strategies to Address Overdose
- prescription monitoring program
- prescription drug take back events
- safe opioid prescribing education
- opioid agonist tx
- supervised injection facilities
- OD education and naloxone distribution
Opiates on tox screen
POSITIVE
comes from poppy seeds
Opium, morphine, codeine, thebaine, diacetylmorphine, mitragyna speciose leaves, slavia divinorum…are examples of what?
Opiates
Semi-synthetic opioids on tox screen
MIGHT be POSITIVE
Created from natural opiates or morphine esters & adjust in the lab
Examples of Semi-synthetic opioids
Hydromorphone
Hydrocodone
Oxycodone
Oxymorphone
Synthetic opioids on tox screen
NEGATIVE
created in the lab
*need specific test for specific substance; order individually
Examples of synthetic opioids
Fentanyl
Tramadol
Methadone
Buprenorphine
Which opioid is the DRIVER of OD deaths in MA?
FENTANYL
specifically illicitly made fentanyl mixed w/ heroin
Is fentanyl more potent than heroin?
YES 50-100x more potent
MOA fentanyl
Rapid onset of potent full mu agonist activity
Transdermal for chronic pain
IV or lozenge/lollipop
What schedule is fentanyl?
schedule II
What schedule is buprenorphine?
schedule III
What is acetyl fentanyl?
- illicitly produced fentanyl anolog
- more potent than heroin, but less potent than fentanyl
- assoc w/ relatively isolated OD outbreaks
Why is there a surge in OD?
- high rate rx opioid use compounded by diversion
- transition to heroin
- change in heroin & drug supply to include fentanyl
- polypharmacy (benzo + opioid)
Which tx option of opioid withdrawal is safe in pregnancy?
a. methadone
b. buprenorphine
c. naloxone
d. naltrexone
b. buprenorphine
Which of the following will be negative on tox screen?
a. methadone
b. morphine
c. codeine
d. thebaine
A. Methadone
