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BASIC INFORMATION
SYNONYMS
Opiate addiction
Opiate abuse
Narcotic addiction
Narcotic abuse
ICD-9CM CODES
304.7X/304.8XOpioid dependence
ICD-10CM CODES
F11.0Mental and behavioral disorders due
to use of opioids, acute intoxication
F11.2Mental and behavioral disorders due to
use of opioids, dependence syndrome
F11.3Mental and behavioral disorders due
to use of opioids, withdrawal stage
F19.20Other psychoactive substance
dependence, uncomplicated
EPIDEMIOLOGY &
DEMOGRAPHICS
INCIDENCE: There are 980,000 opiate addicts
in the U.S.; less than one third are in treatment.
PREVALENCE:
Approximately 6 million persons age 12 yr
used psychotherapeutic drugs for nonmedical purposes in 2004, which represents 2.5%
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
Physical examination is often noncontributory.
Small-sized pupils may be the only observable sign of use because only mild tolerance
develops for miosis.
Scars or tracks from chronic IV use may be
visible over the veins of the arms, hands,
ankles, neck, and breasts.
Inflamed nasal mucosa or respiratory wheezing may be apparent in patients who are
snorting heroin or OxyContin.
Patients in withdrawal may have more dramatic findings such as tachycardia, hypertension, fever, piloerection (goose flesh),
mydriasis, lacrimation, central nervous system (CNS) arousal, irritability, and repeated
yawning. In patients with sympathetic overactivity and panic attacks, use of CNS stimulants, such as amphetamines or cocaine,
should also be ruled out.
Although gastrointestinal symptoms of nausea, vomiting, and abdominal pain are common in opiate withdrawal, other causes such
as gastroenteritis, pancreatitis, peptic ulcer
Opioid Dependence
disease, and intestinal obstruction need to be
ruled out.
The history may provide relevant information
in making the diagnosis. Significant findings
may include:
1. A long history of opiate self-administration, typically by the IV or intranasal route
but sometimes through smoking as well.
2. Polysubstance use. Intoxication by drugs
other than narcotics (e.g., benzodiazepines, barbiturates) should be ruled out
in unconscious patients.
3.
A high incidence of non-opiate-related
psychiatric disorders (>80%).
4. History of problems at work, school, or
relationships associated with drug use.
5. History of legal problems associated with
drug use, such as arrest for possession,
robbery, or prostitution.
6. History of interpersonal violence (as perpetrator or victim).
7.
History of physical problems such as
skin infections, phlebitis, endocarditis, or
liver diseases attributable to acetaminophen toxicity (Vicodin/Percocet) or viral
hepatitis. Hepatitis C is the most prevalent
blood-borne pathogen. It is present in
approximately 90% of opiate-dependent
people and is often spread by sharing IV
drug paraphernalia or snorting devices.
There is also a higher incidence of HIV
infection.
ETIOLOGY
Opioid dependence is a biopsychosocial disorder. Pharmacologic, social, genetic, and psychodynamic factors interact to influence abusive
behaviors. Pharmacologic factors are especially
prominent in opiate addiction because these
drugs are strong reinforcing agents because
of their euphoric effects and their ability to
reduce anxiety and increase self-esteem and
the patients subjective feelings of improved
ability to cope with daily challenges.
Dx DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Psychiatric disorders (e.g., anxiety, depression, bipolar disorder).
Acute medical illness (e.g., hypoglycemia,
seizure disorder, sepsis, renal or hepatic
insufficiency) may mimic opiate withdrawal
symptoms.
WORKUP
The history is the most important part of the
workup.
Observation of opiate withdrawal is indicative
of opiate addiction.
Observation of purposeful behaviors such
as complaints and manipulations directed at
getting more drugs and anxiety during withdrawal is suggestive of opiate addiction.
Screen blood and urine for opiate metabolites.
Screen for communicable diseases: HIV, hepatitis B and hepatitis C, tuberculosis.
845
Diseases
and Disorders
DEFINITION
Opioid addiction/dependence is defined as
a cluster of cognitive, behavioral, and physiologic symptoms in which the individual continues use of opiates despite significant opiate-induced problems. Opiate dependence is
a chronic, relapsing disorder characterized
by repeated self-administration that usually
results in opiate tolerance, withdrawal, and
compulsive drug use. Tolerance is the need
to increase dose to achieve the same effect.
Dependence may occur with or without the
physiologic symptoms of tolerance and withdrawal.
There are four stages of addiction:
1.
Stage I, acute drug effects: rewarding
effects of drug result from neurobiologic
changes in response to the acute drug
use. Duration varies from hours to days.
2.
