Opioids
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Opioids

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Presented in 2009, IMH hyd.

Presented in 2009, IMH hyd.

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Opioids Presentation Transcript

  • 1. OPIOID RELATED DISORDERS Dr. Srinath G Dr. Gowri Devi M
  • 2. Plan of Presentation  Introduction  Epidemiology  Psychiatric classification  DSM Criteria  Management
  • 3. Introduction Opioid= natural opiates+ others Narcotic- “stupor” Rush/ high Oxycodone- Rolls Royce Chasing the dragon
  • 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. Opioids Semi- Naturally Semi- synthetics Synthetic occurring Synthetic • Morphine • Heroin • Methadone • Codeine • Oxycodone • Meperidine Full agonists Partial agonists Antagonists
  • 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. 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. Functions of Opioids Analgesia Psychomimesis Respiratory depression Hormones GIT Cornerstone of pain Feeding management Mood altering properties Sedation NT
  • 9. EPIDEMIOLOGYLife time prevalence of Opiate use in India- 0.4% In US 0.2%
  • 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. Medical disorders CVS effects TB HIV/AIDS Liver disease Immune system
  • 12. Special population Criminal patients Pregnant mothers Neonatal Narcotic Abstinence Syndrome  Hyper excitable CNS  GIT  Respiratory system  ANS
  • 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. 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. 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. 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. 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. Detoxification• Short term• Long term• Rapid• Ultra Rapid
  • 19. Short term Rate of tapering is 5%detoxification to 10% per day• 15-30 mg methadone• 30 days
  • 20. Long term detoxification15-30 mgmethadoneUp to 180 days
  • 21. Rapid detoxificationAntagonist administration Precipitate withdrawal Supportive Treatment Antiemetics, analgesics, buprenorphine
  • 22. Ultra rapid detoxification Under general anesthesiaAntagonist precipitated withdrawal Supportive Treatment
  • 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.  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. Psychosocial Treatment Narcotic anonymous Therapeutic communities Relapse Prevention Cue prevention Harm Reduction Psychodynamic/interpersonal Group and Family therapy Alternate groups- SOS,
  • 26. Narcotic Anonymous
  • 27. Therapeutic communities
  • 28. Relapse prevention- Risk factors, Socialpressure, CravingsInternal/ Cognitive/ Behavioral/External Pharmacologic Self Management/ Others
  • 29. Relapse process Stop Time relapse Full blown relapse Relapse warning signs- mood, attitude, behavioral, thought change
  • 30. References CTP- Kaplan and Sadock Comprehensive text book of substance abuse Clinical practice guidelines- IPS Tasman Psychiatry