T abuhadid opioid_abuse_and_withdrawal
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Opioid Abuse and Withdrawal discusses opioid abuse, withdrawal symptoms, medications used for withdrawal like buprenorphine and methadone, and assessing withdrawal severity using the Clinical Opioid Withdrawal Scale (COWS). It explains that short-acting opioids cause withdrawal sooner than long-acting ones. Precipitated withdrawal can occur if withdrawal medications are given before full withdrawal occurs. The document provides a case study to demonstrate accurately using the COWS scale to rate withdrawal severity.
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T abuhadid opioid_abuse_and_withdrawal
- 1. Opioid Abuse and Withdrawal BY THAER ABUHADID
- 2. Instructions for this Power Point Make sure to play the sound by clicking on play button on the speaker emblem when going through the power-point
- 3. Objectives Understand why people abuse opioids List at least 3 signs and symptoms of opioid withdrawal Identify at least 2 common medications used during opioid withdrawal Analyze a case-study for opioid withdrawal signs and symptoms to measure the individuals withdrawal severity by using a C.O.W.S scale accurately Identify which opioids take longer to withdrawal from Understand Induction and precipitated withdrawal
- 4. Opioids and Abuse Opioids- Class of drugs made from opium, as well as synthetic or semi-synthetic drugs. Definition of abuse- When use of opioids harms a persons health or social functioning. It also occurs when a person is addicted to or physically dependent on opioids. Causes- Opioids produce a quick, intense feeling of pleasure (euphoria), followed by a sense of well-being and calm drowsiness. Symptoms of opioid abuse- Tolerance, drug seeking, and personal problems
- 5. Watch this video about how people become addicted and withdrawal symptoms https://www.youtube.com/watch?v=uvPrmQhhRuE
- 6. Signs and symptoms of opioid withdrawal
- 7. Short Acting VS Long Acting Opioids Short Term- Heroin, Crushed OxyContin, Percocet, Vicodin, Oxycodone, Codeine, Hydrocodone, Hydromorphone (take shorter time to withdrawal from) Long Acting Opioids- Oxycontin, Fentanyl, Methadone, Morphine (Take a longer time to withdrawal from)
- 8. Common Drugs Used For Withdrawal Buprenorphine (Subutex)- Semi- synthetic opioid derived from thebaine, an alkaloid of the poppy Papaver somniferum. It is an opioid partial agonist. Benefits- Its maximal effects are less than those of full agonists like heroin and methadone. At low doses, it produces increase linearly without increasing doses of the drug until it reaches a plateau and no longer continues to increase with further increases in dosage (ceiling effect)
- 9. Methadone (Methadose) It is a synthetic opioid that binds to the mu opiate receptors on the surfaces of brain cells, which mediate the analgesic and other effects of opioids. Therapeutically, appropriate doses of this agonist produce cross- tolerance for short-acting opioids such as morphine and heroin, thereby suppressing withdrawal symptoms and opioid craving as a short-acting opioid is eliminated form the body. The dose needed to produce cross-tolerance depends on the patient’s level of tolerance for short-acting opioids
- 10. Naltrexone (Depade, ReVia) Highly effective opioid antagonist that tightly binds to mu opiate receptors. It is able to displace other opioids that include heroin, morphine, or methadone and block their effects due to its high affinity level. It can precipitate withdrawal in patients who have not been abstinent from short-acting opioids for at least 7 days and have not been abstinent form long-acting ones, such as methadone, for at least 10 days Benefits Negatives
- 11. Precipitated Withdrawal and How to Avoid It Precipitated withdrawal is a rapid and intense onset of withdrawal symptoms initiated by a medication. Patient education and developing realistic expectations are essential before beginning treatment To avoid precipitated withdrawal, physically dependent patients must no longer be experiencing the agonist effects of an opioid. To avoid this, we observe objective symptoms of withdrawal sufficient to score a 5-6 on the COWS. Scores of >10 are preferable. Due to patient individuality, required abstinent times may vary considerable from patient to patient. Only use the time since last use as an estimate to anticipate the onset of withdrawal symptoms