Stage II, transformation to addiction:
associated with changes in neuronal
function that accumulate with repeated
administration and diminish over days or
weeks after discontinuation of drug use.
3. Stage III, relapse after extended periods of
abstinence: precipitated by an incubation
of cue-induced craving (people, places, and things as triggers) and priming
(relapse precipitated by drug exposure).
4.
Stage IV, end-stage addiction: vulnerability to relapse endures for years and
results from prolonged changes at the
cellular level.
Pseudoaddiction: undertreatment of pain
resulting in opiate-seeking behaviors such
as doctor shopping and multiple emergency department visits. These behaviors
disappear with adequate treatment of pain.
of the population. Most of them reported
abusing opiate pain relievers.
In 2004, 2.4 million persons age 12 yr
initiated nonmedical use of prescription
pain relievers, surpassing for the first time
those who initiated abuse of marijuana
(2.1 million).
Opiate addiction is becoming an adolescent
disease. Among twelfth-graders, in 2005,
9.5% reported past-year nonmedical use of
oxycodone (Vicodin) and 5.5% reported pastyear nonmedical use of oxycodone slowrelease tablets (OxyContin).
The percentage of eighth-, tenth-, and
twelfth-graders who have used heroin has
more than doubled since the late 1990s.
This increase has largely been attributed to
decreased price and increased purity in the
last decade.
PREDOMINANT SEX: Males abuse opiates
more commonly than females, with a male/
female ratio of 3:1 for heroin and 1.5:1 for
prescription opiates.
PEAK INCIDENCE: The majority of new abusers
of opiates are <26 yr.
RISK FACTORS:
Family history
Prior history of addiction
Psychiatric disorders
GENETICS:
Genetic epidemiologic studies suggest a high
degree of heritable vulnerability for opiate
dependence.
Gene polymorphism for dopamine receptor/transporters, opioid receptors, serotonin
receptors/transporters, proenkephalin, and
catechol-O-methyltransferase all appear to
be associated with vulnerability to opiate
dependence. Future interventions for opiate
dependence may include medications identified through genetic research.
PTG
846
Opioid Dependence
PTG
Screen for endocarditis in patients with newly
diagnosed murmurs.
LABORATORY TESTS
Urine and serum toxicology screen
Complete blood count
Chemistries (alanine aminotransferase, aspartate aminotransferase, serum creatinine): elevated liver function test (LFT) results may be
from viral hepatitis or acetaminophen toxicity
Hepatitis screen: if hepatitis C antibody positive, follow up with hepatitis C polymerase
chain reaction (viral load) even in patients
with normal LFTs
HIV
PPD
IMAGING STUDIES
Generally not helpful in routine diagnosis
and treatment. Consider echocardiography in
patients with heart murmurs and liver sonography or CT scan in patients with elevated LFTs or
who are positive for hepatitis C or B (increased
risk of hepatocellular carcinoma).
Rx TREATMENT
NONPHARMACOLOGIC THERAPY
Brief counseling interventions during a visit
with their primary care physician or OB/
GYN have proved efficacious in motivating
patients for treatment.
Therapeutic communities (residential).
12-step or other self-help groups
(e.g., Alcoholics Anonymous, Narcotics
Anonymous).
Relapse prevention (counseling).
ACUTE Rx
Medical withdrawal (not overdosed).
Short- (30 days) or long-term (30 to 180
days) protocols.
Buprenorphine (opioid partial agonist) or
methadone (opioid agonist) is initiated in
tapering doses.
Clonidine 0.1 mg bid to tid can be used to
minimize autonomic symptoms (sweating)
and craving.
Nonsteroidal anti-inflammatory drugs for
body and muscle aches.
The anticholinergic dicyclomine can be used
to minimize gastrointestinal hyperactivity.
Nonbenzodiazepine hypnotics, low-dose
atypical antipsychotics (e.g., quetiapine), or
low-dose tricyclic antidepressants are effective for promoting adequate sleep.
CHRONIC Rx
Opioid antagonist treatment:
Naltrexone: does not stabilize neuronal circuitry like partial or full opioid agonists and
generally results in poor outcomes, much like
Antabuse for alcohol.
Opioid partial agonist therapy: buprenorphine.
Opioid agonist therapy: methadone.
note: Buprenorphine and methadone are both
metabolized by the cytochrome P450 3a4
and 2d6 I isoenzyme pathways. Prescribers
should be aware of multiple possible drug
interactions.
