Opioid use disorder and treatment Flashcards
WE NEED THESE MEDICATIONS!!! BUT…
EVERY 19 MINUTES SOMEONE DIES OF A HEROIN/OPIOID OD. Opioid-related deaths are at an all-time high.
Opioid OD deaths nearly equal to # of deaths from car crashes in ‘15 and deaths from heroin alone surpassed gun homicides
how things often start
George had back injuries–> chronic pain–> opiate rx–> dr discontinued it–> buying Oxycodone/ -contin on the street–> heroin abuser.
Doctors do a good job of starting patients on these medications
but not such a good job about counseling them about their dangers: from the simple stuff (constipation) to the dangerous stuff (dependence)
Be a good steward of opioid use. Ensure appropriateness, educate all patients about their use, and have an endpoint and/or plan in mind about how use will be tapered, discontinued, or transitioned and discuss this upfront.
OPIOIDS: The New Epidemic
US “epidemic” of prescription-painkiller abuse “may be starting to reverse course,” …due, in part, to a “disturbing trend: Heroin abuse and overdoses are on the rise.”
-HealthDay News, January 15, 2015
…Number of deaths from heroin use over the past two decades is up by 39%, and this is “the third year in a row that heroin deaths have increased.”
Resurgence of heroin use d/t $$$ of street pills (80 mg OxyContin costs $60-$100/pill; Heroin costs $45-$60 for a multi-dose supply)
CDC: Drug OD leading cause of injury death in 2013.
2013 data: 43,982 drug OD deaths in US. Of these, 22,767 (51.8%) related to prescription drugs.
- Of those 22,767 deaths: 16,235 (71.3%) involved opioid painkillers, and 6,973 (30.6%) involved benzodiazepines.
People who die of drug OD often have combo of benzos & opioid painkillers in their bodies.
OPIOID USE DISORDER: Some basics
It all started with opium…this has been with us for millennia!
Opiate refers to any preparation or derivative of opium and opioid was originally used to denote synthetic opiates; however, the terms have become virtually interchangeable
Painkiller use disorder currently est to affect nearly 2 million Americans (remember, that’s not including abuse, heroin, etc)
**Highly addictive, both physically and physiologically, and is very difficult to stop
Disorder increases morbidity/mortality due to OD (intentional or otherwise) and acquired medical comorbidities and/or poor self care
Routes: po, IV, skin pop, snort, smoke
Physiologic dependence is pure misery for most people. It robs them of life and livelihood and can lead to incarceration due to criminal acts pursued to obtain the drug (prostitution, theft, etc)
many of the main agents with action of one sort or another at opioid receptors:
Morphine, meperidine, oxycodone (OxyContin), hydrocodone, heroin, codeine, hydromorphone (Dilaudid), methadone, meperidine, fentanyl, pentazocine, buprenorphine, naltrexone, naloxone, oxymorphone, kratom, et al
Prescribers!
½ of pts Rx opioids for 30 days are still taking it 3 yrs later (Express Scripts study, Dec 9 2014)
“Reducing inappropriate opioid prescribing remains a crucial public health strategy to address both prescription opioid and heroin overdoses,” said CDC Director Tom Frieden, M.D., M.P.H. “Addressing prescription opioid abuse by changing prescribing is likely to prevent heroin use in the long term.”