- 12. Induction and It’s Goal Induction begins by assessing last use of all opioids, short and long acting, objective and subjective symptoms and a COWS score calculation. The goal of induction If withdrawal symptoms are mild (5-24), it is in the patients best interest to wait. Long-acting opioids will require a longer period of abstinence, than short-acting opioids. Short-acting opioids (prior to induction) Long-acting opioids (prior to induction) Methadone
- 13. Using C.O.W.S We use the Clinical Opioid Withdrawal Scale (C.O.W.S) scale to rate the severity of withdrawal from opioids. Resting Pulse Rate: Have the patient sit or lay down for at least 1 minute before measuring 0 = Pulse rate 80 or below 1 = Subjective report of chills or flushing 2 = flushed or observable moistness on face 3 = Frequent shifting or extraneous movements of legs/arms 5 = Unable to sit still for more than a few seconds
- 14. Sweating: Over Past ½ Hour NOT Accounted for by Room Temp or Pt Activity 0 = No report of chills or flushing 1 = subjective report of chills or flushing 2 = flushed or observable moistness on face 3 = beads of sweat on brow or face 4 = sweat streaming off face
- 15. Restlessness Observation During Assessment 0 = able to sit still 1 = Reports difficulty sitting still, but is able to do so 3 = frequent shifting or extraneous movements of legs/arms 5 = Unable to sit still for more than a few seconds
- 16. Pupil Size 0 = pupils pinned or normal size for room light 1 = pupils possibly larger than normal for room light 2 = pupils moderately dilated 5 = pupils so dilated that only the rim of the iris is visible
- 17. Bone or Joint Aches If the Patient was having pain previously, only the additional component attributed to opiate withdrawal is scored 0 = Not present 1 = mild diffuse discomfort 2 = patient reports severe diffuse aching of joints/muscles 4 = Patient is rubbing joints or muscles and is unable to sit still because of discomfort
- 18. Runny Nose or Tearing Not accounted for by cold symptoms or allergies 0 = not present 1 = nasal stuffiness or unusually moist eyes 2 = nose running or tearing 4 = nose constantly running or tears streaming down cheeks
- 19. GI Upset: Over last ½ hour 0 = No GI symptoms 1 = stomach cramps 2 = nausea or loose stool 3 = vomiting or diarrhea 5 = multiple episodes of diarrhea or vomiting
- 20. Tremor Observation of Outstretched Hands 0 = no tremor 1 = tremor can be felt, but not observed 2 = slight tremor observable 4 = gross tremor or muscle twitching
- 21. Yawning Observation During Assessment 0 = no yawning 1 = yawning once or twice during assessment 2 = yawning three or more times during assessment 4 = yawning several times/minute
- 22. Anxiety or Irritability 0 = none 1 = patient reports increasing irritability or anxiousness 2 = patient obviously irritable/anxious 4 = patient so irritable or anxious that participation in the assessment is difficult
- 23. Gooseflesh Skin 0 = skin is smooth 3 = piloerection of skin can be felt or hairs standing up on arms 5 = prominent piloerection
- 24. SCORE 5-12 = Mild 13-24 = Moderate 25 – 36 = Moderately Severe More than 36 = Severe Withdrawal
- 25. Now Its Your Turn-Case Study A 24 year old veteran comes in to triage and reports that he has a history of back pain due to an injury he suffered in Iraq. He also reports that he has been chronically taking morphine for his back pain. The veteran came in to triage because he reports experiencing withdrawal symptoms and stuffy nose due to having a cold. The nurse observes that the resting PR is 118 BPM, beads of sweat on brow, the veteran is frequently shifting his position. The nurse then observes the veteran's pupils and finds that they are so dilated that only the rim of the iris is visible. The nurse notes that the veteran’s nose is runny, and the veteran is now experiencing stomach cramps and the veteran is rubbing joints or muscles and is unable to sit still because of discomfort. The nurse then tells the veteran to extend his arms and notices gross tremor and muscle twitching. The nurse also observes that the veteran is obviously irritable/anxious and prominent pilorection. During the assessment, the veteran yawned four times. Click to view COWS SCALE
- 26. Click to go back to Case study Click to go rate the veteran
- 27. What would you rate this veteran on C.O.W.S 29-33 40-44 24-28 5-12
- 28. Your score is not accurate Go back to case study.
