opiate abuse; opioid use disorder

Introduction

A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two DSM-5 criteria

Etiology

• risk factors
  • age < 45 years
  • male
  • smoking
  • history of depression
  • personality disorders, somatoform disorders, psychotic disorders
  • personal or family history of substance abuse
  • family history of alcohol abuse
  • military deployment to Iraq or Afghanistan
  • long-term use of opiates increased in patients prescribed opiates in the emergency department
  • history of sexual trauma
  • unemployment
  • use of psychotropic agents
• long-term opioid use often begins with treatment of acute pain
• persistent opioid use after surgery is common for both minor & major procedures
  • risk of opioid abuse increases with duration of post-surgical opioid use
  • opioid dosage is a weaker predictor of opioid abuse
• dental prescription of opiates to adolescents & young adults increases risk of later opiate abuse
• drug misuse & diversion by clinicians & other healthcare workers estimated at 10%, with fentanyl the most common drug diverted drug

Epidemiology

• spike in fentanyl deaths in Florida & Ohio 2016 linked to illicitly manufactured fentanyl rather than diverted prescription fentanyl
• unintentional & intentional opiate use among children & adolescents 14 per 100,000
• 38% of Americans have use opiate in past year
• 5% of Americans have misused opiate in past year
• 1% of Americans with opiate use disorder
• increases associated with labor & delivery
  • 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

Laboratory

• basic metabolic panel
  • 8 AM serum cortisol & plasma ACTH if hyponatremia & symptoms of secondary adrenal insufficiency
• urine drug testing

Complications

• secondary adrenal insufficiency

Management

• inform patient of opioid use disorder
  • offer buprenorphine & link to a buprenorphine provider
  • discuss risks of self-escalations of opioids
  • assess risk-benefit of slow opioid taper
  • prescribe naloxone for opioid overdose
  • if hospitalized
    • build trust
      • 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
      • shared decision making
      • provide oral methadone, buprenorphine, or extended-release naltrexone
• pharmacologic therapy
  • buprenorphine*
    • a weekly injectable depot formulation of buprenorphine may be effective
    • sublingual buprenorphine/naloxone (Suboxone)
    • can precipitate withdrawal if patient has not abstained from opioid use for several hours before the first dose
    • strongest predictor of abstinence at 42 months was continued buprenorphine treatment
    • monthly buprenorphine depot injection is effective
    • buprenorphine reduces risk of suicide mortality by 65%
    • 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
  • methadone for patients in whom buprenorphine-naloxone not an option
    • requires opioid treatment program that is licensed & regulated at the federal & state levels
    • no such requirement is necessary for treatment of pain
    • does not precipitate opiate withdrawal
    • patients more likely to maintain remission & less likely to experience overdose if they continue methadone
  • slow-release oral morphine may be considered when both buprenorphine-naloxone & methadone contraindicated
  • naltrexone (Vivitrol)
    • does not require special training or licensing
    • often requires prior authorization from an insurance company or collaboration with a specialty pharmacy
    • precipitates opiate withdrawal if patient has not abstained from opioid use for several days before initiation
  • retention in treatment: methadone > buprenorphine > naltrexone
  • levo-acetylmethadol (LAAM)
  • abuse-deterrent formulations
  • non-opiate alternatives to pain management
    • extended-release tramadol may help reduce symptoms of opiate withdrawal
• immediate opioid agonist treatment to all people presenting for treatment of opioid use disorder is more effective & costs less than medically supervised withdrawal
• long-term addiction treatment must also accompany withdrawal management
  • see opioid maintenance therapy
  • psychosocial interventions should be offered routinely but are not mandatory
  • mindfulness-oriented recovery enhancement reduces opioid use in patients with chronic pain
• CMS pushing 7-day limit for initial opioid prescriptions for acute pain

* 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
• 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
• 25% of youth receive buprenorphine or naltrexone for treatment of opiate abuse
• Florida enacted legislation regulating pain clinics in 2010 & banned physicians from dispensing schedule II & III drugs from their offices in 2011
  • this halved number of opiate overdoses
• abuse-deterrent OxyContin cut abuse by 75%
  • continued OxyContin abusers often switched from injection to swallowing or inhalation
  • switch to heroin common
• the White House recommends expanding treatment services for substance abuse
• 1/7 of U.S. hospitalizations among older adults is followed by an opioid prescription
  • 20% reported sharing their opioids with someone else
  • 60% report keeping opiates for future use
• opioids prescribed for postoperative pain often go unused or are unsafely stored & discarded
• physician killed for refusing to prescribe opiate
• in home induction programs safe & effective with education & telphone or texting support
• 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
  • most treatments extend > 1 year

More general terms

• substance abuse

Additional terms

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