Source: Doering PL. Substance-Related
Disorders: Overview and Depressants, Stimulants, and Hallucinogens.
In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM,
eds. Pharmacotherapy: A Pathophysiologic
Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7987346.
Accessed June 12, 2012.
- Addiction characterized by behaviors that include:
- Impaired control over drug use
- Compulsive use
- Continued use despite harm
- Physical dependence: state of adaptation manifested by withdrawal
- 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.
- Complications of heroin use include:
- Anaphylactic reactions to impurities
- Nephrotic syndrome
- Acquired immunodeficiency
- Opioids are commonly combined with stimulants (e.g., cocaine [speedball])
- Peak respiratory depressant effects occur later and last longer
than peak analgesic effects.
- Number of people aged 12 and older who used prescription
pain relievers illicitly doubled from 2.6 to 5.2 million from 1999
- In 2006, 5.2 million people surveyed used prescription pain
relievers illicitly in past month, 17 times number of people who
- Majority of illicitly used prescription opioids obtained from
physicians rather than drug dealers.
- Opioid intoxication:
- Attention impairment
- Opioid withdrawal:
- 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.
- 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)
- Other drug dependence (alcohol, amphetamines)
- Underlying psychiatric illness (depression, personality disorder)
- Other drug withdrawal (alcohol, benzodiazepines, amphetamines, cocaine)
- Nausea or vomiting due to other causes (influenza or other
- Delirium suggests withdrawal from another drug (e.g., alcohol).
- Cessation of use of drug
- Termination of drug-seeking behaviors
- Return to normal functioning
- Goals of treatment for withdrawal
progression of withdrawal to life-threatening severity.
- Enable patient participation in treatment program.
- Support vital functions as required.
- Give 0.4–2 mg IV every
3 minutes for acute opioid overdoses.
- Treatment may revive unconscious patients with respiratory
depression but may also precipitate withdrawal in dependent patients.
- Usual starting dose 20–40
mg PO daily.
- Taper by 5–10 mg daily until discontinued.
- Discontinuation schedules over 30–180 days have been
- Once-daily dosage titrated to
target of 16 mg/day (range 4–24 mg/day).
- Available for office-based management of opioid dependence
by qualified physicians.
- Subutex (buprenorphine)
typically used at beginning of treatment.
- Suboxone (buprenorphine and naloxone) used for maintenance
- Can attenuate noradrenergic hyperactivity
of opiate withdrawal without interfering significantly with activity
at opiate receptors.
- Usual dose 2 mcg/kg 3 times a day × 7 days.
- Taper over ...