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SOURCE

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Source: Doering PL, Li RM. Substance-related disorders I: overview and depressants, stimulants, and hallucinogens. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146064131. Accessed April 12, 2017.

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DEFINITION

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  • Addiction characterized by behaviors that include:

    • Chronicity.

    • Impaired control over drug use.

    • Compulsive use.

    • Continued use despite harm.

    • Craving.

  • Physical dependence: state of adaptation manifested by withdrawal syndrome following:

    • Cessation.

    • Rapid dose reduction.

    • Decreasing blood levels.

    • Administration of antagonist.

  • Withdrawal: development of substance-specific syndrome following cessation or reduced intake of substance that had been used regularly.

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PATHOPHYSIOLOGY

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  • Complications of heroin use include:

    • Overdoses.

    • Anaphylactic reactions to impurities.

    • Nephrotic syndrome.

    • Septicemia.

    • Endocarditis.

    • Acquired immunodeficiency.

  • Opioids are commonly combined with stimulants (eg, cocaine [speedball]) or alcohol).

  • Peak respiratory depressant effects occur later and last longer than peak analgesic effects.

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EPIDEMIOLOGY

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  • Number of people aged 12 and older who used prescription pain relievers illicitly doubled from 2.6 to 5.2 million from 1999 to 2006.

  • In 2006, 5.2 million people surveyed used prescription pain relievers illicitly in past month, 17 times number of people who used heroin.

  • Majority of illicitly used prescription opioids obtained from physicians rather than drug dealers.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Opioid intoxication:

    • Euphoria.

    • Dysphoria.

    • Apathy.

    • Sedation.

    • Attention impairment.

  • Opioid withdrawal:

    • Lacrimation.

    • Rhinorrhea.

    • Mydriasis.

    • Piloerection.

    • Diaphoresis.

    • Diarrhea.

    • Yawning.

    • Fever.

    • Insomnia.

    • Muscle aches.

  • Heroin withdrawal begins within a few hours after stopping drug and reaches peak within 36–72 hours.

  • Methadone withdrawal may not begin for several days and peak reached at ~72 hours.

  • Duration of withdrawal ranges from 3–14 days.

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DIAGNOSIS

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LABORATORY TESTS
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  • Opioid use and dependence: Urine drug screen.

    • When toxicology screens necessary, collect urine immediately when patient presents for treatment.

  • Withdrawal: Serum electrolytes, complete blood count (CBC)

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DIFFERENTIAL DIAGNOSIS
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  • Dependence:

    • Other drug dependence (alcohol, amphetamines)

    • Underlying psychiatric illness (depression, personality disorder)

  • Withdrawal:

    • Other drug withdrawal (alcohol, benzodiazepines, amphetamines, cocaine)

    • Nausea or vomiting due to other causes (influenza or other viral syndrome)

    • Delirium suggests withdrawal from another drug (eg, alcohol).

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DESIRED OUTCOMES

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  • Cessation of use of drug.

  • Termination of drug-seeking behaviors.

  • Return to normal functioning.

  • Goals of treatment for withdrawal.

    • Prevent progression of withdrawal to life-threatening severity.

    • Enable patient participation in treatment program.

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TREATMENT: NONPHARMACOLOGIC THERAPY

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  • Support vital functions as required.

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TREATMENT: OPIOID INTOXICATION

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  • Naloxone.

    • Give 0.4–2 mg IV every 3 min for acute opioid overdoses.

    • Treatment may revive unconscious patients with respiratory depression but may also precipitate withdrawal in dependent patients.

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TREATMENT: OPIOID ...

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