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Opioids
 

Opioids

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    Opioids Opioids Presentation Transcript

    • Opioids (Narcotics) “ Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.”
    •  
    •  
    • Ancient History
      • Opium
        • The sap of the seed pod of Papaver somniferum, referred to as early as 3000 BC.
        • Found in Spanish burial sites c.4200 BC
      • Greeks/Romans
        • Used to produce constipation, sleep, panacea
        • God Morpheus (God of Dreams)
    •  
    • Recent History
    •  
    •  
    • Opioids (God Morpheus of Dreams) Narcotics (Narcosis—stupor)
      • Produce analgesia by binding to opiate receptors in the CNS, brain and spinal cord involved with the transmission of pain impulses.
      • Produce Morphine like effects on the opioid receptors
    • Pain Neuro Transmitters Pain Relief Meds
      • Substance P
      • Glutamate
      • GABA
      • Norepinephrine
      • Serotonin
      • Histamine
      • NSAIDS
      • Antidepressants
      • Anti seizure meds
      • Muscle relaxants
      • Local salves- capsaicin
      • Narcotics
    • Body’s Natural Analgesia
      • Activation by physical, chemical or threat of injury.
      • Nociceptive neurons release Substance P = pain!
      • Endogenous opioids are present at brain sites
        • Released during stress, pain & anticipation of pain to produce analgesia
        • Endorphins and enkephalins
    • Opioid Distribution in the Brain
    • Location and time course of pain evoked neural activity in human subjects
    • PET Scans show endogenous opioid activation during sustained pain
    •  
    • Opioid Clinical Indications
      • Analgesia
      • Acute Pulmonary Edema
      • Cough
      • Diarrhea
      • Anesthesia
    • Pharmacologic Types of Opiates
      • Natural Sources
        • Opium, Morphine (10% of opium)
        • and Codeine (5%)
        • Heroin
          • Morphine with 2-acetyl groups
            • Heroin is a pro-drug: it is converted in the liver to morphine
          • Sold as non-addictive
          • Dreser inventor of ASA
          • Banned in 1924
      • Synthetic Group
        • Meperidine (Demerol)- short acting
        • Methadone (Dolophine)- orally effective
        • Hydromorphone (Dilaudid)
        • Pentazocine (Talwin)
        • Propoxyphene (Darvon)
        • Buprenorphine (Buprenex)- partial agonist
        • Oxycodone (Oxycontin, Percodan, Percocet)
        • Hydrocodone (Vicodin, Lorcet, Norco)
    • Drugs Methods of Use
      • Oxycondone HCL
        • Oxycontin, oxy, OC, killer
      • Dilaudid, Percodan
        • Dreamer, Junk
      • Demerol, Morphine
      • Methadone
      • Heroin
        • Smack, horse,bigH
      • Codeine
        • Schoolboy
      • Swallowed, snorted, injected
      • Swallowed, inject
      • Injected, smoked, swallowed
    •  
    • Oxycontin Abuse
      • When tablets are crushed, snorted or extracted & injected.
      • Effective, less toxic, well-tolerated medication.
      • Backlash ‘war on drugs’ challenges legitimate users
    •  
    • Common Opioid Side Effects
      • Constipation
      • Mental clouding, fatigue
      • Nausea, vomiting
      • Itch
      • Sweating
      • Urinary retention
    • Symptoms of Use
      • Drowsiness
      • Droopy Lids
      • Pin Point Pupils
      • Lethargy
      • Needle marks
      • Loss of appetite
      • Hazards of use is addiction with severe withdrawal symptoms
    •  
    • Reinforcing Pharmacologic Properties
      • Pain Relief
      • Change or elevate mood
      • Relieve tension, fear, anxiety
      • Produce feelings of peace, euphoria, tranquility
      • Rapid IV injection complete drive satiation
      • Why?
      • Most opioids increase DA activity!
    • Poly Pharmacy
    • Additive Toxicity Issues
      • Tolerance
      • Dependence
        • Physical
        • Psychological
      • Overdose
      • Drug Interactions
      • Contraindications
