Opioid Use Disorder

Question 1

Opiates vs opium

Answer 1

Opiates = natural opioids from the poppy plant

Opium = natural and synthetic opiates

in practice mean the same thing

Question 2

What is the natural ingredients in natural opium

Answer 2

90% = morphine

10% = codeine

Question 3

How do you make heroin from morphine?

Answer 3

Add two acetyl groups to morphine

- is a direct product from morphine

Question 4

What act made acquiring opioids more difficult to obtain?

Answer 4

Harrison act of 1914

Question 5

Mechanism of action in opioids

Answer 5

3 receptors

Mu = Play a role in pain perception
-most importaint

Kappa = play a role in pain perception

Delta = not sure function

Question 6

What are the most used opioid antagonists for reversal of opioid OD?

Answer 6

Naloxone and nalophine
- will precipitate withdrawal syndrome though so must treat that as well

Naltrexone

• long acting opioid antagonist that works similar to naloxone as well
• in addition, prevents experiencing a high from subsequent opioid use (so good harm reduction strategies)

Question 7

Does cross-tolerance with opiods exist?

Answer 7

Yes and almost all are

Question 8

Can opioid withdrawal kill someone?

Answer 8

No

- if they die its a secondary reason to a Withdrawal side effect (diarrhea, suicidal ideologies, etc.)

Question 9

Opioid withdrawal symptoms

Answer 9

Usually in this order but not always

1) cravings/anxiety
2) yawning, perspiration, runny nose, tear eyes
3) pupil dilation, tremors, hot/cold flashes, aching bones and muscles, loss of appetite
4) innominate, HTN, increased temperature/pulse rate/respiratory rate
5) restlessness nausea/vomiting
6) diarrhea, weight loss, spontaneously ejaculation/orgasm, increased glucose, premature ejaculation
* can be prevented with any opioid agonists, however use makes it harder/longer to break dependence*

Question 10

Opiate toxidrome mnemonic

“CPR-HHH”

Answer 10

Coma

Pinpoint pupils
< 2mm usually

Respiratory depression

Hypotonia

Hypothermia

Hyporeflexia

Question 11

What are the scales used to assess opioid withdrawal

Answer 11

Objective opioid withdrawal scale (OOWS) = based on clinical observation

Subjective Opioid withdrawal scale (SOWS) = based on patient rating

Clinical Opioid withdrawal scale (COWS) = based on clinicians ratings

Question 12

How to treat opioids withdrawal long term

Answer 12

1) gradual tapering doses of opioid agonists (DETOX)
- use methadone or buprenophine
- they will go through opioid withdrawal symptoms

2) use a2 agonists (Clonidine) along with other non-narcotic medications to reduce withdrawal symptoms
- used to reduce withdrawal symptoms

Question 13

Why should buprenorphine be used only after the patient has begun experiencing symptoms?

Answer 13

It is a partial agonist of the u-opioid receptor

- it will kick the opiods (full agonists) out of the receptors and make withdrawal worse

Question 14

Should you use anesthesia-assisted withdrawal management to treat opioid withdrawal?

Answer 14

NO

• doesnt work well
• high chances to kill
• high chance of relapse

Question 15

Contraindications to methadone

Answer 15

Hypersensitivity

Signs of repsitratory depression

QT interval increases

Acute asthma is present

Suspect or know the patient has paralytic ileus

Question 16

Enkephalins vs endorphins

Answer 16

Both are endogenous opioid-like ligands

Enkephalins = morphine like ligand found in brain and adrenal glands

Endorphins = morphine like ligands found in the brain a pituitary gland

Question 17

Benefits of opioids

Answer 17

Pain relief

Reduces emotional response to pain

Diminishes patients awareness and response to aversive stimuli

Drowsiness (but doesnt induce sleep)

Treatment of intestinal disorders
-also counteracts diarrhea and dehydration associated

Decreases peristaltic contractions

Question 18

Tolerance of opioids

Answer 18

Develops rapidly and to most effects

• respiratory depression is the most common
• as well as behavioral effects

pin point pupils CANT develop tolerance (will show up every time)

Question 19

Review all of the drugs associated with opioid use disorder

Answer 19

Naltrexone = relapse prevention
- long acting mu-antagonist

Naloxone = overdose treatment
- short acting mu-antagonist

Clonidine = opioid withdrawal symptom treatment only
- a2- agonist (combats HTN and cramps)

Methadone and buprenorphine = opioid withdrawal treatment via DETOX method

• both are mu-agonists
• buprenorphine is less potent so must make sure withdrawl symptoms are active before use

Question 20

Buprenorphine contraindications

Answer 20

Hepatitis/liver failure

Concurrent use of alcohol, sedative, hypnotic or anxiolytic disorders
- or patients taking drugs associated

Hypovolemia

Severe SVD

Concomitant use with drugs that can cause orthostatic hypotension and syncope

Question 21

Why is overdose potential following treatment with naltrexone much higher than normal?

Answer 21

Chronic antagonism of the mu-receptor leads to upregulation of mu-receptors in the body

Taking opioids after this has occurred = massive response and OD chance

Question 22

Main therapies for opioid use disorder

Answer 22

Contingency management
- give tangible rewards to reinforce positive behaviors

Cognitive behavioral therapy (CBT)

general patient education needs to be recommended

Question 23

What drugs when combined with opioids can lead to increased OD risk

Answer 23

Benzos/barbiturates

Sedative agents

Alcohol

Antihistamine agents (promethazine)