- India has an opioid dependence problem, with approximately 4 million people using opioids and 1 million dependent. Punjab has around 232,000 people dependent on opioids alone. - Opioids are classified as natural, semi-synthetic, synthetic, and endogenous. Common opioids used in India include morphine, heroin, methadone, buprenorphine, and tramadol. - Opioid dependence is treated through pharmacological therapies like opioid substitution therapy (OST) using methadone and buprenorphine, and symptomatic treatments. Non-pharmacological therapies include individual therapy, family therapy, and support groups.

1. MANAGEMENENT OF
OPIOID DEPENDENCE
PRESENTOR: PARUL
MODERATOR: DR. POONAM

2. • India is situated between the two largest illicit opium-
producing regions of the world – “Golden Crescent” and
“Golden Triangle,” which makes it vulnerable for being
both a destination and transit route for opioids.
• It is estimated that currently, India has about 4 million
people who use opioids and around 1 million people
who are opioid dependent.
• A recent study reported that around 232,000 people
were opioid dependent in Punjab alone.

4. Opioids are the class of drugs derived from poppy plant; papaver
somniferum.
CLASSIFICATION TYPE DRUG
A) NATURAL MORPHINE, CODEINE.
B) SEMI SYNTHETIC HEROIN, HYDROCODONE, OXYCODONE.
C) SYNTHETIC FENTANYL, MEPERIDINE, PENTAZOCINE,
METHADONE, LOPERAMIDE
D) ENDOGENOUS ENDORPHINS, ENKEPHALINS AND
DYNORPHINS.

5. ACTIONS

6. PHYSIOLOGICAL ACTIONS

7. DEPENDENCE
6 criteria’s :
1. Strong desire.
2. Difficulty in controlling substance taking
behaviour.
3. Withdrawal.
4. Tolerance.
5. Neglect of activities.
6. Persisting with substance despite knowing its
harmful effects.

8. PHARMACOLOGICAL
MANAGEMENT OF
OPIOIDS

9. INVESTIGATIONS
CBC
U/R
RFT
URINE
FOR
DRUG
LFT

10. • Dysphoric mood.
• Muscle aches.
• Lacrimation.
• Insomnia.
• Runny nose.
• Sweating.
• Yawning.
• Abdominal cramping.
• Diarrhoea.
• Dilated pupils.
• Piloerection.
• Nausea.
• Vomiting.
• Hypertension.
• Tachycardia.
• Temperature dysregulation.
WITHDRAWL

11. MORPHINE AND HEROIN: Withdrawal begins after 4-6 hours of
last dose, usually after 1-2 week of continuous use reaches
peak after 2-3 day and subsides after 7-10 days.
METHADONE: Begin after 1-3 days, peak between 4-5 days and
end in 10-14 days.
Untreated buprenorphine lasts for about 10 days.

12. ASSESSMENT OF WITHDRAWL:
CLINICAL OIPOID WITHDRAWL SCALE(COWS)
Score: 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe; more
than 36 = severe withdrawal

13. SUBJECTIVE OPIATE WITHDRAWAL SCALE

14. OBJECTIVE OPIATE WITHDRAWAL SCALE

15. TREATMENT
PHARMACOLOGICAL NON- PHARMACOLOGICAL
AOPIOID SUBSTITUTION THERAPY A) INDIVIDUAL THERAPY
B) OPIOID ANTAGONISTS B) FAMILY THERAPY
C) SYMPTOMATIC TREATMENT C) SUPPORT GROUPS
D) REAPSE PREVENTION THERAPY

16. GOALS of OST are:
a) To reduce or prevent withdrawal.
b) To reduce or eliminate non prescribe drug use.
c) To stabilize drug intake of lifestyle.
d) To reduce drug related harm.
OPIOID SUBSTITUTION THERAPY

17. TRAMADOL
MOA:

18. Peak plasma conc. Is achieved in 1.5-2 hrs.
Dose range: 300–400 mg/day.
• Because of the short half-life of tramadol, it should be
prescribed in 3–4 divided doses per day.
• Available in the form of tablets (SR) 50mg and 100mg.
S/E: Light-headedness, sedation, nausea, constipation, weight gain,
decreased libido, insomnia, perspiration, fatigue, vomiting, dry
mouth.