- 29. Your score is accurate enough As we can see, interpreting withdrawal symptoms can depend on the observer, but the most important thing to remember is scoring accurate enough to rate mild, moderate, moderately severe, and severe. My score is 31, having a score around this margin is accurate. This is moderately severe withdrawal symptoms. CLICK ON THIS SLIDE TO TAKE QUIZ
- 30. Take the Quiz Which opioid is a short acting drug?
- 31. Why do people abuse Opioids? Natural endorphins in the body is diminished Tolerance Euphoric Feeling and Sense of Well Being All answers are correct
- 32. What is an early sign of opioid withdrawal? Diarrhea Hypotension Dehydration Diaphoresis
- 33. True or False- Withdrawal is dependent to how much a patient is using opioids True False
- 34. What is the goal of induction? Safely suppress opioid withdrawal as rapidly as possible with withdrawal drugs Safely suppress opioid withdrawal slowly as possible with opioid drugs Inducing coma None of the above
- 39. Nice Job! Finish
- 45. Thank You! Thank you everyone for learning about opioids and withdrawal. Thanks for the AWESOME experience I had at this site. Thanks for your kindness and welcoming attitude. I will not forget the wonderful team and experience I had at the VA. References
- 46. References http://www.naabt.org/documents/cows_induction_flow_sheet.pdf McCoy, K. M. (2012). Opioid abuse. Salem Press Encyclopedia Of Health, http://www.ncbi.nlm.nih.gov/books/NBK64158/ https://www.naabt.org/faq_answers.cfm?ID=2
Editor's Notes
- Opioids examples- heroin, morphine, codeine, hydrocodone, oxycodone, and fentanyl. They produce their effects by binding to the opioid receptors of the CNS, which respond to the body’s intrinsic opioids known as endorphins to naturally block or suppress the sensation of pain. When opioid drugs are used repeatedly, the level of natural endorphins in the body is diminished and the brain is likely to become dependent on the drug. That is what makes them highly addictive. One symptoms is tolerance, or the need to increase the dose in order to achieve the same effect. Another symptom is increased amounts of time spent drug-seeking. Other symptoms include the interference of drug or drug-seeking behavior with social, occupational, or school functioning; the continued use of drugs despite social, legal, occupational, or interpersonal problems stemming from drug use; desire or efforts made to decrease or stop drug use without success; and withdrawal, the adverse symptoms that occur when the drug is not taken.
- such as aching, fever, sweating, chills, and craving. Some other symptoms of withdrawal are diarrhea, nausea, and vomiting; sleeplessness, abdominal pain and muscle aches; restlessness; tearing eyes, and runny nose; yawning, panic, and irritability.
