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DISCLOSURES MANAGEMENT OF OPIOID USE DISORDERS Marc A Schuckit I - - PDF document
DISCLOSURES MANAGEMENT OF OPIOID USE DISORDERS Marc A Schuckit I - - PDF document
DISCLOSURES MANAGEMENT OF OPIOID USE DISORDERS Marc A Schuckit I have nothing to declare Distinguished Professor of Psychiatry, UCSD Medical School LECTURE COVERS SUDs ARE IMPORTANT Drug groups & problems Affect > 20% of your
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DRUG PROBLEMS
Overdose Withdrawal
Delirium Psychosis Major depression Anxiety
Drug groups & problems Substance use disorders Criteria Course Treatment Identification/intervention Detoxification Rehabilitation After you’re gone
LECTURE COVERS SUBSTANCE USE DISORDER
In same year 2+ of: Failed roles Hazardous use Social problems Tolerance* Withdrawal* Use longer/more Unable to ↓ Lots time use ↓ activities Use despite probs Craving
* Special re opioids
Fluctuating:
- Controlled use
- Problems
- Abstinence
>20% spontaneous remission In richer & poorer Prevention: NEVER USE FOR A HIGH
SUD COURSE
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Drug groups & problems Substance use disorders Criteria Course Treatment Identification/intervention Detoxification Rehabilitation After you’re gone
LECTURE COVERS OVERDOSE
Symptoms Awake respirations <12/min*/stupor*/miosis* Also: ↓ temp/↓ gut sounds/pulmonary edema Treatment Ventilate Naloxone: 0.04mg IM, IN, IV— but not oral If no ↑ respiration in 2 min →0.5mg → 2mg → 5mg → 10mg → 15mg
Opioid OD Decisions
Resp < 12min when awake YES Long Acting Opioid? Yes NO Awake/alert NO Yes NO
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Long Acting Opioid? NO Yes Observe 8+hr Observe 6hr
~ p last naloxone
O2 Naloxone Continuous IV Naloxone ± Intubate Observe 6hr
~ p IV stop
ICU ICU Refer for OP Rx
Boyer NEJM 2012
STAGES OF RX
Identification/intervention: drop stereotypes Detoxification Physical exam & history Rehabilitation Enhance motivation Help readjust to life Aftercare Reassurance Medications Relapse prevention Medications
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Relationships School or job Accidents TO ID: ASK ABOUT PROBLEMS
Then tie in substances
Legal Health
QUESTIONNAIRES
CAGE-AID (2+): Feel need cut down Feel bad or guilty Annoyed by criticisms Eye-opener for relief/steady Drug Use Questionnaire (DAST-10: 3+) Non-med use/multi drugs/not stop/blackout/guilt/ Complaints/neglect/illegal/withdrawal/med probs
MOTIVATIONAL INTERVIEWING
Build trust Empathic Avoid ↑ resistance Patient is in charge Elicit motivational statements Explore ambivalence Monitor readiness to change
STAGES OF RX
Identification/intervention Detoxification Physical exam & history Vitamins Rehabilitation Enhance motivation Help readjust to life Aftercare Reassurance Medications Relapse prevention Medications
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DETOX
Depressants
Opioids
Stimulants (no specific Rx)
DETOX RX
Physical exam Rest & education Nutrition Meds for:
Opioids
KEY MEDICATIONS
Methadone (oral): Mu-opioid agonist; ½ life 15-20 hrs Buprenorphine (SL or buccal) Partial mu agonist; kappa antagonist ½ life 3 hrs (longer recepter occupation) Mu antagonists: Naltrexone ½ life: oral 4-13 hrs IM 5-10 days Naloxone (not oral): onset 2 min; action 20-90 min
OPIOID WITHDRAWAL
Symptoms opposite of acute effects Timing depends on drug length action PE, educate, motivate Methadone or Buprenorphene
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CLINICAL OPIOID WITHDRAWAL SCALE (COWS)
Pulse > 80 Rhinorrhea Sweating Cramps/naus/vomit Restless Tremor Pupils ↑ Yawning Bone/joint pain Anxous/irritable Goosebumps Each scored 1-4 or 1-5 Total: 5-12 = mild 25-36 = mod/severe 13-24 = mod > 36 = severe
WITHDRAWAL
Detox ≠ rehabilitation Onset symptoms Naloxone: in 2 minutes Short acting (heroin): ~ 8 hrs, ↓ day 4 Long acting (methadone): 1+ days, ↓ day 10 Protracted withdrawal: 2 weeks to 2+ months Fatigue ↓ appetite insomnia anhedonia
LONG ACTING OPIOID TAPER
Oral methadone SL buprenorphine PE PE: Rx at mild sympt Initial dose (ck in 1 hr; adjust) 10 mg < current dose 4-8 mg 10-30 mg/d (÷) Stabilize 7-14 days 2-5 days Taper ~ 0-20% of initial dose Every 1-2 days
OPIOID-FREE DETOX
Med Dose Target
Clonidine 0.1-0.2mg q 4h Flu-like patch 1 for 100-200 # Diazepam 2-10mg q 4h Insom/anxiety Imodium 4mg, then 2mg Diarrhea Naproxin 500mg 2x/d Aches/pain Compazine 5-10mg q 4h Naus/vomit
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STAGES OF RX
Identification/intervention Detoxification Physical exam & history Vitamins Rehabilitation Enhance motivation Help readjust to life Aftercare Reassurance Medications Relapse prevention Medications
REHABILITATION
Increase motivation Help rebuild life Relapse prevention +/- medications
REHAB: NALTREXONE
Action: Blocks opioid high/↓ craving Restriction: Must be opioid free Induction: Test : 12.5mg; in 4 h 25-50mg Day 1: Begin 50-100mg/d Maintenance: 100mg Mon & Wed 150mg Fri OR 380mg IM/mo
MAINTENANCE GOALS
Substitute safer opioid Oral to avoid craving set on by needles Long acting to avoid daytime symptoms Use 1+ years— note OD danger when stop Rx includes counseling pain control monitoring Goals: ↓ IV dangers ↑ Health Crime Work OD Relationships
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