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SUD I | Opioid-Related Disorders Cheat Sheet by

Termin­ology

Natural Opiates
Semi­-Sy­nth­etic
Synt­hetic Opioids
Codeine
Burpre­nor­phine
Fentanyl
Morphine
Heroin
Meperidine
 
Hydroc­odone
Methadone
 
Hydrom­orphone
Sufentanil
 
Oxycodone
Sufentanil
 
Oxymor­phone
 
Tramadol

PATHOP­HYS­IOLOGY

Risk Factors: males, history of depression or anxiety, family history of alcohol or drug abuse, age ≤ 30, long-term opioid use

Involves the mesolimbic reward system

Standa­rdized Assessment Tools

Score
Seve­rity
5 to 12
Mild
13 to 24
Moderate
25 to 36
Moderate to Severe
> 36
Severe
COWS: Clinical Opiate Withdrawal Scale
• used clinically to monitor withdrawal
• often utilized to determine when PRNs are needed

NALOXONE

MOA
Opioid Antagonist
Warn­ing­s/A­DRs
Cardiac or respir­atory effects associated with rapid reversal of opioids
 
Aggression (from immediate withdr­awal)
Admi­nis­tra­tion
Call 911 FIRST
 
Administer
 
If no response after 3 minutes, administer 2nd dose
• It only works on opioid receptors!

• It will NOT affect someone (posi­tively or negati­vely) if they do not have opioids in their system

Opioid Use Disorder | TREATMENT

 
FIRST LINE
SECOND LINE
APA:
 
Bupren­orphine
Naltrexone PO
 
Methadone
BAP:
 
Bupren­orphine
Naltrexone PO
 
Methadone
VA/D­OD:
 
Suboxone
Naltrexone
 
Bupren­orphine
 
Methadone
Psyc­hos­ocial treatment is also the first line in addition to pharma­cot­her­apy

Bupren­orphine Formul­ations

 
Bupr­eno­rph­ine
Bupr­eno­rph­ine­-Na­lox­one
Brand
Subutex
Suboxone, Zubsolv
MOA
Mu opiate receptor - partial agonist
Mu-partial agonist and opioid antago­nists
Formul­ation
SL tablet
SL tablet, SL film; (4:1 ratio of bupren. and naloxone)
Dosing range
8 to 32 mg bupren./day
8 to 32 mg bupren/day
Warnings
initiation should not begin until pt is experi­encing withdrawal
same
 
respir­atory depression
same
 
risk of abuse or dependence
same
DDIs
CYP3A4 inhibi­tor­s/i­nducers
same
 
CNS depresants
same
Monitoring
Tolera­bility, resp. depres­sion, (LFTs), urine drug screening, PMP, urine bupren­orphine
same
Clinical Pearls
Preferred in pregnancy; higher abuse potential
naloxone added as an abuse deterrent; preferred formul­ation in non-pr­egnant patients
 
partial agonist activity results in ceiling effect, higher binding affinity than other opioids, newer formul­ation include sub-dermal implant, and subcut­aneous injection
same
Prescr­ibing Restri­ctions:
Schedule III
DATA waiver
Initial no. of pts is 30
May apply 1 year to increase no. of patients to 100, then 275
DEA number will begin with X

Signs and Sx of opioid WITHDRAWAL

Dysphoric mood
Fever
Lacrim­ation or Rhinorrhea
Muscle aches
Yawn­ing
Diar­rhea
N/V
Insomnia
Pupillary Dilartion
Piloer­ection (goose­bumps)
Sweating

WITHDRAWAL TIMELINE

Onset of withdrawal will depend upon the half-life of the opioid used (normally within 36 to 72 hours)
Completed within 7 days for short acting opioids (heroin) and 14 days for long-a­cting opioids (bupre­nor­phine, methadone)

Preferred treatment

Meth­adone
bupr­eno­rph­ine
Chronic Pain
Prolonged QT interval
history or diversion or pilysu­bstance use
not able to attend daily clinic
requires closer monitoring
requires less monitoring and no untreated psychi­atric comorb­idities
pregnant women
dependent on lower doses of opioids (ceiling effect)
requires wide dosing range
 

