Opioids

What are opioids?

• Class of drugs which have morphine like effects

• The effects can be reversed by naloxone

• CNS depressants• Powerful analgesics • Prolonged use results in

tolerance, less effective analgesic properties

Use & Effects of Opioid Drugs

• Opioids that bind to receptors & activate them are “agonist” drugs (such as morphine & methadone)

• Those that bind to receptors but not activate them are “antagonists” (naloxone & naltrexone)

• Partial agonists (buprenorphine) bind to the same receptors but have less of an activation effect

Harmful Effects Dependence Amenorrhoea Infection

Scarring, thrombosis, thrombophlebitis Cellulitis, abscessSepticaemia, infective endocarditis,

osteomyelitisBlood borne viruses - HIV, HCV(90%),

HBV Overdose-related morbidity symptoms

Hypoxic brain injuryRhabdomyolysis

Poly drug and alcohol use highly prevalent

Types of Opioids available

Heroin Morphine Oxycontin Oxycodone Methadone Buprenorphine

History to take

• Name of the drug/s used• Dose of the drug (no. of injections

per day, dollars spent per day)• Route of administration• Frequency of use• Duration of use• Date and time of last use• Other drugs used ?• Alcohol/ Smoking

Assessing Opioid Use

• Heroin dosages estimates are difficult - wide variations in the concentration & purity of illicit heroin

• Oxycontin – More popular than heroin

• Consumption may be recorded as:The no of injections / dayThe no of grams ingestedDollars spent

Assessing Opioid Use

Approximate guide to a patient’s level of opioid use:

Low end= 1 to 2 injections / day, OR= 0.5 gram heroin or less / day

High end= 4 + injections / day, OR= 1-2 grams heroin or more / day

Signs and Symptoms of opioid intoxication

Analgesia Euphoria Miosis (‘pinned’ pupils) Constipation Sedation Itching, red eyes (histamine release) Respiratory depression and reduced cough

reflex Decreased level of consciousness (‘on the

nod’) Hypotension/bradycardia

Other Clinical Presentations

General – cachexia, CV – Murmurs, Pulse pressure,

stigmata of IE GE - CLD / hemetemesis Respiratory – LRTI /COPD Neuro - Septic Embolus /Discitis ID – Cellulitis /Abcesses / Sepsis/

BBV

Investigations

UDS Bloods including FBC, LFTs, UEC,

BBV (consent please) BAC CXR ECG

Opioid Overdose

Drowsy Decrease in GCS Decrease in O2 saturations Respiratory depression Rx: 400 mcg of Naloxone initially as

test dose and then further 400 mcg of naloxone

Consider alternative dx if failure to respond

Unplanned Withdrawal

• Patients in hospital, prison or other institutional care may undergo unplanned opioid withdrawal

• Patients may not always reveal their opioid use

Withdrawal Syndrome

Opioid Time after last dose Sx appear

Duration withdrawal

syndrome (days)

Heroin / Morphine / IV oxycontin

6 – 24 hours 5 – 10 days

Pethidine 3 – 4 hours 4 – 5 days

Methadone 36 – 48 hours 3 – 6 weeks

Buprenorphine 3 – 5 days Up to several weeks

Kapanol / MS Contin(if intravenous)

8 – 24 hours 7 – 10 days

Codeine PO 8 – 24 hours 5 – 10 days

Duration of opioid withdrawal

• Following acute withdrawal, protracted, low-grade symptom of discomfort (psychological & physical) may last many months

Signs & Symptoms of Opioid Withdrawal

Diarrhoea

Vomiting

Muscle twitching – restless legs when lying down

Intense craving

PiloerectionCramps

Dilated pupilsInsomnia & disturbed sleep

RhinorrhoeaBone, joint & muscle pain

PerspirationHot & cold flushes

YawningAbdominal pain

RestlessnessAnorexia & nausea

SignsSymptoms

Diarrhoea

Vomiting

Muscle twitching – restless legs when lying down

Intense craving

PiloerectionCramps

Dilated pupilsInsomnia & disturbed sleep

RhinorrhoeaBone, joint & muscle pain

PerspirationHot & cold flushes

YawningAbdominal pain

RestlessnessAnorexia & nausea

SignsSymptoms

Course of Opioid withdrawal

NSW Department of Health (2007).

