Opioids

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Presented in 2009, IMH hyd.

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Opioids

  1. 1. OPIOID RELATED DISORDERS Dr. Srinath G Dr. Gowri Devi M
  2. 2. Plan of Presentation  Introduction  Epidemiology  Psychiatric classification  DSM Criteria  Management
  3. 3. Introduction Opioid= natural opiates+ others Narcotic- “stupor” Rush/ high Oxycodone- Rolls Royce Chasing the dragon
  4. 4. ENDOGENOUS OPIOIDS • POMC Endorphins • ß- Endorphin, MSH, ACTH, LPH • Preproencephalin Encephalins • Leu & Met Encephalin • Preprodynorphin Dynorphins • Dynorphin A & B Opioid motif- Tyr- Gly- Gly- Phe (Leu or Met)
  5. 5. Opioids Semi- Naturally Semi- synthetics Synthetic occurring Synthetic • Morphine • Heroin • Methadone • Codeine • Oxycodone • Meperidine Full agonists Partial agonists Antagonists
  6. 6. Opioid Receptors Opioid receptors µ receptors DAMGO δ receptors К receptors CTOP DPDPE Orphanin Analgesia, DPDTE Nor- Naltrindole binaltorphimine NociceptinRespiration, Analgesia,GI, Feeding, Analgesia, GI, Feeding, GH Psychomimetis, Prolactin, GH, Ach, Feeding, SedationDA, Sedation
  7. 7. Neurobiology G protein coupled- Gi Inhibit Adenyl cyclase, effect potassium channels and calcium channels during acute administration Chronic administration causes superactivation of adenyl cyclase Reward circuit Drive/ Motivation Emotional circuit Executive function Learning
  8. 8. Functions of Opioids Analgesia Psychomimesis Respiratory depression Hormones GIT Cornerstone of pain Feeding management Mood altering properties Sedation NT
  9. 9. EPIDEMIOLOGYLife time prevalence of Opiate use in India- 0.4% In US 0.2%
  10. 10. Psychiatric co-morbidity 24% non substance Axis I disorders 35% Axis II disorders 47% overall non substance illness MC- Mood disorders, Antisocial PD, Anxiety Females- BPD, Depression
  11. 11. Medical disorders CVS effects TB HIV/AIDS Liver disease Immune system
  12. 12. Special population Criminal patients Pregnant mothers Neonatal Narcotic Abstinence Syndrome  Hyper excitable CNS  GIT  Respiratory system  ANS
  13. 13. Terms Misuse- incorrect use of a medication • Amount, Longer time and frequency Abuse- maladaptive pattern of use leading to clinical distress or impairment • Harmful use in ICD-10 Addiction- chronic neurobiologic disease with various factors Dependence- set of behaviors, a neurobiological adaptation Pseudo addiction- iatrogenically produced in pain patients
  14. 14. Laboratory testing Emergency testing, rehabilitation testing, diagnostic testing Tested drugs- Opioids, PCP, LSD, Cannabis, Amphetamines Tests  Thin layer chromatography  Enzyme Immuno Assays  Medtox Profile II ER  On Trak TesTCup Specimens  Urine screening  Oral fluids Other
  15. 15. DrugsMethadone Full µ agonist Very high lipid solubility Half life - 15 to 60 hours Methadone clinicClonidine α- 2 agonist reduces nausea, vomiting, diarrhea, abdominal cramps, and sweating Not helpful in insomnia, opioid craving
  16. 16. Buprenorphine Partial agonist at mu and kappa receptors- Ceiling effect Poor oral availability- sublingual administration Buprenorphine: Naloxone = 4:1 Less abuse potential Office based maintenanceLAAM (l-Alpha Acetyl Methadol)Opioid antagonists- Naltrexone, Nalmefene
  17. 17. Withdrawal • Dysphoria, nausea & vomiting, lacrimation & rhinorrhoea, Pupillary dilatation, piloerection, sweating, diarrhea, yawning, fever and insomnia, cold turkey, aches-kick the habit Features • Depends upon the half life of the drug • OWS, SOWS, COWSMeasurement • Opioid agonists, Non-opioids • Rapid and Ultra rapid Detoxification, in physician office,Detoxification
  18. 18. Detoxification• Short term• Long term• Rapid• Ultra Rapid
  19. 19. Short term Rate of tapering is 5%detoxification to 10% per day• 15-30 mg methadone• 30 days
  20. 20. Long term detoxification15-30 mgmethadoneUp to 180 days
  21. 21. Rapid detoxificationAntagonist administration Precipitate withdrawal Supportive Treatment Antiemetics, analgesics, buprenorphine
  22. 22. Ultra rapid detoxification Under general anesthesiaAntagonist precipitated withdrawal Supportive Treatment
  23. 23. Methadone maintenance Phase Purpose Range• Initial dose • Relieves abstinence • 20-40 mg• Early induction • Reach tolerance level • +/- 5- 10 mg q 3-4 hrs• Late induction • Establish adequate dose • +/- 5- 10 mg q 3-4 hrs• Maintenance/ • Steady state occupation • 60-120 mg/ day Stabilization of receptors• Maintenance to • Medically supervised • 10% q 5- 10 days abstinence withdrawal• Medical maintenance • Indefinite management • Adequate dose in medical setting Lapse Relapse
  24. 24.  Plasma levels of methadone- 150-200ng/ml Adequate blockade achieved at 400+ng/ml Methadone drug interactions ADR- constipation, sweating, transient skin rash, weight gain, water retention, libido changes 3 phases- Vocational Continued Stabilsation programs maintenance
  25. 25. Psychosocial Treatment Narcotic anonymous Therapeutic communities Relapse Prevention Cue prevention Harm Reduction Psychodynamic/interpersonal Group and Family therapy Alternate groups- SOS,
  26. 26. Narcotic Anonymous
  27. 27. Therapeutic communities
  28. 28. Relapse prevention- Risk factors, Socialpressure, CravingsInternal/ Cognitive/ Behavioral/External Pharmacologic Self Management/ Others
  29. 29. Relapse process Stop Time relapse Full blown relapse Relapse warning signs- mood, attitude, behavioral, thought change
  30. 30. References CTP- Kaplan and Sadock Comprehensive text book of substance abuse Clinical practice guidelines- IPS Tasman Psychiatry

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