Opioid Use Disorder OUD JULIA SORELLE FNPBC Opioid
Opioid Use Disorder (OUD) JULIA SORELLE FNP-BC
Opioid Use Disorder OUD is defined by the Diagnostic and Statistical Manual of Mental Disorders 5 th edition (DSM-V) as a “problematic pattern of opioid use leading to clinically-significant impairment or distress” characterized by the presence of at least 2 criteria 1)opioid cravings 2) tolerance and withdrawal symptoms over a 12 month period
OUD Each year more Americans die from drug overdose than traffic accidents From 2000 -2016 over 600, 000 deaths involving opioids On average 115 Americans die each day from opioid overdose The amount of prescription opioids sold to pharmacies, hospitals, and doctors has quadrupled from 1999 -2010 Providers wrote nearly a quarter of a million opioid prescriptions in 2013 Most common drugs involved with overdose are Methadone, Oxycodone, and Hydrocodone
OUD Increases the Risk of Early Death Accidental Overdose Trauma Suicide Infectious Disease (HIV, Hepatitis C)
OUD Prescription opioids and heroin are chemically similar and work through the same mechanism of action Both heroin and prescription opioids work on the Mu-opioid receptor Reward regions in the brain have high concentration of Mu-opioid receptors Because prescription opioids are similar to and act on the same brain systems affected by heroin, they present an intrinsic abuse and addiction liability
Categories of Opioids Natural opioid analgesics: morphine, codeine Semi-synthetic opioid analgesics: oxycodone, hydromorphone, oxymorphone Methadone: synthetic opioid Synthetic opioid analgesic(other than methadone): tramadol, fentanyl
Risk Factors Opioid Abuse and Overdose Multiple overlapping prescriptions from multiple providers High daily doses Mental illness History of alcohol and/or substance abuse Low income Living in rural areas Overlapping pain reliever and Benzodiazepine Long acting extended release pain relievers
Pain-Overview The IASP describes pain as “an unpleasant sensory and emotional experience” (International Association for the Study of Pain, 1074) Pain is a complex multidimensional experience that involves biological, psychological, social, and spiritual domains and is made up of cognitive, emotional and sensory components When pain becomes persistent, biopsychosocial and behavioral influences change the brain and central nervous system, such that circuits involved in pain processing are sensitized and circuits involved in goal-directed behavior, emotional modulation, and the embodied sense of self appear to be disrupted As pain becomes persistent the processing of pain in the brain shifts from nociceptive brain circuits-where pain perception arises from stimulation of pain sensors-to brain circuits involved with emotional and cognitive processing
Assessing Pain and Function
Preferred Treatments for Pain Self-Care and Active Non. Pharmacologic Therapies Enhance whole health self-care and lifestyle modification Provide behavioral, mindfulness and cognitive therapies Offer movement therapies Use coordinated team-based approach
Bridging Therapies Safe, short-term therapies that are implemented to help patients transition to more active strategies from less safe, passive strategies 1) Acupuncture 2)Spinal manipulation (e. g. , chiropractic) 3) Physical modalities(e. g. , self-applied electrical stimulation) Invasive therapies that may be implemented when the benefits of facilitating active treatment strategies outweigh the potential risks of therapy 1)trigger point injections 2)joint injections 3)nerve blocks 4) spinal injections
Pharmacological Therapies: Non. Opioids medications are Preferred Non-steroidal anti-inflammatory drugs (NSAIDs) and Acetaminophen Antidepressants: tricyclic antidepressants (TCAs), serotonin/norepinephrine reuptake inhibitors (SNRIs) For musculoskeletal/nociceptive pain not neuropathic pain For musculoskeletal pain and neuropathic pain Anticonvulsants: gabapentin/pregabalin For neuropathic pain Topical therapies: lidocaine, capsaicin, NSADs Muscle relaxants Usually only short term use
Best Practices for Appropriate and Effective Prescribing of Opioid Pain Medications Use caution when opioid is considered for acute pain ( even a single opioid prescription may increase risk for developing OUD, and often opioid therapy for an acute pain condition unintentionally becomes long-term opioid therapy Start with a whole person biopsychosocial assessment Avoid opioids for minor injuries (low back pain, sprains) Prescribe the lowest effective dose of immediate release opioids for the shortest therapeutic duration 3 days or less is often sufficient, more than seven days rarely needed Combine opioids with other pharmacological and non-pharmacological modalities –do not use opioids in isolation
Best Practices Opioid Pain medications Do not use long-acting opioid medications for acute pain, as-need or postoperatively Discuss with the patient benefits, side effects and risks (e. g. , sedation, addiction, and overdose) Check patients understanding of treatment plan Counsel patient about safe storage
