Opioids

Question 1

Clinical presentation of opioid withdrawal:

Answer 1

Often peaks at 2-3 days, can last 1-2 weeks

Precipitated by:
- Reduction/ cessation
- Antagonism (Full: Naloxone, naltrexone. Partial: Buprenorphine/suboxone)

Anxiety, restlessness
Dysphoria
Craving

Lacrimation
Salivation
Rhinorrrhoea

GI upset

Piloerection
Diaphoresis
Flushing

Achey joints

NOT ALTERED MENTAL STATUS/ SEIZURE/ DELIRIUM
Rare to get tachycardia/ HTN

Not life threatening

Question 2

Management of opioid withdrawal:

Answer 2

1- DETOX
Support with: fluids, antiemetic, buscopan for GI, simple analgesia for myalgia.
Diazepam or clonodine for anxiety/dysphoria
Ideally in D&A unit or with D&A staff

or

2- REPLACEMENT TX
Methadone or suboxone

Methadone: synthetic opioid that doesn’t produce euphoria (avoid abuse) or sedation (avoid OD)

Suboxone: buprenorphine (high-affinity partial agonist so prevents withdrawal whilst hogging receptors) + naloxone (active if injected to prevent abuse)

Tapered over many weeks/months

Question 3

At what rate should BZD be tapered in dependence?

Answer 3

15% per week

Question 4

How long should you observe for in opioid OD?

Answer 4

4 hours for standard release
12 hours for extended release

Question 5

Opioid overdose differentials?

Answer 5

FULL TRIAD:
Clonidine
GHB

CNS + MIOSIS (and 2 resp depr)
Barbiturates
Clozapine
Olanzapine
Valproate

Question 6

Clinical features of Opioid OD:

Answer 6

Triad:
- Miosis
- Resp depression
- ALOC

Plus:
- Hypotension
- Constipation, ileus
- N&V
- +- histamine / itch

Question 7

Specific OPIOIDS and their peculiar toxic effects:

Answer 7

Dextropropoxyphene: Na-channel blockade
Pethidine/ tramadol: Serotonin Sx
Methadone/ oxycodone: QT prolongation