Opioid Use Disorder Flashcards
define opioid use disorder
problematic pattern of opioid use that leads to clinically significant impairment or distress
has to have at least 2 of the designated criteria, occurring within a 12mth period
list 3 characteristics of OUD
taking opioids in larger amounts/ longer time
significant amount of time spent trying to get them
cravings
persistent desire or unsuccessful efforts to get them
not doing major role obligations due to use
giving up social, occupational, or rec activities
continued despite persistent/ recurrent social/ interpersonal problems caused by opioids
continued despite knowing that it is a physical/ psyc problem
use in situations where it is physically hazardous
tolerance
withdrawal
define tolerance
needing increased amounts to achieve desired effect
diminished effect with continued use of same amount of opioid
define withdrawal
characteristic opioid withdrawal sx or
using the same or a closely related substance to relieve/ avoid sx
why is opioid withdrawal dangerous
tolerance may be lost rapidly (days) and when pt relapses and uses same amount as before, they can OD
describe some reinforcing effects of opioids
pain relief (analgesia), euphoria, warmth, numbness, relief of anxiety (anxiolytic)
describe some AEs of opioids
constipation, dry mouth, hypogonadism, weight gain, CNS/ respiratory depression
list 3 sx of withdrawal
Rapid HR
Sweating
Restlessness
Dilated pupils
Aches (bone/ joints)
Runny eyes and nose
Upset stomach
Tremor
Yawning
Irritability
Anxiety
Goosebumps
list 3 sx of OD
cyanosis, dizziness and confusion, can’t be woken up, choking/ gurgling/ snoring sounds, slow/ weak/ no breathing, drowsiness or difficulty staying awake
what to do if you suspect an OD
call 911, admin naloxone, stay with person until help arrives
how does naloxone work to prevent OD
rapidly reverses CNS and respiratory depression secondary to opioids by competitively booting opioids out of receptors + binding to them instead as an antagonist
naloxone IM onset
2-3min
currently, nasal naloxone spray kits are covered for pts with
NIHB coverage
when should a second dose of naloxone be administered?
if the person has not responded within 2-3 minutes
what tx is the lowest intensity for OUD
withdrawal management
what is the gold standard for OUD tx
agonist therapies
what are the 2 agonist therapies for OUD
buprenorphine/ naloxone or methadone
when should harm reduction be offered in OUD
at all stages of the treatment intensiyt spectrum
what is the main downside to withdrawal management for OUD
risk of relapse after losing tolerance, resulting in increased mortality
list the 3 advantages of OAT over withdrawal management
↑ treatment retention, substance abstinence than illicit opioids, ↓ risk of morbidity/ mortality
buprenorphine MOA
Partial mu opioid receptor agonist with high binding affinity, antagonist at kappa receptor
very strong binding affinity
what are the 4 advantages of buprenorphine’s strong binding affinity
Good at blocking effect of other opioids = ↓ euphoria from illicit substances, important to consider when managing acute pain (↓ pain control)
Slow dissociation = long relief of withdrawal sx (can miss up to 5 consecutive days before reinitiation required)
Ceiling effect for respiratory depression
standard doses are well below legal threshold for those that are opioid naive
what is the major con of buprenorphine/ naloxone
will have precipitated withdrawal if used too soon after last full agonist dose
which is the preferred tx option now? suboxone or methadone
suboxone
how is suboxone administered
dissolved sublingually, then swallowed
suboxone…
1. is absorbed SL
2. is made in noncrushable tablets
3. is an orally absorbed substance
4. has naloxone, which is responsible for the withdrawal effect
3
why is naloxone present in suboxone
to prevent diversion by injection
is not absorbed PO if the tablet is taken appropriately, but will be absorbed if crushed and injected = unpleasant effects
how is suboxone induction done? what are the 2 options?