Terms

Opioid Tolera­nce
Person using opioids begins to experience a reduced response to medication requiring more opioids to experience the same effect
Opioid Depend­ence
Occurs when the body adjusts its normal functi­oning around regular opioid use (unple­asant physical symptoms occurs when med is stopped)
Opioid Addict­ion
Occurs when attempts to cut down use are unsucc­essful or when results insocial problems and a failure to fulfill obliga­tions; often comes after person has developed opioid tolerance and dependence

Narcan MOA

DSM-5 DIAGNOSTIC CRITERIA

A proble­matic pattern of substance use leading to clinically signif­icant impairment or distress, manifested by ≥ 2 of the following over a 12-month period
⓵ Substance is taken in larger amounts or over a longer period than intended
⓶ Persistent desire or unsucc­essful efforts to reduce or control use
⓷ A great deal of time is spent in activities necessary to obtain, use, or recover from effects
⓸ Cravings or a strong desire to use
⓹ Recurrent use resulting in a failure to fulfill major obliga­tions
⓺ Continued use despite having persistent social or interp­ersonal problems caused by the substance
⓻ Important social, occupa­tional, or recrea­tional activities are given up or reduced
⓼ Recurrent use in situations that are physically hazardous
⓽ Recurrent use despite knowledge of having a persistent or recurrent physical or psycho­logical problem due to use
⓾ Tolerance
⑪ Withdrawal

FIRST - LINE TREATMENT

APA
British Associ­ation of Psycho­pha­rma­col­ogy
Bupren­orphine
Alpha-2 agonist
Methadone
Bupren­orphine
 
Methadone
Targeted at individual symptoms of withdrawal
Common practice if an opioid treatment program (OTP) or bridging medica­tio­n-a­ssisted treatment (MAT)

Methadone

Brand
METHADOSE
MOA
opioid agonist
Formul­ation
Liquid (opioid mainte­nance); tablets (pain only) | this is for pharmacies (methadone clinics do tabs)
Mainte­nance dose
80 to 120 mg daily
Warnings
QTc prolon­gation, respir­atory depres­sion, risk of abuse or dependence
DDI
QTc prolon­gating meds, CYP3A4 inhibitors or inducers, Medica­tions that induce hypoka­lemia, hypoca­lcemia, or hypoma­gne­semia; CNS depres­sants
Monitoring
Tolera­bility, respir­atory depres­sion, HR/BP, EKG, electr­olytes, UDS, urine methadone, PMP
Clinical Pearls
prolonged or delayed withdrawal due to long half-life; overdose risk is highest during initial 2 weeks of treatment
Prescr­ibing restri­ctions:
- schedule II; restricted to certified opioid treatment program (OTP)
- it is not approp­riate to dispense methadone from a community pharmacy for the purposes of opioid detox, withdr­awal, or mainte­nance
- pts must be currently addicted and have opioid use disorder ≥ 1 year
- except­ions: pregnancy, recently released from correc­tion, and previous treatment in OTP

know difference between prescr­ibing of methadone and bupren­orp­hine

Signs and Sx of INTOXI­CATION

Pulillary Constr­iction
Slurred Speech
Drowsiness
Impaired attention or memory

Signs and Sx of Opioid OVERDOSE

Pupillary constr­iction
Shallow or slow respir­ations
Stupor
Coma
Hypoth­ermia
Bradyc­ardia

Narcan Formul­ations

Naloxone
IM/IV/SQ
Naloxone
Intranasal
Evzio
IM auto-i­njector
Narcan
Intranasal

SYMPTO­MATIC TREATMENT (PRN)

Medi­cat­ion
Clas­s/MOA
Indi­cat­ion
Clonidine
Alpha-2 agonist reduced the noradr­energic hypera­ctivity associated with opioid withdrawal
Genera­lized Sx of opioid withdrawal
Loperamide
Anti-d­iar­rheal
Diarrhea
Ondans­etron
Antiemetic
N/V
Trazodone
Sedatine antide­pre­ssant
Insomnia
Hydrox­yzine
Antihi­sta­min­e/a­nxi­olytic
Anxiety
Ibuprofen
NSAID
muscle pain
Cyclob­enz­aprine
skeletal muscle relaxant
muscle cramps
                           

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