OUD (Background, Overdose, Withdrawal Management) Flashcards
What are the differences between opioids and opiates?
Opiates are the naturally derived from poppy,
Opioids inlcude both the definition of natural and synthetic
What is an opioid?
Class of drugs that can provided illicitly or prescribed and acts as depressants
What may opioids be used for?
Reduce pain
Manage opioid dependence
Produce temporary uophoria/relaxation
What are the main opioid receptors?
Mu
Delta
Kappa
What is the Mu receptor responsible for?
responsible for most of the opioid analgesic effect
What are the effects of the Mu receptor? (5)
respiratory depression, reduced GI motility, euphoria, physical dependence, sedation
What are the effects of the delta recepotr?
analgesia, euphoria, physical dependence`
What are the effects of the kappa receptor
analgesia, sedation, ? mood, does NOT contribute to physical dependence
What is the OUD definition?
primary chronic disease of brain reward, motivation,
memory, and related circuitry with a “dysfunction in
these circuits” being reflected in “an individual
pathologically pursing reward and/or relief of
withdrawal symptoms by substance use and other
behaviors”
What was OUD formerly classified as?
opioid “dependence”,
“addiction”, “misuse”, “abuse”
What is OUD?
Long-lasting chronic brain disease
What can OUD involve?
misuse of prescribed opioid medications, use of
diverted opioid medications, use of illicitly obtained opioids
OUD is a ___ condition
relapsing
Occurs in cycles of drug use, reduce use/ abstinence, relapse
What does OUD treatemtn require?
Long-term chonric disease management
OUD ____ end when the drug is removed from the
body or when acute post-drug taking illness dissipates
DOES NOT
What is OUD similar to?
T2DM and HTN in which it cannot be cured but can be treated and managed
OUD is associated with ___ morbidity and mortality
Increased
What has OUD been associated with increasing the rates of?
HIV, Hepatitis, and STDs
what is the apparent opioid toxicity related deaths in Canada in 2023?
Just over 8000
What is the Opioid related poisoning emergency visits in Canada in 2023?
28345
What are the opioid related poisoning hospitalization in canada?
6312
What are the opioid related emergency medical service response to suspected opioid related overdoses?
41938
What is the cycle of OUD?
What are the 3 stages of addiction of OUD?
Binge/Intoxication
Withdrawal/negative affect
preoccupation/anticipation
What is the binge/intoxication stage description?
individual consumes an
intoxicating substance and experiences its
rewarding or pleasurable effects
What is the Withdrawal/negative affect description?
individual experiences a negative emotional state in the
absence of the substance
What is the preoccupation/anticipation description?
Individual seeks substance again after a period of abstinence
How often does someone go through the three stage cycle?
over the course of
weeks or months or progress through it several times in a day.
How many regions of the brain do the stages of OUD go through?
many different brain regions, circuits, NTs, and result in changes in the brain
The addiction cycle tends to ___ over time ___
Intensify, leading to greater
physical and psychological harm.
When an opioid attaches to the mu receptor it triggers a ___ in the brain called the ___
structure, mesolimbic midbrain,
The Mesolimbic midbrain is triggered my mu receptors.
The midbrain is a reward system in the ___
ventral tegmental area (VTA)
The Ventral segmental area is responsible for the release of ___ in the nucleus accumbens in the ___
Dopamine, basal ganglia
Release of dopamine in the nucleus accumbens =
pleasure
Over time with repeated opioid use and the feedback to the prefrontal cortex to the vta this feedback path becomes
dysregultated
When taken ___ opioids trigger the brain’s reward
system driving a compulsion to take the drug again and
again
repeatedly
opioid receptors in the ___ become ___ sensitive to opioid stimulation
VTA, less
Dopamine production is ___ and the experience of pleasure/opioid effect is ___
decreased, diminished
Where is dopamine production?
VTA or ventral tegmental area
In addition to the changes in the VTA feedback pathway, OID results in changes in the
Locus coeruleus
Neurons in the LC produce
Noradrenaline
What does noraderenaline do?
Distribute it to other parts of the brain where it stimulates wakefulness, breathing, blood, pressure, alertness, etc
When opioids bind the mu receptors in the LC they suppress the release of noradrenaline leading to
drowsiness, slowed respiration, low blood
pressure → opioid intoxication
What is naloxone?
Binds the same sites as opioids in the brain more tightly
– Displaces opioid
– Antagonist at receptor
What are the effects of naloxone?
Restores breathing within about 2 to 5 min when it has been dangerously slowed or stopped due to opioid use
What are the routes of administration of naloxine?
IM or IN
Of the 2 formulations which is most expensive?
Intranasal
What can cause opioid withdrawal in those with opioid dependence
Benefit > Risk
How long after administration of naloxone do the effects last?
