aaaaaaaa

1. Dr Jia uddin Ahmed, DPO,DMHP
Nagaon

2.  The nonmedical use or abuse of, or
dependence on natural opioids (morphine),
semi-synthetic opioids (heroin, hydrocodone,
oxycodone) and synthetic opioids
(methadone, propoxyphene, fentanyl)
 OPIOIDS refers to Opium (including
doda/phukki/poppy husk), Heroin
(including brown sugar/smack) and
Pharmaceutical Opioids.

7.  The Mediterranean region contains the earliest
archaeological evidence of human use of opium;
 the oldest known seeds date back to more than
5000 BC in the Neolithic age[9] with purposes such
as food, anaesthetics, and ritual.
 Evidence from ancient Greece indicates that opium
was consumed in several ways, including inhalation
of vapours, suppositories, medical poultices, and as
a combination with hemlock for
suicide.[10]The Sumerian, Assyrian, Egyptian, Indian,
Greek, Roman, Persian and Arab Empires all made
widespread use of opium,

8.  India has almost 2.3 crore opioid users in 2018,
which was a five-fold jump in 14 years. The
maximum growth was reported in consumption
of heroin. In 2004, the number of opium users
(20,000) was more than twice that of heroin
(9,000). Some 12 years later, trends reversed,
and number of heroin users went up to 2.5 lakh,
almost double than opium consumers.
 India Today Data Intelligence Unit (DIU) analysed
a report on substance abuse by the National Drug
Dependence Treatment Centre, AIIMS, and found
that India has developed into a major hub of
illegal drugs. The study focuses mostly on drug
addicts in the age group of 10-75 years.

9.  INJECTING DRUG USE IN INDIA
Use of drugs through injecting route is a significant
public health concern because of the associated risk of
spread of infections like HIV and Hepatitis C and B.
Current Injecting drug use is defined operationally in
study of National Survey on Extent and Pattern of
Substance Use in India 2019 as use of any intoxicating
substance through injecting route even once within
past three months (as defined by the National AIDS
Control Programme of India).
Findings show that there are estimated 8.5 Lakh people
who inject drugs (PWID) in India. Other than the UTs of
A&N and Lakshadweep.

11. Clinical Presentation
 Intoxication symptoms include sedation,
euphoria, cognitive deficits, miosis, slurred
speech, itching, nausea, constipation, and
respiratory depression.
 Withdrawal symptoms include nausea, vomiting,
dysphoria, muscle aches, lacrimation,
rhinorrhea, pupillary dilation, piloerection,
diaphoresis, diarrhea, yawning, and insomnia

12.  Overdose presents as respiratory depression
or arrest and can result in death.
Behavioral changes
 Isolation and/or deviation from normal
activities at home, work, or school. Over
time, opioids are used in greater quantities
and for a longer duration despite efforts to
decrease or quit.
 There can be a craving, or drive, to use the
opioid.

13.  Use is maintained despite detrimental
effects on social, occupational and
educational responsibilities, as well as
physical and mental health.
 Tolerance can occur, in that more opioids
are needed to become
affected/intoxicated.

14.  Standard urine drug testing immunoassays only
screen for natural opiates (morphine and
codeine) but will not screen for synthetic or
semi-synthetic opiates other than heroin.
Separate testing for each other opioid of interest
(e.g. oxycodone, fentanyl, methadone,
buprenorphine) must be specified.
 Heroin (diacetylmorphine) use can be
differentiated from a positive morphine screen
by testing for 6-monoacetylmorphine (6-MAM),
which is a metabolite specific to heroin.

15.  Random urine drug testing should be a
standard part of treatment in order to
assess progress toward recovery goals. In
addition, patients on methadone or
buprenorphine maintenance should be
screened for the presence of those drugs
help to prevent diversion.

16. o Opioid Intoxication
 Alcohol intoxication
 Drug Toxicity (benzodiazepine, barbiturate,
clonidine, ketamine, PCP, gamahydroxybutyrate,
neuroleptic)
 Pontine hemorrhage
 Hypoglycemia
 Acidemia

17. o Opioid Withdrawal
 Gastroenteritis (viral or bacterial)
 Peptic ulcer disease
 Influenza
 Pancreatitis

18. o General
 Treatment plans should be individually
tailored, using the principles and techniques
described below, taking into consideration
the patient’s resources and support system.
Pharmacotherapy should be combined with
psychosocial treatments for best results.

