Opioid Use/Abuse Flashcards
1
Q
Opioids
A
- Made to resemble structure of naturally occurring opioids in body
- Used for pain relief, cough suppression
- Abuse potential
2
Q
Opioid Receptors
A
- Mu, delta, and kappa
- Addictive effects occur through mu receptor activation
- Role of kappa and delta in addiction isn’t well defined
3
Q
Opioid ADME
A
- 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
4
Q
Opioid Tolerance
A
- 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
5
Q
Physical Dependence vs Syndrome of Dependence
A
- 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
6
Q
Withdrawal
A
- 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
7
Q
Opioid Overdose
A
- Respiratory depression (leads to death)
- Coma, hypotension, pinpoint pupils
- Dilated pupils when hypoxic
- Noncardiogenic pulmonary edema
- Naloxone given as antidote (not effective for buprenorphine)
8
Q
DSM-V Criteria for Opioid Use Disorder
A
- 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
9
Q
Opioid Dependence Treatments
A
- Short-term: medical withdrawal opioid and non-opioid (detox)
- Long-term: opioid antagonist, opioid agonist or partial agonsit
10
Q
Medical Withdrawal Options
A
- Methadone: 40 mg/day and taper
- Buprenorphine: variable dose and taper
- Helps with less withdrawal symptoms
- Short vs prolonged tapers
- HUGE relapse rates
11
Q
Non-Opioid Detox
A
- 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)
12
Q
Naltrexone
A
- 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
13
Q
Methadone
A
- C II
- Highly regulated
- Narcotic Treatment Program settings
- Better retention than buprenorphine
14
Q
Buprenorphine
A
- C III
- Prescribed from doctor’s offices
- Safer in overdoses
- Less NAS in pregnancy than methadone
15
Q
Obtain before Maintenance Therapy
A
- 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
16
Q
Methadone Dosing
A
- 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
17
Q
Methadone SE
A
- Minimal sedation once tolerance achieved
- Constipation: may need bowel program
- Increased appetite/weight gain
- Lowered libido
- QT interval prolongation
18
Q
Buprenorphine + Maintenance/Withdrawal
A
- 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)
19
Q
Non-Pharm Opioid Dependence Options
A
- 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
20
Q
Toxicology Screens
A
- 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
21
Q
Opioids + Pregnancy
A
- 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
22
Q
Methadone + Pregnancy
A
- 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
23
Q
NAS
A
- 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
24
Q
HIV + Opioids
A
- 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
25
Q
Methadone + Acute Pain
A
- 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
26
Q
Buprenorphine + Acute Pain
A
- 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
27
Q
Opioid Dependence + Chronic Pain
A
- 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.
28
Q
Adolescents + Opioid Dependence
A
- 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