Opioid Use/Abuse

Question 1

Opioids

Answer 1

• Made to resemble structure of naturally occurring opioids in body
• Used for pain relief, cough suppression
• Abuse potential

Question 2

Opioid Receptors

Answer 2

• Mu, delta, and kappa
• Addictive effects occur through mu receptor activation
• Role of kappa and delta in addiction isn’t well defined

Question 3

Opioid ADME

Answer 3

• First pass metabolism varies; buprenorphine for example is highly metabolized
• Analgesia lasts 3-6 hours, but constipation or respiratory depression could last longer
• Metabolized by liver
• Excreted in urine and bile
• Impaired liver function could increase [opioid] and renal dysfunction could accumulate metabolites

Question 4

Opioid Tolerance

Answer 4

• Need for more drug for same effect
• Occurs for euphoria, sedation, resp depression, vomiting, and analgesia
• Minimal tolerance to constipation, miosis, sweating
• Gradual increases in doses to gain such tolerance

Question 5

Physical Dependence vs Syndrome of Dependence

Answer 5

• Physical dependence: physiological change or adaption in an organism in response to repeated administrations
• Syndrome of dependence is group of signs/symptoms indicating a pattern of addiction

Question 6

Withdrawal

Answer 6

• Physically dependent on my agonist opioids stops suddenly or markedly decreases dose
• Usually begins 6-12 hours after last dose and lasts 5 days (short-acting opioids)
• Longer acting meds have less severe withdrawals but they last longer

Question 7

Opioid Overdose

Answer 7

• Respiratory depression (leads to death)
• Coma, hypotension, pinpoint pupils
• Dilated pupils when hypoxic
• Noncardiogenic pulmonary edema
• Naloxone given as antidote (not effective for buprenorphine)

Question 8

DSM-V Criteria for Opioid Use Disorder

Answer 8

• Substance use disorder spans range of problem (11 criteria)
• 2/11 criteria must be met for diagnosis
• 2-3 = mild; 4-5 = moderate; 6=< severe

Question 9

Opioid Dependence Treatments

Answer 9

• Short-term: medical withdrawal opioid and non-opioid (detox)
• Long-term: opioid antagonist, opioid agonist or partial agonsit

Question 10

Medical Withdrawal Options

Answer 10

• Methadone: 40 mg/day and taper
• Buprenorphine: variable dose and taper
• Helps with less withdrawal symptoms
• Short vs prolonged tapers
• HUGE relapse rates

Question 11

Non-Opioid Detox

Answer 11

• Clonidine: alpha 2 adrenergic agonist
• Approved for hypertension
• Helps relieve autonomic excess in withdrawal (anxiety, agitation, sweating, cramping)
• AE: Sedation, dry mouth, hypotension (limiting SE)

Question 12

Naltrexone

Answer 12

• Maintenance therapy option
• Blocks effects of opiate dose
• Prevent impulse use of drug
• Injectable naltrexone may help with adherence
• SE: hepatotoxicity
• Monitor: Liver fxn tests at baseline and every 3-6 mo
• Lack of compliance, works well with motivated patients

Question 13

Methadone

Answer 13

• C II
• Highly regulated
• Narcotic Treatment Program settings
• Better retention than buprenorphine

Question 14

Buprenorphine

Answer 14

• C III
• Prescribed from doctor’s offices
• Safer in overdoses
• Less NAS in pregnancy than methadone

Question 15

Obtain before Maintenance Therapy

Answer 15

• History
• Signs of dependence
• Urine toxicology
• Naloxone challenge can be given if unsure of dependence
• Obtain ECG before starting methadone in those with risk factors

Question 16

Methadone Dosing

Answer 16

• Target: 80-120 mg
• Stops withdrawal, avoids sedation/euphoria (reduce dosing if this is experienced)
• At beginning, only up dose every 5-7 days
• Monitor patient at least 2 hours after first dose
• 40 mg methadone will block withdrawal but no address craving

Question 17

Methadone SE

Answer 17

• Minimal sedation once tolerance achieved
• Constipation: may need bowel program
• Increased appetite/weight gain
• Lowered libido
• QT interval prolongation

Question 18

Buprenorphine + Maintenance/Withdrawal

Answer 18

• Preferred mixed with naloxone to reduce diversion
• SL tablets more abusable (only use in preggo and naloxone allergy)
• Partial agonist with longer half life to help decrease overdose and withdrawal
• Little effect on respiration on its one but in combination with other drugs can cause serious AEs or death (benzos)

Question 19

Non-Pharm Opioid Dependence Options

Answer 19

• Psychosocial services: required for opioid addiction treatment
• Individual and group therapy
• Family therapy
• 12 step
• Higher psychiatric severity patients more response to increases services
• Take-home medication very useful

Question 20

Toxicology Screens

Answer 20

• Gold standard
• Must be completely randomly and regular in drug abuse treatment
• Heroin excreted as morphine
• Poppy seeds can give trace amounts of codeine and morphine

Question 21

Opioids + Pregnancy

Answer 21

• Methadone is gold standard but buprenorphine is shown to be effective as well
• Removes mothers from drug-using environment and increases their likelihood to get obstetrical care
• Improves birth weights and maternal/fetal nutrition
• Opioids are not teratogenic

Question 22

Methadone + Pregnancy

Answer 22

• Maintenance is preferred
• Safest to withdrawal weeks 14-32
• Withdrawal can precipitate miscarriage in 1t trimester or premature labor in 3rd
• Less drop out rates than buprenorphine

Question 23

NAS

Answer 23

• Neonatal abstinence syndrome
• Irritability, fever, diarrhea, hyperreflexia, seizure
• Treat with tincture of opium or morphine
• Methadone and buprenorphine excreted in breast milk, encourage breast feeding
• Only methadone in breast milk thought to help with NAS

Question 24

HIV + Opioids

Answer 24

• HIV-associated pain can be a problem
• Avoid carbamazepine because methadone and buprenorphine metabolism can be induced
• Treat with anticonvulsant
• Few drug interactions between buprenorphine and antivirals

Question 25

Methadone + Acute Pain

Answer 25

- Usual methadone dose will not provide analgesia - Increasing methadone dose acts too slowly - Give regular methadone for addiction plus a short-acting medication for acute, severe pain

Question 26

Buprenorphine + Acute Pain

Answer 26

- Can be difficult to achieve adequate analgesia - Consider non opioid alternatives first - Severe pain: regional anesthetic, fentanyl, switch to full agonist and reintroduce suboxone when pain is resolved - Moderate: suboxone divided doses shown some benefit - Watch for relapse risk!! Short term scripts and coordinate care

Question 27

Opioid Dependence + Chronic Pain

Answer 27

- Treatment Agreement/Informed Consent advised - Chronic pain may do better with methadone maintenance - Suboxone could be used too - Patient needs to be willing to complete pill counts, refill verification, etc.

Question 28

Adolescents + Opioid Dependence

Answer 28

- Increasing problem that could lead to heroin use - Recommend non-pharm treatment following medical withdrawal - Office buprenorphine may be better than methadone - Extended medication assisted treatment (suboxone) shown to be better than detox