Rx Opioids
Most popular ones are OxyContin (Oxycodone), Vicodin (Hydrocodone/Acetaminophen), Percocet (Oxycodone/Acetaminophen)
aka “Oxys,” “Vics,” “Percs”
Swallowed or crushed and snorted, sometimes injected as well
Leads to feelings of euphoria and sedation. Causes constricted pupils, slurred speech, impaired coordination. Can cause ↓BP/HR and respiratory depression
Consider drug-drug interactions and CYP-450 system (most of these are metabolized thru liver) –> possible ↑ risk of respiratory depression
Rx Opioids: Consider this -
One study suggested that the likelihood of an opioid-naïve individual becoming a chronic opioid user can increase after just 5 days
According to a recent study in Addiction, 43% people on buprenorphine also filled Rx for another opioid. Suggests that physicians are not checking prescription records & may be Rx opiates to the very individuals who shouldn’t be getting them
Heroin
aka H, horse, dope, junk, smack
Full opioid agonist
IV, IM, snorted (sometimes smoked but not efficient, $$), “skin popping”
Euphoria, sedation, constricted pupils, impaired coordination, can cause ↓BP/HR, respiratory depression (dangerous when combined w/other substances)
IV use –> shared/dirty needles –> risk of HIV, HCV, HBV, cellulitis, sepsis, bacterial endocarditis, etc
Can be “cut” w/adulterants such as Fentanyl, barbiturates, household powders, etc
In last decade, use has increased 5-fold and addiction has nearly tripled
OD deaths in US quadrupled from ’10-’15
FENTANYL & CARFENTANIL: WILD CARDS
Fentanyl
80x more potent than morphine. Implicated in ↑ OD & deaths
“Wooden chest” (chest wall rigidity, interferes with CPR)
Carfentanil
10,000x more potent than morphine; never approved for human use, 2mg can sedate a 2,000 lb elephant
July ‘16: Akron, OH had 35 OD + 4 deaths in a 3-day period
- Intoxication symptoms
Pupillary constriction Flushing Sedation Slurred speech Bradycardia Hypotension Respiratory depression Hypothermia Constipation (nausea/vomiting are rarer)
Intoxication rapid if IV, delayed if po. Duration of effect depends on the drug (wide variety available)
Typically, users always yearn for that first high that can never be recreated (“chasing the dragon”)
- Withdrawal symptoms
Pupillary dilation Piloerection Nausea Vomiting Diarrhea Lacrimation Rhinorrhea Joint/muscle pain Abdominal cramps Yawning
Withdrawal peaks in 3-4 days (for short-acting opiates, longer for others), but symptoms can continue for weeks, even months
Won’t kill you (fetuses excepted)…but it’s very unpleasant (can actually die of dehydration)
Kratom (not technically an opioid, yeah, but…)
Might be safer, less addictive than current tx for pain &/or opioid withdrawal
DEA debating, 660 adverse rxns reported over 6 yrs (incl some deaths?)
Stimulant/analgesic at low-mod doses (vs sedation) & even @ higher doses, doesn’t suppress respiration & doesn’t usu produce euphoria or intense high
Ingested or in teas. Just be aware of it. Stay tuned.
PREVENTION OF OPIOID-RELATED DEATHS
Watch for co-morbid respiratory conditions (asthma, PNA, flu, OSA).
Reduce opioid dose 20-30% in presence of these
Do not use ER/XR opioids for acute pain!
*Avoid benzos! If they must be used, consider reduction of opioid dose. Benzos enhance opioid toxicity. FDA Black Box Warning
Rx Naloxone when/where appropriate
NALOXONE (NARCAN)
Now available for patients, friends, family (check your State law). In CO, anyone who is an interested party in someone’s care can obtain a Rx for it
If a patient is using ≥100mg morphine equivalents/day, this is recommended
The same drug that the ED uses to reverse opioid OD
Available in “Epi-Pen”-like format, or intranasal as well
Detoxification
Detox is the first step in treatment. Assures safe removal to prevent uncomfortable withdrawal; also reduces risk of pt turning to continued drug use to prevent withdrawal
“Rapid detox” no longer performed due to fatalities
Detox options:
“Cold turkey”
- Methadone (either short-term or long-term)
- Buprenorphine
- Supportive medications: Trimethobenzamide (for nausea/vomiting), Dicyclomine (stomach cramps), Loperamide (diarrhea), Ibuprofen (muscle/joint pain) all used during withdrawal period
- Clonidine is very useful both as monotherapy for mild withdrawal or as adjunct tx for “supportive medication” option above. Good at treating tremor, diaphoresis, and agitation
Detoxification –> Maintenance
Detox does absolutely nothing to address cravings (physiological and psychological)
Other agents are usually required after the detox period to assist the patient in remaining sober. Many patients are simultaneously both detoxed and transitioned to new treatment
Patients who do not transition to maintenance treatment have an extremely high likelihood of returning to drug use
Methadone
Synthetic opioid
Pros:
long ½ life –> once daily dosing
Safety
Safe in pregnancy (fetal withdrawal can be fatal)
Intoxicating effects are less euphoric and less sedating than heroin
Pts may eventually be allowed to utilize daily tablets from home
Cons:
Usu have to go to clinic daily
Can’t leave clinic vicinity > 1 day (“the methadone chain”)
Prolongs QT
Multiple drug-drug interactions
Use is restricted only to certain facilities
Patient is still opioid-dependent
LAAM
Levo-α-acetylmethadol (LAAM)
Very similar to Methadone treatment except that the dosing is less (2-3x/week vs. daily)
Many of the same problems with Methadone exist & rarely utilized
Buprenorphine
High affinity for opioid receptors mu (as partial agonist) and kappa (as antagonist)
Can cause nausea/vomiting
Lower potential for abuse because partial activation produces much less effect (↓euphoria) and ↓risk of resp depr as partial agonist
Sublingual d/t poor oral bioavailability
Still can be abused, esp if taken IV. Can still be fatal.