Withdrawal Monitoring

• Patients should be monitored regularly & this may include use of a withdrawal scale

• Frequency of observations should be determined by the severity of the withdrawal

• Monitoring should be based on observations, objective signs & subjective Sx

Withdrawal Scales

• The Clinical Opiate Withdrawal Scale (COWS) rates 11 items describing severity of symptoms from scores of 0 (not present) to > 36 (severe)

• The COWS is considered a reliable & valid withdrawal scale

Withdrawal Scales

• Withdrawal scales do NOT diagnose withdrawal, but merely guides to the severity of an already diagnosed withdrawal syndrome

• Re-evaluate the patient regularly to ensure that it is opioid withdrawal & not underlying medical condition, especially if the patient is not responding well to Rx

Opioid Withdrawal Rx

• An opioid withdrawal syndrome can be managed with:

BuprenorphineMethadoneSymptomatic Meds

Buprenorphine

• A partial opioid agonist – an opioid analgesic with both agonist and antagonist properties

• Available in 2 forms: buprenorphine & bup/naloxone (Suboxone film)

• Administered sublingually (tab usually take 5 minutes to dissolve, film adheres within 90 secs)

• Less respiratory depression than full agonists

Buprenorphine

• Buprenorphine is the principal Rx option for managing opioid withdrawal

• Well suited in the hospital setting

• Can effectively relieve symptom severity in opioid withdrawal, meaning that other symptomatic medication may not be required

Buprenorphine

• Buprenorphine binds very tightly to opioid receptors & can displace other opioids

• Buprenorphine can precipitate withdrawal

• 1st doses bup should be delayed for at least -

- 6 hours after heroin & oxy - 24 hours after methadone

NB: buprenorphine is NOT to be administered until withdrawal is

evident

Buprenorphine

• If using a withdrawal scale as part of patient assessment Rx should not begin until: A COWS score of a least 8 (representing the mid point of scale)Give 2mg buprenorphine (test dose) If tolerated, can give a further 4-8mg in 1 hourPt can have a total of 32mg Day 1 if clinically indicated

Methadone

“Gold standard” pharmacotherapy for opioid dependence for over 30 years

Synthetic opioid with a long half life Administered daily Dispensed from a clinic, hospital or

registered pharmacy Authorised prescribers Clients are registered with NSW

Pharmaceutical Services Unit

Methadone to Treat Opioid W/D

Maximum initiation dose 40mg/d (in consultation with D&A Team)

Usually 15mg BD in hospital in initiation Usually increase every 3/7’s Commonly used in patients who have opioid

analgesia requirements D&A Team always offer to link patient in with

community OST Patient may or may not want ongoing OST

Symptomatic Mx for Opioid Withdrawal

Muscles Aches / Pains

Paracetamol 1000mg, every 4 hours PRN (maximum 4000mg in 24 hours ORIbuprofen 400mg 6 hourly PRN (if no Hx of peptic ulcer or gastritis)

Nausea Metoclopramide 10mg, 4-6 hourly PRN, reducing to 8th hourly as Sx reduce ORProchlorperazine (Stemetil) 5mg, every 4-6 hours PRN, reducing to 8th hourly as Sx reduce2nd line Rx for severe nausea/vomiting: Ondansetron (Zofran) 4-8mg, every 12 hours PRN

Symptomatic Mx for Opioid Withdrawal

Abdominal cramps

Hyoscine (buscopan) 20mg, every 6 hours PRN

2nd line Rx for severe gastrointestinal Sx: Octreotide (sandostatin) 0.05-0.1mg, every 8-12 hours PRN by subcutaneous injection (hospital setting only)

Diarrhoea Kaomagma or loperamide (gastro-stop) 2mg PRN

Symptomatic Mx for Opioid Withdrawal

Sleeplessness Temazepam 10-20mg nocte. Cease dose after 3-5 nights

Agitation / Anxiety

Diazepam 5mg QID PRN

Restless legs Diazepam (as above) ORBaclofen 10-25mg every 8 hours

Sweating, sedating agitation

Clonidine 75mcg every 6 hours

Altered tolerance and pain management

Analgesics should not be withheld unless medically indicated

Providing pain relief will not make the patient more drug dependent

Methadone patients will not receive pain relief from their usual daily dose

First indication of tolerance to opioids is decreased duration of effect, decreased analgesia – an involuntary physiological response

Opioid maintenance treatment in hospital

• Patients who are on methadone or buprenorphine when admitted to SVH should remain on their current dose – UNLESS THEY HAVE MISSED DOSES – PLS RING D&A

• PSU – 9424 5921 Confirm last dose from the dosing point Remove takeaway doses from patient if

they are on their person Ensure adequate pain relief is given Dosing point will need fax of last dose on

D/C

Buprenorphine & Pt’s in Acute Pain….

Standard doses of opioid analgesia are not likely to be effective in any patient who has taken buprenorphine within the last 3-4 days

Non opioid analgesia, local anaesthetics approaches, higher dose opioid prescriptions, ceasing or increasing bup may be required for pain relief – Contact D&A & APS

Buprenorphine / methadone prescribing…

• In hospital, doctors can prescribe methadone or buprenorphine as part of management of opioid-dependent people

• Outside hospital, methadone & buprenorphine may only be used in the treatment of opioid dependency by authorised medical practitioners

Take Home

Take a good substance use history Screen for BBV Rx with naloxone in suspected od with

400 mcg x 2 Rx opioid withdrawal with suboxone or

methadone