19. o Pharmacotherapy
 In Overdose/Intoxication
 Administer naloxone 0.2-2 mg IV initially.
May repeat 2-3 min as needed(upto max
10mg).Reverses respiratory depression
rapidly.
 Can also be administered IM/SC, but onset
of action is slower.

20.  Medical Treatment of Withdrawal
(Detoxification)
 Buprenorphine SL or buprenorphine/naloxone SL are
treatments of choice Better than clonidine at relieving
withdrawal symptoms
 Tapers can range from 3-21 days
 Usual short-term taper: buprenorphine/naloxone 8/4
mg SL the first day; taper by 2/0.5 mg per day.
 Prescription of buprenorphine restricted to certified
physicians. May also be dispensed at licensed OST
Centre.

21.  Methadone Tapers can range from 5-30 days
 Usual short-term taper: methadone 30 mg PO the first day, then
taper down by 5 mg per day
 May be dispensed for purposes of detoxification in licensed
methadone clinics or hospitals/OST Centre.
 Clonidine and lofexidine (alpha2-adrenergic agonists)
 Used ("off label") for treatment of opioid withdrawal
 Reduce hyperadrenergic withdrawal symptoms
 The usual dosage for clonidine is 0.1 PO mg bid or tid
 No restrictions on prescribing for opioid withdrawal treatment.

22.  Maintenance treatment
 Naltrexone (NTX): μ-opioid receptor antagonist
 Dosage: 50-100 mg PO daily.
 Helps maintain abstinence, as euphoric effect from opioids is
absent or diminished when taken after NTX administration
 Administer NTX a minimum of 7-10 days after the last use of a
short-acting opioid
 Patients transitioning from buprenorphine/methadone
maintenance may need an opioid-free period of up to 14 days.
 Common side effects: abdominal complaints, dysphoria
 Black box warning for hepatotoxicity (rare). LFT monitoring is
recommended
 No addictive potential and not a controlled substance. No
restrictions on prescribing for treatment of opioid dependence

23.  Methadone (full μ-opioid receptor agonist)
 Usual therapeutic dosage ranges from 60-120 mg daily
 Induction usually starts at 30 mg daily with increases by 10 mg every 3-5
days, as needed.
 May be appropriate for individuals who have relapsed several times. The
goal of this therapy is to decrease cravings, avoid withdrawal, and allow
the patient to become a functioning member of society
 Side effects: constipation, dizziness, sweating, nausea, vomiting,
sedation, increased appetite, decreased libido
 May cause prolonged QT interval at higher dosages (>100 mg daily).
Consider baseline ECG and ECG monitoring, especially in patients with
cardiac conditions and those on other QT-prolonging medications.

24.  Buprenorphine (partial μ-opioid receptor
agonist)Usual dosage 8 mg-16 mg SL daily.
Maximum dosage 24 mg SL daily
 Buprenorphine/naloxone (4:1) combination used
to prevent diversion by IV use. Use
buprenorphine mono product in pregnant women
 Buprenorphine/naloxone available as sublingual
tablets and soluble film. Buprenorphine alone is
only available as sublingual tablets.
 Common side effects: nausea, constipation

25. o Psychotherapy
 Therapeutic communities (TCs) are sophisticated human service
agencies that include a variety of inpatient and outpatient programs
these utilize a peer-staff community to facilitate changes needed to
remain abstinent from opioid (or other drug) use.
 Motivational Interviewing
 Contingency Management
 Cognitive Behavioral Therapy
 Relapse Prevention
 Group therapy
 Family Therapy
 12-step programs (Narcotics Anonymous)

27.  Hopkins, John (2014). Psychiatry Guide
 Magnitude of Substance use in India 2019,
MINISTRY OF SOCIAL JUSTICE AND
EMPOWERMENT,GOVERNMENT OF INDIA
 Google Image