19. TAPENTADOL
MOA Mu -opioid receptor agonist and norepinephrine
reuptake inhibitor.
DOA Analgesia occurs within 32 minutes of oral
administration, and lasts for 4–6 hours.
DOSE 100-500 mg/day.
S/E: Nausea, vomiting, dizziness, sleepiness, itchiness, dry
mouth, headache, and fatigue, hypotension.
C/I: In people prone to seizures.

20. NOTE:
*Combination with SSRIs/SNRIs, SRAs, serotonin receptor
agonists may lead to potentially lethal serotonin syndrome.
*Tapentadol was invented at the German pharmaceutical
company Grünenthal in the late 1980s.

21. BUPRENORPHINE
MOA: Synthetic partial opioid agonist
with low intrinsic activity and high
affinity at mu receptors, also weak
antagonist at kappa receptors.
It has a ceiling effect, therefore high
clinical safety.
Pk: s/l, takes 5-10 min to disintegrate
and absorb.
SIDE EFFECTS:
Headache, nausea, constipation,
orthostatic hypotension.

23. DOSING RANGE:
• Start from 2-16mg/day
• Maximum dose is 32mg/day
FORMS:
• S/L tablet: 0.2, 2mg/8mg alone.
• Plus naloxone: 2/0.5mg and 8/2mg.
INSTRUCTION:
Patient should be asked to place it under the tongue until it is
completely absorbed not to swallow or chew it.
Note: 4mg of buprenorphine = 40mg of methadone.
* Precipitated withdrawal.

24. PATIENT STATUS DOSE OF BUPRENORPHINE
IN WITHDRAWAL AND NO RISK FACTORS 8MG
NO WITHDRAWAL AND NO RISK FACTORS 4MG
RISK FACTORS (MEDICAL CO MORBIDITY,
POLY DRUG USE OR PSYCHIATRIC DISORDER)
2-4MG
According to Maudsley guidelines.
• No more than 8mg on day 1.
• Maximum to 32mg/day.
• Recommended maintenance dose: 12-16mg/day.

25. RECOMMENDED DOSE REDUCTON SCHEDULE
DAILY BUPRENORPHINE DOSE REDUCTION RATE
ABOVE 16 MG 4 MG EVERY 1-2 WEEKS
8-16 MG 2-4 MG EVERY 1-2 WEEKS
2-8 MG 2 MG PER WEEK OR FORTNIGHT
BELOW 2 MG REDUCE 0.4-0.8 MG PER WEEK

26. METHADONE:
• Synthetic opioid.
• Schedule 2 drug.
• MOA: acts as a pure agonist at mu-
receptor and negligible activity on any
other receptor.
• DOA: >24hrs; od dose is adequate.
• Adv; in c/o injectable , no drowsiness,
minimal euphoria.
• Disadv; high dependency potential and
low lethal dose.

27. USED FOR:
• Short term detoxification(7-30 days)
• Long term detoxification(up to 180 days)
• Maintenance (>180 days)
DOSAGE:
Initial dose of 15-20mg, increased to 70mg over weeks, maximum
dosage is 120mg.
*Daily supervised consumption is recommended. Cumulative
toxicity may develop (3-10 days) because of long half life,
therefore reviewed regularly.

28. Five institutions/hospitals were chosen for feasibility assessment
through site visits where methadone was made available. These
include:
• National Drug Dependence Treatment Centre, AIIMS
(including its community centres), New Delhi.
• Department of Psychiatry and Drug De-addiction Centre,
King Edward Memorial Hospital, Mumbai, Maharashtra.
• Department of Psychiatry and Drug De-addiction Centre,
Regional Institute of Medical Sciences, Imphal, Manipur.
• Drug De-addiction Centre, Civil Hospital, Bathinda, Punjab.
• Drug De-addiction Centre, Civil Hospital, Kapurthala, Punjab.

30. OPIOID ANTAGONIST
Naloxone:
Highest affinity for mu receptors , but
competitive antagonist of all receptors.
Half- life is 15-30 minutes.
Naltrexone: Active metabolite is 6 beta
naltrexol, half life of naltrexone is 1-3hrs and
active metabolite is 13hrs.
Potent mu antagonist and weak kappa
antagonist.
Nalmefene: Half life is 8-10hrs.