30-90 minutes there overdose may return
In overdose who may experience the wear off effects and the overdose may return?
Those who take long acting opioids (Methadone)
What is naloxine kits?
One of the most promising and tangible pharmacist activities to ↓ opioid related risks
What does the acronym “SAVE ME” stand for?
Stimulate
Airway
Ventilate
Evaluate
Medication
Evaluate
What are the physical symptoms of withdrawal?
Myalgia, abnormal cramps, nausea, chills, hot flashes, electric feeling, yawning.
Is Opioid withdrawal life threatening?
No
What may be the early symptoms of opioid withdrawal?
What are the late symptoms of opioid wthdrawal?
What are the prolonged symptoms of opioid withdrawal?
How can we manage the Aches/Pains/Myaglia of opioid withdrawal?
NSAID (give regularly initially), Acetaminophen
How can we manage the bowel function withdrawal symptom?
Laxative, loperamide
How can we manage the Nausea/Vomiting of opioid withdrawal?
Dimenhydrinate, haloperidol,
How can we manage anxiety/irritability/cramps/rhinorrhea/insomnia of opioid withdrawal?
Hydroxyzine
How can we manage the insomnia effects of opioid withdrawal?
Non-drug and sleep hygiene measures, trazodone
How can we manage the physical withdrawal of opioid withdrawal?
Clonidine
How can we manage the sweating effect of opioid withdrawal?
Oxybutynin
Should benzos be used ofr opioid withdrawal symptoms?
NO, increase risk of CNS depression/opioid toxicity
What are the signs and symptoms of opioid overdose?
- difficulty
- walking
- talking
- staying awake
- blue lips or nails
- very small pupils
- cold and clammy skin
- dizziness and confusion
- extreme drowsiness
- choking, gurgling or snoring sounds
- slow, weak or no breathing
- inability to wake up, even when shaken or shouted at
What are the factors of overdose
Overdose?
Substances, how it was taken, individual
What is tolerance?
Lower tolerance when you have:
* Taken a break from using
* Recently been in detox/treatment
* Recently been incarcerated
* Recently started using
* Lung, liver & other health issues e.g. asthma, COPD, Hep C
* Had a recent overdose
What is important about tolerance?
Know your tolerance, use less, pace yourself, do testers, if you have been abstinent, start using much less
What is the importance of ROA with regards to drug usage?
if you use enough of that drug in a short enough period of time OD is possible
What are some of the modes of taking opioids?
What is polysubstance use?
heroin + alcohol
methadone + benzos
alcohol + benzos
Where multiple substances are used including alcohol and prescribed medications together in some cases
What is important about drugs and alcohol
✓ Be aware that prescribed medication can
increase OD risk
✓ If you do mix, use drugs before alcohol
What is fentanyl?
Used as a painkiller or anaesthetic.
50-100 times more toxic than morphine
Whati s the estaimted lethal dose of pure fentanyl
2mg
What can illicit fentanyl be sold as?
fentanyl, heroin,
or fake oxys OR any street drug may be
intentionally or unintentionally contaminated
In most cases fentanyl is taken
intentionally or unknowingly
How much more potent is carfentanil than fentanyl?
100x
What makes carfentanil more potent?
What is 15x more poten than fentanyl?
What is the main dialogue in t erms of pruchasing illicit substances?
Small variations of the drug could be lethal (Molecularly)
Why might people use substances alone?
– Stigma
– Fear
– Preference
Why is it dangerous to take too much of an opioid?
- Lose the urge to breath
- Breathing slows decreasing
oxygen to the brain - Can lead to permanent brain
injury or death if untreated
How long does naloxone work for?
30-90 minutes overdose can return
What are some opioids that can lead to re-overdose when the effects of naloxone wear off?
What does opioid OD look like?
- Small pupils
- Snoring or gurgling
- Blue lips, fingernails
- Cold clammy skin
After approximately ___ before your cosnider a second dose of naloxone?
20-30 breaths
What is the goal of utilizing naloxone?
Goal is for someone to be breathing on their
own (at least 1 breath every 5 seconds)
Aftercare of naloxone and paramedics?
– How long person has been unresponsive
– Known medical conditions
– Drugs used
– How much naloxone given
- Allocation of health care resources
What is the COWS scale?
Clinical Opiate Withdrawal Scale
Example of a PPO for a inpatient bup-nal induction order
PPO
What is the theory of Low-dose/microdosing Bup/Nal
– Repetitive administration of very small buprenorphine doses should not precipitate opioid withdrawal
– Buprenorphine will accumulate at the receptor due to long t1/2
– Over time, an increasing amount of the full agonist will be replaced by buprenorphine at the receptor
Is suboxone better tolerated or methadone longterm?
Suboxone
How would be micodose Bup-nal using the bernese method?