pt must be in mod withdrawal (COWs scale) during clinical induction, or can do a microinduction to avoid waiting until mod withdrawal
may get to max tolerated dose in 24-72hrs
how soon can suboxone be tolerated to max tolerated dose
24-72hrs
can patients use illicit opioids during microinduction with suboxone?
yes
what are 2 other formulations of buprenorphine
probuphine and sublocade
what is probuphine
a buprenorphine subdermal implant
who is probuphine indicated for
for pts with OUD that are clinically stabilized on no more than 8mg of SL buprenorphine for the last 90 days
what is sublocade
a buprenorphine ER injection
sublocade is indicated for pts who
have been stabilized on an eq of 8-24mg SL per day for min 7 d
what are some cons for sublocade
very aggressive dosing
may have a visible depot after injection
methadone MOA
full mu opioid agonist with slow onset of action
methadone peaks at
2-4hrs
methadone does not
1. have a long half life
2. have a slow onset
3. have a max dose
4. have the most evidence for use in pregnancy
3
why must methadone doses be titrated slowly?
because of the long half life- to avoid risk of accumulation
T or F: methadone for OUD is also effective for acute pain in dependent pts
F- will also need short acting agent in addition
which OAT has the most evidence in pregnancy?
1. methadone
2. buprenorphine
3. buprenorphine/ naloxone
4. none of the above
1
studies show that methadone has efficacy for 5 things
decreased drug use
decreased transmission of HIV and Hep C
decreased criminal activity
decreased OD and premature mortality
increased tx retention
methadone dose is typically increased by __ q___d
by 10mg q3d
how is methadone formulated for OAT
1. tablets SL
2. tablets PO
3. liquids PO
4. injection
- dispensed in juice and diluted to 100mL to minimize risk of diversion + improve taste
tablets not usually used for OAT
list the 6 cons for methadone OAT
delayed sedation
slow to achieve therapeutic dose due to longer titration time
more potential for interactions
high risk for OD
risk for serious SEs
loss of tolerance occurs quickly
which one can be titrated to max dose the fastest? which has a higher risk of OD?
1. methadone
2. buprenorphine/ naloxone
2, 1
methadone can cause ____ or _____ with other agents
respiratory depression or QT interval prolongation
what are some more serious SEs of methadone
CNS depression, constipation, sweating, hypogonadism, weight gain, dental concerns
how soon does loss of tolerance to methadone happen?
3 days
if last dose was >3 days, must decrease dose
what is a monitoring parameter specific to methadone
ECG
when should ECG monitoring with methadone be done
baseline, then within 30 d of initiation, then if dose ≥ 100mg + thereafter at every dose that meets/ exceeds multiples of 20 mg
if pt experiences unexplained syncope, seizures, or other sx suggesting cardiac involvement
if pt is initiated on a med that causes QTc prolongation
purpose of urine drug screening with OAT
Confirms reports of substance use
Identify presence of concerning substances
Monitor for tx efficacy and adherence
what are some specialist led tx options for OUD?
slow release oral morphine (SROM)
injectable opioid agonist treatment (IOAT)
SROM is the preferred option for
those who have not stabilized on or have have CI to preferred tx options
data suggests that SROM is better than MMT for (3 things)
pt satisfaction
decreasing cravings
decreasing sx of persistent mild depression
what is the only formulation studied for SROM
kadian (24hr morphine product)
how is kadian usually used for OAT
Typically once daily as OAT as witnessed PO
Requires diligent measures to avoid diversion + mitigate risk of OD
Capsules are opened into med cup, ingestion of beads witnessed (sometimes mixed with pizza)
Can not crush or chew pellets
how is IOAT done?
Pts self administer prefilled syringes of hydromorphone IV/IM up to TID in supervised setting
which of the following is false
1. opioids can be used safely in pts with hx of OUD but should be carefully monitoring
2. OAT does not treat acute pain
3. nonopioid pharmacotherapy should not be included
4. undertreated acute pain is a RF for returning/ ongoing opioid use
3- nonopioid should be included
