Opioids presented by : Torki El-jandali 121120877.

Opioids Opioids

presented by : Torki El-jandalipresented by : Torki El-jandali121120877 121120877

• https://www.youtube.com/watch?v=NaMgdlUcsko

epidemoilogy epidemoilogy • Opioids are powerful pain killers that are highly

addictive. Opioid dependence affects nearly 5 million people in the United States and leads to approximately 17,000 deaths annually. According to the CDC, rates of opioid overdose deaths jumped significantly, from 7.9 per 100,000 in 2013 to 9.0 per 100,000 in 2014, a 14% increase. Half of deaths due to drug overdose (22,000 per year) are related to prescription drugs, according to a report on the leading cause of deaths from injury in the United States.

Heroin PrevalenceHeroin Prevalence

• Across years and across cultures, prevalence of heroin abuse is fairly stable at about 1.5% of the adult population.– Social upheaval linked to increases in heroin

abuse (Afghanistan, Iraq, Russia)

• Opioid dependence is considered a biopsychosocial disorder.

• Pharmacological• social• genetic• psychodynamic factors interact to influence abuse behaviors

associated with drugs.

Pharmacological factorsPharmacological factors

Opioids are strongly reinforcing agents because of the euphoric effects and reported ability to reduce anxiety, increase self esteem, and help coping with daily problems. Most opioids associated with abuse and dependence are mu-agonists, such as heroin, morphine, hydrocodone, oxycodone, and meperidine. Some partial mu-agonists, such as buprenorphine, or some that have no mu-agonism, such as pentazocine, also can possess reinforcing properties.

Social factorsSocial factors

• Easy drug availability and acceptable social attitudes make experimentation easy. A high rate of drug use is seen in areas of the city with poor parental functioning and higher crime and unemployment rates. Except for the association between higher exposure to the drug and higher rates of addiction, the precise role of social factors in creating dependent and addictive behaviors is uncertain. Of US service personnel in Vietnam between 1970 and 1972, 42% tried heroin; one half of those personnel became physically dependent, but very few continued to use heroin in their civilian life.

Psychological factorsPsychological factors

• Ego defects in certain patients are postulated to form the basis of drug use. Opioids are theorized to help the ego in managing painful effects such as anxiety, guilt, and anger. Behavioral theory postulates that basic reward-punishment mechanisms perpetuate addictive behavior.

• Preexisting mental health diagnoses appear to increase the risk for long-term use of opiods among adolescents and young adults with chronic pain

Genetic factors Genetic factors

• Genetic epidemiologic studies suggest a high degree of heritable vulnerability for opioid dependence.

Substance Dependence Substance Dependence A Multifactorial Brain DiseaseA Multifactorial Brain Disease

Substance-related disordersSubstance-related disorders• Intoxication

– use of substance resulting in maladaptive behavior Withdrawal

negative reactions that occur when use is discontinued or drastically reduced Delirium Dementia Psychosis Mood disorder Anxiety Sexual dysfunction Sleep disorder

Addiction is NOTAddiction is NOT

• Physical dependence - characteristic withdrawal syndrome emerges upon decreased blood levels of substance or antagonist administration

• Tolerance - increasing amount of drug needed over time to induce the same effect

Both are neuroadaptive states resulting from chronic drug administration

ToleranceTolerance

• Tolerance is the need for increasing doses of medication to achieve the initial effect of the drug. Tolerance to the analgesic and euphoriant effects and unwanted adverse effects, such as respiratory depression, sedation, and nausea, may develop.

• Withdrawal:Withdrawal:Continuous administration of opioids leads to physical dependence, the emergence of withdrawal symptoms during abstinence. Physical dependence is expected after 2-10 days of continuous use when the drug is stopped abruptly. The onset and duration of withdrawal varies with the drug used.

DependenceDependence

• Mental status effects include depression with any or all of its symptoms, such as sleep disturbances, lack of interest, selflessness, suicidal ideation, and poor coping skills.

• Physiological effects: Because tolerance to many of the actions of the opioids develops, it is not likely for even a careful observer to notice the effects of opioids. Small-sized pupils may be the only observation because only very mild tolerance develops for miosis. Inflamed nasal mucosa may be seen if heroin is snorted.

AddictionAddiction

• The phenomenon of addiction is seen in a variable number of patients using drugs. Addiction is characterized as a psychological and behavioral syndrome in which the following features are observed:

• Drug craving• Compulsive use• Strong tendency to relapse after withdrawal

Intoxication

• Mental status effects include euphoria, sedation, decreased anxiety, a sense of tranquility, and indifference to pain produced by mild-to-moderate intoxication. Severe intoxication can lead to delirium and coma.

• Physiological effects include the following:

• Respiratory depression Alterations in temperature regulations• Hypovolemia , leading to hypotension• Miosis• Needle marks or soft tissue infection• Increase sphincter tone (can lead to urinary retention)

manifestationmanifestation

• Symptoms of opioid abuse can be categorized by physical state.

• Intoxication state

• Patients with opioid use disorders frequently relapse and present with intoxication. Symptoms vary according to level of intoxication. For mild to moderate intoxication, individuals may present with drowsiness, pupillary constriction, and slurred speech. For severe overdose, patients may experience respiratory depression, stupor, and coma. A severe overdose may be fatal.

