3. ADDICTION, ABUSE, DEPENDENCE
3 distinct terms: reflect the state of the body and mind of an individual
in relation to an addictive substance
Addiction: 1) when a lot of time is spent in obtaining a substance,
using a substance or recovering from it 2) Important social,
occupational and recreational activities are given up because of it 3)
the use is continued despite having a physical or psychological
problem
Abuse: 1) Recurrent substance use severely impacts obligations and
responsibilities at work, school or home 2) Legal problems due to
over use 3) Recurrent use despite social, interpersonal problems 4)
Absence of Dependence
Dependence: 1) Tolerance 2) Withdrawal 3) Unsuccessful urge,
effort to quit
4. OPIATES
Opiates belong to the large biosynthetic group of
benzylisoquinoline alkaloids
Naturally occur in the opium poppy
5. OPIATES
Major psychoactive opiates are morphine, codeine and thebaine
Semi synthetic opioids are hydrocodone, hydromorphone,
oxycodone and oxymorphone
Heroin is a synthetic substance that converts into 6 acetyl
morphine in the body
Heroin is colloquially known as H, smack, horse, brown, black, tar
etc.
6. PHARMACODYNAMICS
Reward pathway: modifies the action of dopamine in the nucleus
accumbens and the ventral tegmental area of the brain
Powerful agonist at the mu opioid receptors subtype
Binding inhibits the release of GABA from the nerve terminal,
reducing the inhibitory effect of GABA on dopaminergic neurons
Increased activation of dopaminergic neurons and the release of
dopamine into the synaptic results in sustained activation of the
post-synaptic membrane
Continued activation of the dopaminergic reward pathway leads to
the feelings of euphoria and the ‗high‘ associated with heroin use
Also binds to areas involved in the pain pathway (including the
thalamus, brainstem, and spinal cord) which leads to analgesia
7. ROUTES OF ADMINISTRATION
Heroin is usually injected, sniffed/snorted, or smoked
Typically, a heroin abuser may inject up to four times a day.
Intravenous injection provides the greatest intensity and most
rapid onset of euphoria (7 to 8 seconds)
Intramuscular injection produces a relatively slow onset of
euphoria (5 to 8 minutes)
When sniffed or smoked, peak effects are usually felt within 10 to
15 minutes
8.
9. SHORT TERM EFFECTS
Mitotic ―pinpoint‖ pupils: Less than 2.9 mm; stimulates the
oculomotor nuclei and affecting the sphincter muscle of the iris
which cause narrowing of pupils
10. SHORT TERM EFFECTS
Nausea and vomiting occur because heroin stimulates the area
postrema equaling chemoreceptor trigger zone in the medulla and
affects gastrointestinal receptors
Heroin affects the sphincter pylori, sphincter urethrae, and sphincter
ani externus
Warm, flushed skin; dry mouth; severe itching
Binds to the u-receptors that decrease gut motility and cause severe
constipation
Urinary retention
Bradycardia
Badypnea and respiratory depression
CNS depression
Spontaneous abortions
11. LONG TERM EFFECTS
Physical dependence and withdrawal as well as addiction
Infectious diseases, for example, HIV/AIDS and hepatitis B and C
Collapsed veins
Bacterial infections- pneumonia, TB
Abscesses
Infective endocarditis
Arthritis and other rheumatologic problems
13. WITHDRAWAL
Restlessness
muscle and bone pain
insomnia,
diarrhea, vomiting,
cold flashes with goose bumps ("cold turkey")
leg movements
Withdrawal is not fatal in healthy adults
14. TREATMENT
Naloxone for acute overdose management
Detoxification — controlled and medically supervised withdrawal
from the drug
Naltrexone for management: : opioid antagonist
Methadone maintenance
Clonidine is sometimes added to shorten the withdrawal time and
relieve physical symptoms
Buprenorphine- partial opioid agonist
Behavioral therapy, contingency management therapy and
cognitive-behavioral interventions
15. METHADONE MAINTENANCE
Specialized clinics for methadone
Taken daily in liquid form; a single dose lasts 24–36 hours
Some methadone clinics also provide other services, including vocational and
educational aid, referrals to other medical and social service agencies, help
for the families of addicts, and treatment for cocaine or alcohol abuse.