- Other benefits- carries a lower risk of abuse, addiction, and side effects compared to full opioid agonists. This drug can actually block the effects of full opioid agonists and can precipitate withdrawal symptoms if administered to an opioid-addicted individual while a full agonist is in the bloodstream. The reason for this is because it has a higher affinity or strength attraction to bind to receptor sites, therefore, will compete for the receptor and win. It will “knock off” other opioids and occupy that receptor blocking other opioids from attaching to it. If there is enough Buprenorphine to knock the opioids off the receptors but not enough to occupy and satisfy the receptors, withdrawal symptoms can occur; in which case the treatment is more Buprenorphine until withdrawal symptoms disappear. In summary, the benefits are- less euphoria and physical dependence -Lower potential for misuse -A ceiling on opioid effects -Relatively mild withdrawal profile At the appropriate dose buprenorphine treatment may: -Supress symptoms of opioid withdrawal -Decrease cravings for opioids -Reduce illicit opioid use -Block the effects of other opioids -Help patients stay in treatment
- When given intramuscularly or orally, methadone suppresses pain for 4-6 hours. Because of its extensive bioavailability and longer half-life, an adequate daily oral dose of methadone suppresses withdrawal and drug craving for 24-36 hours in most patients who are opioid addicted. After pt induction into methadone pharmacotherapy, a steady-state concentration )I.e, the level at which the amount of drug entering the body equals the amount being excreted) of methadone usually is achieved in 5-7.5 days (four to five half-lives of the drug). Its pharmacological profile supports sustained activity at th emu opiate receptors, which allows substantial normalization of many pphysiological disturbances resulting form the repeated cycles of intoxication and withdrawal associated with addiction to short-acting opioids. Appropriate doses of methadone also block the euphoric effects of heroin and other opioids.
- Because naltrexone has no narcotic effect, there are no withdrawal symptoms when a patient stops using naltrexone, no does nalstrexone have abuse potential. Early research concluded that tolerance does not develop for naltrexone’s antagonist properties, even after many months of regular use. A 50 mg tab markedly attenuates or blocks opioid effects for 24 hours, and a 100 to 150 mg dose can block opioid effects for up to 72 hours. Negatives- Although the FDA approved naltrexone for maintenance treatment in 1984 based on its pharmacological effects, without requiring proof of its efficacy in clinical trials for opioid addiction treatment. Despite its potential advantages, it has little impact on the treatment of opioid addiction in the U.S, primarily because of poor pt compliance.
- For example, Buprenorphine, because it has a higher binding strength at the opioid receptor, it competes for the receptor, to kick off and replace existing opioids. If a significant amount of opioids are expelled from the receptors and replaced, the opioid physically dependent patient will feel the rapid loss of the opioid effect, initiating withdrawal symptoms. More precisely, precipitated withdrawal can occur when an antagonist (or partial agonist, such as Buprenorphine) is administered to a patient who is physically dependent on full agonist opioids. Due to the high affinity but low intrinsic activity of Buprenorphine at the U-receptor, the partial agonist displaces full agonist opioids from the U-receptors, but activates the receptor to a lesser degree than full agonists which results in a net decrease in agonist effect, thereby predicating withdrawal.
- The goal of induction- Is to safely suppress opiod withdrawal as rapidly as possible with adequate doses of Buprenorphine. Failure to do so many cause patients to use opioids or other medications to alleviate opioid withdrawal symptoms or may lead to early treatment doropout. TO achieve this, some physicians have found they may need to dose as high as 32 mg, the first day with some methadone to Buprenorphine transfers. Prior to induction, patients must abstain from all short-acting opioids for 12-24 hours and or have objective withdrawal symptoms sufficient to produce a score of 5 to 24 on the COWS. For long acting opioids- Discontinue use for at least 24 hours prior to induction. A minimal score of a least 5 on the COWS is recommended, although some physicians prefer scores of 15 or higher. Methadone- Is recommended that patients transitioning from methadone to Buprenorphine slowly taper to 30 mg./day of methadone, for at least one week. Last dose must be no less than 36 hours prior to induction, and may be 96 hours or more. A minimal score of at least 5 on the COWS is recommended, although some physicians prefer scores of 15 or higher.
- The goal of induction- Is to safely suppress opiod withdrawal as rapidly as possible with adequate doses of Buprenorphine or other withdrawal drugs. Failure to do so many cause patients to use opioids or other medications to alleviate opioid withdrawal symptoms or may lead to early treatment doropout. TO achieve this, some physicians have found they may need to dose as high as 32 mg, the first day with some methadone to Buprenorphine transfers.