• Withdrawal state

diagnosis diagnosis

• The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) defines opioid use disorder as a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:[4]

• Taking larger amounts of opioids or taking opioids over a longer period than was intended• Experiencing a persistent desire for the opioid or engaging in unsuccessful efforts to cut down or

control opioid use.• Spending a great deal of time in activities necessary to obtain, use, or recover from the effects of

the opioid.• Craving, or a strong desire or urge to use opioids.• Using opioids in a fashion that results in a failure to fulfill major role obligations at work, school, or

home.• Continuing to use opioids despite experiencing persistent or recurrent social or interpersonal

problems caused or exacerbated by the effects of opioids.• Giving up or reducing important social, occupational, or recreational activities because of opioid

use.• Continuing to use opioids in situations in which it is physically hazardous.• Continuing to use opioids despite knowledge of having persistent or recurrent physical or

psychological problems that are likely to have been caused or exacerbated by the substance.• Tolerance, as defined by either a need for markedly increased amounts of opioids to achieve

intoxications or desired effect, or a markedly diminished effect with continued use of the same amount of an opioid.

• Withdrawal, as manifested by either the characteristic opioid withdrawal syndrome, or taking opioids to relieve or avoid withdrawal symptoms.

Laboratory StudiesLaboratory Studies

• Addiction• In case of historical or clinical evidence of IV

drug abuse, perform the following:

• LFT• Rapid plasma reagent (RPR)• Hepatitis viral testing• HIV testing• Blood cultures

Abuse and dependenceAbuse and dependence

• Urine drug screen

treatment

• Opioid intoxication• General supportive measures for opioid intoxication are as follows:

• Assess patient to clear airway.• Provide support ventilation, if needed.• Assess and support cardiac function.• Provide IV fluids.• Frequently monitor the vital signs and cardiopulmonary status until

the patient has cleared opioids from the system.• Give IV naloxone if necessary. Naloxone is a specific opiate

antagonist with no agonist or euphoriant properties. When administered intravenously or subcutaneously, it rapidly reverses the respiratory depression and sedation caused by heroin intoxication.

Opioid overdoseOpioid overdose• intranasal naloxone was approved by the FDA after fast

track designation and priority review. It is indicated for the emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression. The ready-to-use single-dose sprayer delivers a 4-mg dose by intranasal administration.

Opioid maintenance therapyOpioid maintenance therapy• Methadone maintenance therapy[27] (MMT) has been the standard of care for more

than 30 years. However, the recent advent of buprenorphine maintenance therapy (BMT) is changing the landscape of treatment for opioid-dependent patients.[28]

• Methadone, a long-acting synthetic opioid agonist, can be dosed once daily and replaces the necessity for multiple daily heroin doses. As such, it stabilizes the drug-abusing lifestyle, reducing criminal behaviors, and also reducing needle sharing and promiscuous behaviors leading to transmission of HIV and other diseases.

• Methadone is a highly regulated Schedule II medication, only available at specialized methadone maintenance clinics.

• Buprenorphine is a mu-opioid partial agonist that, like methadone, suppresses withdrawal and cravings. However, the property of partial agonism confers a "ceiling effect," at which higher doses of buprenorphine cause no additional effects. This ceiling effect affords a wider margin of safety than methadone, which can be lethal in overdose. The increased safety of buprenorphine has allowed it to become available by prescription as a Schedule III medication.

• Psychotherapies and support groups: Detoxification alone, without ongoing treatment, is not adequate to manage patients.[50]

• Patients in methadone programs often benefit from cognitive behavioral, supportive, or analytical-oriented psychotherapies if they are added to standard drug counseling.

• Cognitive behavior psychotherapy primarily focuses on the patient's thoughts and behaviors. Cognitive behavior–based models are widely used in drug rehabilitation programs. Cognitive behavior theories were aimed at substance abuse beginning in the mid 1980s. The techniques used help patients acquire specific skills for resisting substance use and teach coping skills to reduce problems related to drug use. Two major cognitive behavior theories of substance abuse are the following:

• Relapse prevention: Based on the work of Marlatt and Gordon, important relapse prevention concepts and techniques include identification and avoidance of high-risk situations, understanding the chain of decisions leading to drug use, and changing one's lifestyle.

• Cognitive therapy of substance abuse: Developed by Beck and colleagues, cognitive therapy of substance abuse is based on the concept that drug abusers engage in complex behaviors and thought processes, such as positive and negative drug-related beliefs and spontaneous flashes related to drug use before giving in to the actual drug use

Four questions patients ask:Four questions patients ask:

• How is methadone better for me than heroin?

• What is the right dose of methadone for me?

• How long should I stay on methadone?• What are the side effects of methadone?

Refrence Refrence

• http://emedicine.medscape.com/article/287790-clinical

• Basic psychiatry -second edition -2011

• Tomkins DN, Sellers EM (2001) Addiction and the brain: the role of neurotransmitters in the cause and treatment of drug dependence. Canadian Medical Association Journal 164 817-821

• O’Connor P, Fiellin DA. (2000) Pharmacological Treatment of Heroin-Dependent Patients Annals of Internal Medicine 133 40-54

• Sneader W. (1998)The Discovery of Heroin. Lancet 352 (9141) 1697-1699