Switching from illicit opiates to methadone avoid the highs and lows and the
medical risks of intravenous injection and the criminal behavior that supports
it.
less depressed, more likely to hold a job and maintain a family life, less likely
to commit crimes, and less likely to contract HIV or hepatitis
Methadone can be continued indefinitely, or the dose can be gradually
reduced in preparation for withdrawal.
estimated that about 25% of patients eventually become abstinent, 25%
continue to take the drug, and 50% go on and off methadone repeatedly.
16. BUPRENORPHINE (SUBOXONE)
partial opioid agonist
Taken three times a week as either a tablet or film, sublingually
It occupies opiate nerve receptors and produces a mild opiate-like
effect.
In a person who is physically dependent on opiates, buprenorphine causes a
withdrawal reaction.
There is some risk of abuse if the tablet is dissolved and injected
buprenorphine has been made available in combination with naloxone, which
has little effect when absorbed under the tongue but neutralizes the effect of
injected opiates.
The main advantage of this is that patients do not have to come to clinics to
take it, because there is no illicit market and no danger of diversion.
Since 2002, individual physicians with proper training and certification have
been allowed to prescribe buprenorphine in their offices for patients to take
home
17. THERAPY
Residential behavioral therapy most effective.
Contingency management therapy uses a voucher-based system,
where patients earn "points" based on negative drug tests. They
can exchange these for retail items or e allowed to take home
methadone instead of coming to the clinic
Cognitive-behavioral interventions are designed to help modify
the patient's expectations and behaviors related to drug use, and
to increase skills in coping with various life stressors.
18. AS A PHYSICIAN…
Perform HIV, Hepatitis B S Ag, Hepatitis C Ab screening tests on
opioid dependent patient
Watch out for Latent TB infection
Immunizations Hep A, Hep B and Tetanus are up to date
Counsel patient, provide information
Remember, drug seeking behavior is not a personality trait; do not
judge your patients
Because there is a risk of diversion to the illicit market, addicts must come to specialized clinics for methadone, which they take daily in liquid form. A single dose lasts 24–36 hours, and there are few side effects. Some methadone clinics also provide other services, including vocational and educational aid, referrals to other medical and social service agencies, help for the families of addicts, and treatment for cocaine or alcohol abuse.Addicts who switch from illicit opiates to methadone avoid the highs and lows and the medical risks of intravenous injection and the criminal behavior that supports it. Studies show that they are less depressed, more likely to hold a job and maintain a family life, less likely to commit crimes, and less likely to contract HIV or hepatitis. Methadone can be continued indefinitely, or the dose can be gradually reduced in preparation for withdrawal. It has been estimated that about 25% of patients eventually become abstinent, 25% continue to take the drug, and 50% go on and off methadone repeatedly.Buprenorphine:A promising approach to maintenance is the partial opioid agonist buprenorphine. This drug is taken three times a week as a tablet held under the tongue. It occupies opiate nerve receptors and produces a mild opiate-like effect. At higher doses, it continues to produce the same weak effect while displacing more potent drugs. In a person who is physically dependent on opiates, buprenorphine causes a withdrawal reaction. There is some risk of abuse if the tablet is dissolved and injected, so buprenorphine has been made available in combination with the short-acting opiate antagonist naloxone, which has little effect when absorbed under the tongue but neutralizes the effect of injected opiates.The main advantage of this combination, sold under the name Suboxone, is that patients do not have to come to clinics to take it, because there is no illicit market and no danger of diversion. Since 2002, individual physicians with proper training and certification have been allowed to prescribe buprenorphine in their offices for patients to take home. It could be a solution for opiate addicts who will not or cannot attend a methadone clinic because of the inconvenience, the stigma, or a long waiting list. And switching some addicts to buprenorphine could free places in methadone clinics for others.Behavioral therapy: residential most effective. Contingency management therapy uses a voucher-based system, where patients earn "points" based on negative drug tests, which they can exchange for items that encourage healthy living. Cognitive-behavioral interventions are designed to help modify the patient's expectations and behaviors related to drug use, and to increase skills in coping with various life stressors. Both behavioral and pharmacological treatments help to restore a degree of normalcy to brain function and behavior, with increased employment rates and lower risk of HIV and other diseases and criminal behavior.
