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opioid dependence; chronic opioid use

Etiology: - adverse effect of drug tolerance to opioid receptor agonists (narcotics) Epidemiology: - the U.S. represents < 5% of the world's population, yet it consumes ~80% of the world's opioid supply [2] - 1/3 of long-term opiate users report dependence [4] Clinical manifestations: - drug-withdrawal may occur if the drug is stopped abruptly or when opioid antagonists are administered Complications: - associated with worse functional status, diminished quality of life, & worse pain [1] - longer duration of opioid therapy associated with increased risk for death due to overdose or suicide after stopping opioids [12] Differential diagnosis: - differs from opioid abuse (which includes a component of opiate use for effects other than relief of pain) Management: - buprenorphine/naloxone - opioid-dependent individuals visiting the emergency department are much more likely to participate in addiction treatment when buprenorphine/naloxone therapy is started in the emergency department (78% vs 37-45%) [3] - one week of escalating oral naltrexone administration transitioned to extended-release naltrexone injections improves chances of successful outpatient detoxification [5] - extended-release naltrexone (Vivitrol) as safe & effective as daily oral buprenorphine-naloxone [6] - NSS-2 Bridge device FDA-approved to help reduce the symptoms of opioid withdrawal [7] - negotiated taper of opioid dosage with educational support effective in ~1/2 of patients [8] - meditation, hypnosis, & cognitive behavioral therapy mat reduce both opioid use & pain [11] Notes: - long-term opiate users - 1/3 said their physicians talked about a plan for stopping opioids when first prescribing them - 62% reported that their physicians discussed other pain management strategies - 65% said their physicians talked to them about the risk for addiction or dependence [4] - inpatient opioid administrationin opioid niave patients leads to continued outpatient opioid use at 3 months & 1 year [9] - opioid discontinuation in long-time users - reduce dose 5-20% every 4 weeks - longer opioid users may require longer tapers - consider transitioning patient to buprenorphine if high dose opioid & unable to taper, even if criteria for opioid use disorder not met [10] - after a successful taper - patients who attempt to abruptly return to their higher dose may experience opioid overdose - tolerance may be lost in 1 week [10]

Related

opiate withdrawal opioid receptor agonist (narcotic)

General

drug dependence

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 19. American College of Physicians, Philadelphia 2006, 2012, 2021.
  2. Express Scripts Drug Safety and Abuse Dec 9, 2014 http://lab.express-scripts.com/insights/drug-safety-and-abuse/americas-pain-points
  3. D'Onofrio G et al Emergency Department-Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence. A Randomized Clinical Trial. JAMA. 2015;313(16):1636-1644 PMID: 25919527 - Physician's First Watch, Dec 12, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
  4. Orciari Herman A, Sadoughi S, Sofair A. 1 in 3 Long-Term Rx Opioid Users Report Dependence Physician's First Watch, Dec 12, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
  5. Sullivan M, Bisaga A, Pavlicova M et al. Long-acting injectable naltrexone induction: A randomized trial of outpatient opioid detoxification with naltrexone versus buprenorphine. Am J Psychiatry 2017 Jan 10; PMID: 28068780 http://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2016.16050548
  6. Tanum L, Solli KK, Latif Z et al The Effectiveness of Injectable Extended-Release Naltrexone vs Daily Buprenorphine-Naloxone for Opioid DependenceA Randomized Clinical Noninferiority Trial. JAMA Psychiatry. Published online October 18, 2017. PMID: 29049469 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2657484
  7. FDA News Release. Nov 15, 2017 FDA grants marketing authorization of the first device for use in helping to reduce the symptoms of opioid withdrawal. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm585271.htm
  8. Darnall BD, Ziadni MS, Stieg RL, Mackey IG, Kao MC, Flood P. Patient-centered prescription opioid tapering in community outpatients with chronic pain. JAMA Intern Med 2018 Feb 19 PMID: 29459978 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2672574
  9. Donohue JM, Kennedy JN, Seymour CW et al. Patterns of opioid administration among opioid-naive inpatients and associations with postdischarge opioid use: A cohort study. Ann Intern Med 2019 Jun 18; [e-pub]. PMID: 31207646 https://annals.org/aim/article-abstract/2736099/patterns-opioid-administration-among-opioid-naive-inpatients-associations-postdischarge-opioid?doi=10.7326%2fM18-2864 - Larochelle MR, Bohnert ASB. Opportunities to address first opioid prescriptions to reduce incident long-term opioid use. Ann Intern Med 2019 Jun 18 PMID: 31207647 https://annals.org/aim/article-abstract/2736100/opportunities-address-first-opioid-prescriptions-reduce-incident-long-term-opioid
  10. HHS News Release. Oct 10, 2019 HHS Announces Guide for Appropriate Tapering or Discontinuation of Long-Term Opioid Use. https://www.hhs.gov/about/news/2019/10/10/hhs-announces-guide-appropriate-tapering-or-discontinuation-long-term-opioid-use.html
  11. Garland EL et al. Mind-body therapies for opioid-treated pain: A systematic review and meta-analysis. JAMA Intern Med 2019 Nov 4; PMID: 31682676 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2753680
  12. Oliva EM et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: Observational evaluation. BMJ 2020 Mar 4; 368:m283. PMID: 32131996 Free Article https://www.bmj.com/content/368/bmj.m283