31. NALOXONE CHALLENGE TEST
0.8mg of naloxone is drawn
into a needle, out of which
0.2 is injected.
Observe for 20 seconds for
withdrawal signs , if no
evidence, inject rest 0.6mg.
Observe for next 20 minutes,
if no signs can start with
naltrexone.
IV CHALLENGE

32. NALTREXONE
THERAPEUTIC INDICATIONS
1. Opioid dependence
2. Rapid detoxification
3. Alcohol dependence
SIDE EFFECTS
• Nausea
• Vomiting
• Decreased appetite
• Dizziness
• Dysphoria
CONTRAINDICATIONS:
• Hepatic disease.
• Failed naloxone challenge.
• If patient is taking opioid analgesic.

33. DOSAGE AND GUIDELINES
INITIATING TREATMENT
• Wash out period is required.
• Informing the patient.
• Negative urine drug screen test
• Naloxone challenge test should be
negative.
DOSE:
• Initial dose of 25mg is given,
monitored for 4hrs.
• If tolerated a dose is increased to
50mg daily as a maintenance dose or
100mg every alternate day, 150 mg
every third day.

34. RAPID DETOXIFICATION
• 0.2mg orally every 2 hours for 9 doses to
maximum of 1.8mg.
• BP monitoring every 30-60 minutes for first
8 hours.
CLONIDINE
• 12.5 mg, 1-3 hours after first dose of
clonidine, increased to 25mg on 2nd day and
to 50mg on 3rd day.
NALTREXONE
• To reduce muscle cramps 30-60mg is given
with the first dose of clonidine and half of the
initial dose is given after every 4-6 hours.
• Maximum is 180mg.
OXAZEPAM
Benzodiazepines and clonidine are tapered off over next 5-10 days.

35. SMPTOMATIC TREATMENT
• CLONIDINE
• PREGABALIN/GABAPENTIN
• LUPIRTIN

36. MOA: Alpha-2 agonistic action.
Half life is 12-16hours.
DOSAGE: 0.1mg three times
daily.
*Next dose withheld if BP falls
<90/60mmHg.
*Tapering required, abrupt
stoppage leads to rebound
hypertension.
SIDE EFFECTS: Dry mouth,
dizziness, constipation, sedation,
hypotension.
CLONIDINE

37. PAIN MANAGEMENT
PREGABALIN
* Has analgesic, anxiolytic, and sedative actions.
DOSE: 150 – 600 mg/ day.
SIDE EFFECTS:
• Sedation
• Dizziness.
• Tremor, ataxia, fatigue.
• Vomiting, dry mouth, blurred vision.
• Memory impairment.
*GABAPENTIN addition helps in increasing efficacy.
Dose range: 900-1800 mg/day.

39. FLUPIRTINE
MOA:
• Potassium channel opener.
• NMDA receptor antagonist.
• GABA receptor modulatory properties.

40. DOSE:
100-400mg/day.
SIDE EFFECT:
Most imp is hepatotoxicity.

42. PROCHASKA’S MODEL OF CHANGE

43. INDIVIDUAL THERAPY
A) COGNITIVE BEHAVIOUR THERAPY
This is a short list of the types of negative thinking that are
obstacles to recovery and are topics for cognitive therapy:
1)My problem is because of other people;
2) I don’t think I can handle life without using;
3) Maybe I can just use occasionally;
4) Life won’t be fun — I won’t be fun — without using;
5) I’m worried I will turn into someone I don’t like;
6) I can’t make all the necessary changes; I can’t change my
friends;

44. 7) I don’t want to abandon my family;
8) Recovery is too much work;
9) My cravings will be overwhelming; I won’t be able to resist
them;
10) If I stop, I’ll only start up again; I have never finished
anything;
11) No one has to know if I relapse; and
12) I’m worried I have been so damaged by my addiction that I
won’t be able to recover.
WHAT WE HAVE TO DO??
• FEAR.
• REDEFINING FUN.
• LEARNING FROM SETBACKS.
• BECOMING COMFORTABLE WITH BEING UNCOMFORTABLE

47. B) MOTIVATIONAL ENHANCEMANT THERAPY
The need or desire to change from using to quitting a substance.
BASIC PRINCIPLES:
• Express empathy.
• Develop discrepancy.
• Avoid argumentation.
• Role with resistance.
• Support self-efficacy.

