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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.

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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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  • Complications of heroin use include:
    • Overdoses
    • Anaphylactic reactions to impurities
    • Nephrotic syndrome
    • Septicemia
    • Endocarditis
    • Acquired immunodeficiency
  • Opioids are commonly combined with stimulants (e.g., cocaine [speedball]) or alcohol).
  • Peak respiratory depressant effects occur later and last longer than peak analgesic effects.

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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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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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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 (e.g., alcohol).

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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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  • Support vital functions as required.

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  • Naloxone
    • 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.

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  • Methadone
    • Usual starting dose 20–40 mg PO daily.
    • Taper by 5–10 mg daily until discontinued.
    • Discontinuation schedules over 30–180 days have been used.
  • Buprenorphine
    • 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 treatment.
  • Clonidine
    • 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 ...

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