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
• 1/3 of long-term opiate users report dependence

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
• longer duration of opioid therapy associated with increased risk for death due to overdose or suicide after stopping opioids

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%)
• one week of escalating oral naltrexone administration transitioned to extended-release naltrexone injections improves chances of successful outpatient detoxification
• extended-release naltrexone (Vivitrol) as safe & effective as daily oral buprenorphine-naloxone
• NSS-2 Bridge device FDA-approved to help reduce the symptoms of opioid withdrawal
• negotiated taper of opioid dosage with educational support effective in ~1/2 of patients
• meditation, hypnosis, & cognitive behavioral therapy mat reduce both opioid use & pain

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
  • inpatient opioid administrationin opioid niave patients leads to continued outpatient opioid use at 3 months & 1 year
• 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
  • 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

More general terms

• drug dependence

Additional terms

• opiate withdrawal
• opioid receptor agonist (narcotic)