48. OUR ROLE:
• Eliciting self motivational statements.
• Listening with empathy.
• Questioning.
• Presenting personal feedback.
• Affirming the client
• Handing resistance.
• Reframing
• Summarizing.
• Discussing the plan.
• Communicating free choice.
• List of consequences of action and inaction.
• Information and advice.
• The change plan worksheet.

49. GROUP THERAPY
• Groups provide positive peer support and pressure to abstain
from substances of abuse.
• Groups reduce the sense of isolation that most people who have
substance abuse disorders experience.
• Groups enable people who abuse substances to witness the
recovery of others.
• Groups help members learn to cope with their substance abuse
and other problems by allowing them to see how others deal
with similar problems.
• Groups provide feedback concerning the values and abilities of
other group members.
• Groups allow a single treatment professional to help a number
of clients at the same time.
• Groups can effectively confront individual members about
substance abuse and other harmful behaviors with each other.

50. TYPES OF RELAPSE:
a) EMOTIONAL:
Signs of emotional relapse:
1) bottling up emotions;
2) isolating;
3) not going to meetings;
4) going to meetings but not sharing;
5) focusing on others (focusing on other people’s problems or
focusing on how other people affect them);
6) poor eating and sleeping habits.
The common cause for emotional relapse is *poor self-care.
HALT: hungry, angry, lonely, and tired.
RELAPSE

51. b) MENTAL RELAPSE:
Signs of mental relapse:
1) craving for drugs or alcohol;
2) thinking about people, places, and
things associated with past use;
3) minimizing consequences of past use or
glamorizing past use;
4) bargaining;
5) lying;
6) thinking of schemes to better control
using;
7) looking for relapse opportunities; and
8) planning a relapse.

52. c) PHYSICAL RELAPSE:
• Either lapse or relapse.
Educating clients in these rules can help them focus on what is
important:
1) change your life (recovery involves creating a new life where it
is easier to not use);
2) be completely honest;
3) ask for help;
4) practice self-care; and
5) don’t bend the rules.

54. Withdrawal
assessment
OST
Symptomatic
management
or SOS OST
Withdrawal
subsides, start
tapering.
Behavioural
therapies.
Plan to start
naltrexone.

55. 1. M Raga J, Sabater A, Perez-GB, Castellano M, Cervera G. Add-on gabapentin in the treatment of opiate
withdrawal. Prog Neuropsychopharmacol Biol Psychiatry. 2004; 28(3): 599-601.
2. Steigerwald I, Müller M, Davies A, Samper D, Sabatowski R, Baron R et.al. Effectiveness and safety of
tapentadol prolonged release for severe, chronic low back pain with or without a neuropathic pain
component: results of an open-label, phase 3b study. Curr Med Res Opin. 2012; 28(6): 911-36.
3. Alekseev VV. [Flupirtin (katadolon): a nonstandard action on pain transmission]. Zh Nevrol Psikhiatr Im S S
Korsakova. 2011; 111(4): 101-4.
4. Freynhagen R, Backonja M, Schug S. Pregabalin for the Treatment of Drug and Alcohol Withdrawal
Symptoms: A Comprehensive Review. CNS Drugs. 2016; 30(12): 1191-200.
5. Larimer ME, Palmer RS, Marlatt GA. Relapse prevention. An overview of Marlatt's cognitive-behavioral
model. Alcohol Res Health. 1999; 23(2): 151-60.
6. Melemis SM. Relapse Prevention and the Five Rules of Recovery. Yale J Biol Med. 2015; 88(3): 325-32.
7. Tamaskar R, Parran TV Jr, Heggi A, Brateanu A, Rabb M, Yu J. Tramadol versus buprenorphine for the
treatment of opiate withdrawal: a retrospective cohort control study. J Addict Dis. 2003; 22(4): 5-12
8. Bell J. Pharmacological maintenance treatments of opiate addiction. Br J Clin Pharmacol. 2014; 77(2): 253-
63.
REFFERENCES

56. 9. Bart G. Maintenance medication for opiate addiction: the foundation of recovery. J Addict Dis. 2012; 31(3): 207-
25.
10. Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. Dialogues
Clin Neurosci. 2007; 9(4): 455-70.
11. Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Rockville (MD): Substance
Abuse and Mental Health Services Administration (US); 2005; 41(1): 1-8.