    • Acute Opioid Overdose
      • Acute intoxication
      • Depressed BP & Respiration
      • Fixed pinpoint pupil
      • Depressed sensorium
      • Coma, pulmonary edema
    • Opioid Antagonists
      • Pure Opioids Antagonist
        • Naloxone (Narcan)
        • Naltrexone
      • Mixed agonist – antagonist
        • Nalorphine
    • Abstinence or Withdrawal Symptoms
      • Related to the t 1/2 of the opioid in use
      • First 24 hrs.
          • Chills, hot flashes, restless sleep, piloerection on the skin (cold turkey), rhinorrhea, drowsiness, lacrimation, mydriasis
          • Sneezing, yawning, cramping, vomit, diarrhea, anorexia, increased BP, P, Temp, drug craving
          • If severe results in CV collapse
    • Abstinence Syndrome
      • Depending on agent
        • Develops 2-48 hours
        • Peaks 72 hours
        • Untreated withdrawal may continue up to 7-10 days
        • Physical dependence is eventually lost
        • Psychological dependence continues longer or forever
    • Non-Opioid Withdrawal Treatments
      • Clonidine (Catapres)
        • Reduces SANs flow by stimulating alph receptors in the brain
        • Tablet- rapid
        • Patch- 2-3 days
          • SE-sedative, hypotensive
      • Reduction
        • HR, TPR, BP
      • Withdrawal Programs
        • Cold turkey?
        • Therapeutic
      • Therapeutic Community Programs
        • Goal relief from compulsive craving for the drug of abuse
    • Methadone
      • Detox/ Withdrawal
        • Cross-tolerance
        • No euphoria, rush
      • Guide:
        • 1mg of methadone for:
          • 20 mg meperidine
          • 4 mg morphine
          • 2 mg heroin
        • Methadone reduction 5mg increments
      • Supportive Care
        • Psychologic/Psychiatric
      • 25% continue Heroin
      • Maintenance
        • Controversial
        • Requires Licensing
        • Hospital Environment
        • Goal complete w/drawal from drug dependency
      • Methadone Dependence
        • Less severe symptoms, lasts longer
        • Supplemental Rehabilitation
    • Additional Agonist Analgesics Use For Maintenance
      • Buprenorphine/Naloxone (Suboxone)
          • Opioid agonist used in pain management and opiate dependence
          • Reduction in craving and increased success in abstinence programs
      • Levomethadyl Acetate (ORLAAM)
          • Longer acting alternative to methadone
          • Given three times a week
      • Diacetylmorphine (Heroin)
          • CI with no accepted medical use in the US
          • European hospitals and clinics
            • For use with a history intractable dependence
    •  
    • Pain Syndromes
      • Acute Pain  recent onset, transient, identifiable cause
      • Chronic Pain  persistent or recurrent pain, beyond usual course of acute illness or injury
        • Nonmalignant
          • Diagnosed or undiagnosed cause such as a nonmalignant disease
        • Malignant
          • Disease present pain severity worsens as progresses
      • Breakthrough Pain  transient pain, severe or excruciating, over baseline of moderate pain
    • ABC’s of Pain Management Assess pain regulary Believe patients & their families in their reports of pain Choose interventions appropriately Deliver these in a timely fashion Enable/Empower patients & Families to overcome pain no pain mild discomforting horrible excruciating
    • Pain Management
    • Non-Drug Pain Management Techniques
      • Distraction
        • Ice/Heat
        • TV/ read/visiting
      • Relaxation
        • Breathing, yoga
        • Tapes, music
      • Massage
      • Physical Therapy
      • Biofeedback
      • Acupuncture
      • Acupressure
      • Imagery
      • Aromatherapy
    • Analgesic Ladder
        • NSAID (ASA)
        • Adjuvant analgesic (APAP, antihist)
        • Non-narcotic analgesic (NSAID)
        • Weak opioid (Codeine, propoxyphene)
      Strong opioid (Morphine) with adjuvant analgesic
    • PCA (patient-controlled analgesia pump)
    • Why a Pump?