Transcript opiods -psychiatry - mcststudent

Opioids
presented by : Torki El-jandali
121120877
• https://www.youtube.com/watch?v=NaMgd
lUcsko
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 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 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 muagonists, such as heroin, morphine,
hydrocodone, oxycodone, and meperidine.
Some partial mu-agonists, such as
buprenorphine, or some that have no muagonism, such as pentazocine, also can
possess reinforcing properties.
Social 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 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 epidemiologic studies suggest a high
degree of heritable vulnerability for opioid
dependence.
Substance Dependence
A Multifactorial Brain Disease
Substance-related disorders
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Intoxication
– use of substance resulting in maladaptive behavior
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Withdrawal
 negative reactions that occur when use is discontinued or drastically reduced
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Delirium
Dementia
Psychosis
Mood disorder
Anxiety
Sexual dysfunction
Sleep disorder
Addiction 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
Tolerance
• 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: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.
Dependence
• 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. Smallsized pupils may be the only observation because only
very mild tolerance develops for miosis. Inflamed nasal
mucosa may be seen if heroin is snorted.
Addiction
• 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-tomoderate intoxication. Severe intoxication can lead to delirium and
coma.
• Physiological effects include the following:
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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)
manifestation
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Symptoms of opioid abuse can be
categorized by physical state.
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Intoxication state
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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.
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Withdrawal state
diagnosis
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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]
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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.
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Laboratory Studies
• Addiction
• In case of historical or clinical evidence of IV
drug abuse, perform the following:
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LFT
Rapid plasma reagent (RPR)
Hepatitis viral testing
HIV testing
Blood cultures
Abuse and dependence
• Urine drug screen
treatment
• Opioid intoxication
• General supportive measures for opioid intoxication are as follows:
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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 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 singledose sprayer delivers a 4-mg dose by intranasal
administration.
Opioid maintenance therapy
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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]
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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 drugabusing lifestyle, reducing criminal behaviors, and also reducing needle sharing and
promiscuous behaviors leading to transmission of HIV and other diseases.
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Methadone is a highly regulated Schedule II medication, only available at specialized
methadone maintenance clinics.
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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.
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Psychotherapies and support groups: Detoxification alone, without ongoing
treatment, is not adequate to manage patients.[50]
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Patients in methadone programs often benefit from cognitive behavioral,
supportive, or analytical-oriented psychotherapies if they are added to
standard drug counseling.
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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:
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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.
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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:
• 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
• 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