PATIENT SELECTION
FOR BUPRENORPHINE
OR METHADONE
Appropriate patients for buprenorphine
office-based treatment:
C
Patients interested (highly motivated) in
treatment
C Have no major contraindications (see following)
C Can be expected to be reasonably compliant with treatment
C
Understand the benefits and risks of
buprenorphine treatment
C Willing to follow safety precautions
Less likely to be appropriate for office-based
treatment:
C Have comorbid dependence on benzodiazepines or other CNS depressants (including ethylene alcohol)
C
Have significant untreated psychiatric
comorbidities
C Have active or chronic suicidal or homicidal ideation or attempts
C
Have multiple previous treatments with
frequent relapses
C Have poor response to previous treatment
with buprenorphine
C
Have significant medical complications
(e.g., hepatic insufficiency, bacterial endocarditis, active tuberculosis)
Methadone maintenance: narcotic treatment
program (clinic setting) indications
Evidence of opiate addiction >1 yr
Two failed previous treatment attempts
Patients not appropriate for office-based
treatment
Eligible without active use if prior methadone maintenance patient within previous
2 mo
Pregnancy
DISPOSITION
Opioid addiction is a chronic, relapsing disease.
High rate of relapse after detox.
Relapse potential after medically supervised
withdrawal from methadone:
C 90% after 1 yr stable in treatment
C 80% after 3 yr stable in treatment
C 70% after 5 yr stable in treatment
REFERRAL
Refer to addiction medicine specialist or narcotic treatment program when the neurobiologic
disease of opioid addiction is identified.
PEARLS &
CONSIDERATIONS
COMMENTS
Methadone maintenance is the gold standard for the pregnant opiate-addicted patient
regardless of the duration of the addiction
or prior treatment attempts. Detoxification is
contraindicated during pregnancy.
Breastfeeding is encouraged in mothers
on methadone maintenance. The American
Academy of Pediatrics statement regarding
Transfer of Drugs and Other Chemicals into
Human Milk has placed methadone into
the usually compatible with breastfeeding group based on the assumption that
maternal urine is monitored to detect use of
illicit drugs. The U.S. Department of Health
and Human Services also recommends that
mothers on methadone be encouraged to
breastfeed.
When a physician identifies a patient as
a drug seeker, it is imperative that the
physician avoid abruptly stopping the opiate
prescription because this will often result in
the patients buying the drugs illegally. These
patients should be counseled and referred for
treatment.
Patients on methadone or buprenorphine
who have pain resulting from an acute injury
will need pain medication in addition to their
daily dose of methadone or buprenorphine.
They will require higher than usual doses of
pain medications because of opiate receptor
blockade attributable to their methadone or
buprenorphine use.
Opiate-dependent patients have a lower pain
threshold resulting from hyperalgesia caused
by the long-term use of opiates.
PREVENTION
Education is the hallmark of prevention.
School drug prevention education programs.
Educate children about their family medical
history, including diseases of addiction.
Address childhood psychiatric disorders to
prevent self-medicating.
PATIENT & FAMILY EDUCATION
Stigma of addictions and treatment often
interferes with good treatment.
Family needs to be educated so they can
support the patients efforts.
Encourage family meeting with addiction
specialist, counselor.
Recommend support groups for family members.
SUGGESTED READINGS
available at www.expertconsult.com
RELATED CONTENT
Drug Abuse (Patient Information)
AUTHOR: STEVEN PELIGIAN, D.O.
Opioid Dependence
SUGGESTED READINGS
Ballantyne JC etal: Opioid dependence vs addiction, Arch Intern Med 172:1342,
2012.
Bowman S et al: Reducing the health consequences of opioid addiction in primary
care, Am J Med 126:565-571, 2013.
Daniel A: Acute pain management for patients receiving methadone or buprenorphine therapy, Ann Intern Med 144:127, 2006.
Kalinas PW, Volkow ND: The neural basis of addiction: a pathology of motivation
and choice, Am J Psych 162:1403, 2005.
Krupitsky E etal: Injectable extended-release naltrexone for opioid dependence:
a double-blind, placebo-controlled, multicenter randomized trial, Lancet
377:1506-1513, 2011.
Olsen Y, Alford D: Chronic pain management in patients with substance use disorders, Johns Hopkins Advanced Studies in Medicine 6:110, 2006.
Shapiro B et al: A primary care approach to substance misuse, Am Fam Physician
88(2):113-121, 2013.
Sullivan L, Fiellin DA: Narrative review: buprenorphine for opioid-dependent
patients in office practice, Ann Intern Med 148:662-670, 2008.
Von Korff Met etal: Long-term opioid therapy reconsidered, Ann Intern Med
155:325-328, 2011.
Wilford B: Principles of addiction medicine, ed 3, Chevy Chase, MD, 2003, American
Society of Addiction Medicine.
Woody GE etal: Extended vs short-term buprenorphine-naloxone for treatment of
opioid-addicted youth, JAMA 300(17):2003-2011, 2008.
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