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opiate abuse; opioid use disorder

A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two DSM-5 criteria [51] Etiology: - risk factors - age < 45 years - male [46] - smoking - history of depression - personality disorders, somatoform disorders, psychotic disorders [45,46] - personal or family history of substance abuse [46,52] - family history of alcohol abuse [1,4] - military deployment to Iraq or Afghanistan [5] - long-term use of opiates increased in patients prescribed opiates in the emergency department [16] - history of sexual trauma [52] - unemployment [52] - use of psychotropic agents [52] - long-term opioid use often begins with treatment of acute pain [17] - persistent opioid use after surgery is common for both minor & major procedures [19] - risk of opioid abuse increases with duration of post-surgical opioid use - opioid dosage is a weaker predictor of opioid abuse [33] - dental prescription of opiates to adolescents & young adults increases risk of later opiate abuse [38] - drug misuse & diversion by clinicians & other healthcare workers estimated at 10%, with fentanyl the most common drug diverted drug [44] Epidemiology: - spike in fentanyl deaths in Florida & Ohio 2016 linked to illicitly manufactured fentanyl rather than diverted prescription fentanyl [15] - unintentional & intentional opiate use among children & adolescents 14 per 100,000 [18] - 38% of Americans have use opiate in past year [27] - 5% of Americans have misused opiate in past year [27] - 1% of Americans with opiate use disorder [27] - increases associated with labor & delivery [36] - 1.5 per 1000 delivery hospitalizations in 1999, increasing to 6.5 per 1000 in 2014 - veterans who used 2 prescription plans to obtain opiates had greater risk of fatal overdose [43] Laboratory: - basic metabolic panel - 8 AM serum cortisol & plasma ACTH if hyponatremia & symptoms of secondary adrenal insufficiency [1] - urine drug testing Complications: - secondary adrenal insufficiency [1] Management: 1) inform patient of opioid use disorder [50] a) offer buprenorphine & link to a buprenorphine provider [50] b) discuss risks of self-escalations of opioids [52] c) assess risk-benefit of slow opioid taper [52] d) prescribe naloxone for opioid overdose [47] e) if hospitalized - build trust [53] - ask permission to discuss substance abuse - acknowledge patient expertise - communicate care plans - treat acute pain - some patients might have high opioid tolerance, especially with fentanyl use - treat acute withdrawal early - options: oral methadone, sublingual buprenorphine, clonidine, loperamide - co-occurring withdrawal symptoms can potentiate or prolong opioid effects - stimulants (amphetamines, cocaine) - benzodiazepines (xylazine) is common and . - consult an addiction medicine specialist as indicated - offer pharmaceutical treatment for opioid abuse - continue it throughout hospitalization & during perioperative periods - oral methadone, buprenorphine, extended-release naltrexone - delau initiation for 48-72 hours if patient has been using fentanyl) - provide naloxone - avoid judgment, coercion, or discrimination - care transitions to the community [53] - shared decision making - provide oral methadone, buprenorphine, or extended-release naltrexone 2) pharmacologic therapy a) buprenorphine* - a weekly injectable depot formulation of buprenorphine may be effective [24] - sublingual buprenorphine/naloxone (Suboxone) [1,35] - can precipitate withdrawal if patient has not abstained from opioid use for several hours before the first dose [41] - strongest predictor of abstinence at 42 months was continued buprenorphine treatment [41] - monthly buprenorphine depot injection is effective [42] - buprenorphine reduces risk of suicide mortality by 65% [47] - for severe pain not response to non-opioid analgesics in patients taking buprenorphine/naloxone, split buprenorphine/naloxone dose & prescribe short-acting opioid for no more than 3 days [52] b) methadone for patients in whom buprenorphine-naloxone not an option [35] - requires opioid treatment program that is licensed & regulated at the federal & state levels [41] - no such requirement is necessary for treatment of pain [41] - does not precipitate opiate withdrawal [41] - patients more likely to maintain remission & less likely to experience overdose if they continue methadone [50] c) slow-release oral morphine may be considered when both buprenorphine-naloxone & methadone contraindicated [35] d) naltrexone (Vivitrol) [3] - does not require special training or licensing - often requires prior authorization from an insurance company or collaboration with a specialty pharmacy [41] - precipitates opiate withdrawal if patient has not abstained from opioid use for several days before initiation [41] e) retention in treatment: methadone > buprenorphine > naltrexone [41] f) levo-acetylmethadol (LAAM) g) abuse-deterrent formulations [9] h) non-opiate alternatives to pain management [9] - extended-release tramadol may help reduce symptoms of opiate withdrawal [25] 3) immediate opioid agonist treatment to all people presenting for treatment of opioid use disorder is more effective & costs less than medically supervised withdrawal [31] 4) long-term addiction treatment must also accompany withdrawal management [35] - see opioid maintenance therapy - psychosocial interventions should be offered routinely but are not mandatory [35] - mindfulness-oriented recovery enhancement reduces opioid use in patients with chronic pain [48] 5) CMS pushing 7-day limit for initial opioid prescriptions for acute pain [34] * Qualified physicians (addiction specialists or physicians who complete 8 hours of approved training) may now prescribe buprenorphine & buprenorphine-naloxone (Suboxone) for office- based maintenance or detoxification Notes: - patients require long-term psychosocial support & medication [1] - use of methadone or buprenorphine substitution treatment for opioid dependence associated with reduced mortality, although all-cause mortality higher in the 1st 4 weeks of methadone treatment [21] - 25% of youth receive buprenorphine or naltrexone for treatment of opiate abuse [23] - Florida enacted legislation regulating pain clinics in 2010 & banned physicians from dispensing schedule II & III drugs from their offices in 2011 [6] - this halved number of opiate overdoses - abuse-deterrent OxyContin cut abuse by 75% [7] - continued OxyContin abusers often switched from injection to swallowing or inhalation - switch to heroin common [7] - the White House recommends expanding treatment services for substance abuse [10] - 1/7 of U.S. hospitalizations among older adults is followed by an opioid prescription [12] - 20% reported sharing their opioids with someone else - 60% report keeping opiates for future use [12] - opioids prescribed for postoperative pain often go unused or are unsafely stored & discarded [28] - physician killed for refusing to prescribe opiate [30] - in home induction programs safe & effective with education & telphone or texting support [37] - benzodiazepine can be coprescribed with buprenorphine - attempt to taper or reduce benzodiazepine use if possible - do not stop buprenorphine in patients who relapse - avoid mandatory counseling or participation in a 12-step program - offer psychosocial interventions - do not discharge patients from buprenorphine treatment based on drug testing; offer nonjudgmental, therapeutic discussions - other substance use is not treatment failure or reason for stopping buprenorphine - buprenorphine is not a short-term treatment [37] - most treatments extend > 1 year [37]

Related

addiction (psychological dependence) drug tolerance; drug habituation opioid dependence; chronic opioid use opioid maintenance therapy Opioid Overdose opioid receptor agonist (narcotic)

General

substance abuse

References

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