Caution When Continuation of Opioid Therapy is Considered for Persistent Pain Opioid therapy should be used only short-term (<90 days) Prescribe lowest effective dose Combine opioids with other pharmacological and non-pharmacological modalities Ensure that risk do not outweigh the benefits Educate regarding realistic effects, risks, responsibilities and goals of therapy Determine realistic goals for pain & function Set criteria for stopping or continuing opioid Identify exit strategy Reassess benefit/risk within 1 -4 weeks
Essential Components of Opioid Safety Informed consent for long term opioid therapy Prescription drug monitoring (PDMPs) Random urine drug testing Overdose education and naloxone distribution
Medical and Psychological Adverse Effects of Long-term Opioid Therapy Endocrine deficiencies : low testosterone, sexual dysfunction, osteoporosis Cognitive Impairment Worsening Anxiety, depression and PTSD symptoms Falls Immunosuppression and cardiovascular side effects Disrupted or impaired sleep Opioid induced hyperalgesia
Urine Drug Screen length of time drugs stay in urine Drug/Substance Time Alcohol Amphetamine Methamphetamine Barbiturate Short-acting (eg, pentobarbital) Long-acting (eg, phenobarbitol) Benzodiazepine Short-acting (eg, lorazepam) Long-acting (eg, diazepam) Cocaine metabolites 7 -12 h 48 h --Mayo Clinic Proc. 2008; 83(1)66 -76 24 h 3 wk 3 d 30 d 2 -4 d Marijuana Single use Moderate use (4 times/wk) Daily use Long-term heavy smoker Opioid Codeine Heroin (detected as morphine) Hydromorphone Methadone Morphine Oxycodone Propoxyphene Phencyclidine 3 d 5 -7 d 10 -15 d 30 d 48 h 2 -4 d 3 d 48 -72 h 2 -4 d 6 -48 h 8 d
Opioid Risk Increases with Dosage Prescription risk factors No completely safe opioid dose Risk increases with dose and begins to significantly increase at 20 -50 mg/d MED Generally avoid increasing above 50 mg/d MED and is >50 mg/d MED then must additional education and more frequent monitoring Avoid increasing dose above 90 mg/d MED Avoid combining with benzodiazepines
Side Effects of Opioids Tolerance Physical Dependence Increased sensitivity to pain Constipation Nausea/vomiting dry mouth Sleepiness Dizziness Confusion Depression Low levels of testosterone sexual dysfunction Itching sweating
Risks of Opioid Therapy Mortality (of all causes) Hazard ratio (HR)1. 64 for long acting opioids for non-cancer pain Overdose deaths (unintentional) HR 7. 18 -8. 9 for MED>100 mg/d Opioid use Disorder (for patients on long-term opioids >90 days) HR 15 for 1 -36 mg/d MED HR 29 for 36 -120 mg/d MED HR 122 for >120 mg/d MED
Recognizing Opioid Overdose Small constricted pupils Falling asleep Loss of consciousness Shallow slow breathing Choking or gurgling sounds Limp body Pale blue or cold skin
Principles of Engaging Patients With OUD Treatment works Respect patient’s preferences Use Motivational Interviewing Techniques Promote mental health programs Address concurrent problems and pursue Whole Health and Well Being Emphasize that options will remain available
Medication Assisted Treatment (MAT)along with Addiction Focused Medical Management /or Addiction Treatment Considered 1 st line treatment Allow patient to focus on recovery by preventing withdrawal and reducing cravings Helps achieve long-term goal of reducing opioid use and associated negative medical, legal or social consequences Patient with active OUD opioid withdrawal management should be followed with OUD pharmacotherapy Do not provide MAT as sole therapy; MAT is assisting therapies for psycho -social-spiritual well-being.
Medications Used to Treat OUD Methadone: opioid receptor agonist schedule 2 drug Data suggest methadone is more effective in dosages in excess 60 mg/day Buprenorphine: partial agonist and produces milder withdrawal syndrome Patients must abstain from using short acting opioid for 12 -24 hours Long acting opioids 24 -48 hours
Managing Withdrawal Symptoms
Buprenorphine Induction Protocol Patient dependent on opioids Long-acting opioids Short-acting opioids Reevaluate suitability for induction Day 1 dose established Withdrawal symptoms relieved?
Buprenorphine Induction Protocol Patient dependent on opioids Long-acting opioids Short-acting opioids Methadone: Taper to ≤ 30 mg/day. LAAM: Taper to ≤ 40 mg per 48 -hour dose Methadone: Withdrawal symptoms 24+ hr after last dose? LAAM: Withdrawal symptoms 48+ hours after last dose? Discontinue short-acting opioids No Reevaluate suitability for induction No Yes Administer 4/1 mg buprenorphine/naloxone. Observe 2+hours Administer 2 mg buprenorphine monotherapy. Observe 2+ hours Yes Withdrawal symptoms relieved? No Repeat dose up to max 8 mg 24 hr Withdrawal symptoms present 12 -24 hours after last dose of opioids? Day 1 dose established Yes Withdrawal symptoms relieved? No per Repeat dose up to max 8/2 mg 24 hr per
Induction day 2
Induction stabilization
References https: //www. ncbi. nlm. nih. gov/books/NBK 64246/ Addictive Behaviors reports Hyyp: //www. ncbi. nlm. nih. gov/pmc/srticles/PMC 5800559/ Guideline for Prescribing Opioids for chronic pain https: //www. cdc. gov/mmwr/volumes/65/rr/rr 6501 el. htm Pharmacotherapy for opioid use disorder www. uptodate. com/contents/pharmacotherapy-for-opioid-use-disorder Tarascon Pocket Pharmacopoeia 2017 edition Psychiatric Drug Treatment
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