Opioid Use Disorder Flashcards
Opiates vs opium
Opiates = natural opioids from the poppy plant
Opium = natural and synthetic opiates
in practice mean the same thing
What is the natural ingredients in natural opium
90% = morphine
10% = codeine
How do you make heroin from morphine?
Add two acetyl groups to morphine
- is a direct product from morphine
What act made acquiring opioids more difficult to obtain?
Harrison act of 1914
Mechanism of action in opioids
3 receptors
Mu = Play a role in pain perception
-most importaint
Kappa = play a role in pain perception
Delta = not sure function
What are the most used opioid antagonists for reversal of opioid OD?
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)
Does cross-tolerance with opiods exist?
Yes and almost all are
Can opioid withdrawal kill someone?
No
- if they die its a secondary reason to a Withdrawal side effect (diarrhea, suicidal ideologies, etc.)
Opioid withdrawal symptoms
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*
Opiate toxidrome mnemonic
“CPR-HHH”
Coma
Pinpoint pupils
< 2mm usually
Respiratory depression
Hypotonia
Hypothermia
Hyporeflexia
What are the scales used to assess opioid withdrawal
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
How to treat opioids withdrawal long term
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
Why should buprenorphine be used only after the patient has begun experiencing symptoms?
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
Should you use anesthesia-assisted withdrawal management to treat opioid withdrawal?
NO
- doesnt work well
- high chances to kill
- high chance of relapse
Contraindications to methadone
Hypersensitivity
Signs of repsitratory depression
QT interval increases
Acute asthma is present
Suspect or know the patient has paralytic ileus
Enkephalins vs endorphins
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
Benefits of opioids
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
Tolerance of opioids
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)
Review all of the drugs associated with opioid use disorder
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
Buprenorphine contraindications
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
Why is overdose potential following treatment with naltrexone much higher than normal?
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
Main therapies for opioid use disorder
Contingency management
- give tangible rewards to reinforce positive behaviors
Cognitive behavioral therapy (CBT)
general patient education needs to be recommended
What drugs when combined with opioids can lead to increased OD risk
Benzos/barbiturates
Sedative agents
Alcohol
Antihistamine agents (promethazine)
