Opioid Use Disorder

Question 1

Symptoms of opioid withdrawal

Answer 1

Abdominal pain, sweats, diarrhea, body aches

Pupillary dilation, lacrimation, rhinorrhea, mild fever

Dysphoric and irritable mood

Question 2

If someone is acutely intoxicated with opioids, give ___.

If someone is withdrawing from opioids, give ___.

Answer 2

If someone is acutely intoxicated with opioids, give naloxone.

If someone is withdrawing from opioids, give suboxone (naloxone + buprenorphine) OR methadone.

Question 3

Methadone and buprenorphine can both cause severe respiratory depression if combined with. . .

Answer 3

. . . benzodiazepines or alcohol

Question 4

Buprenorphine is a ___ agonist while methadone is a ___ agonist.

Answer 4

Buprenorphine is a partial mu agonist (with a ceiling effect) agonist while methadone is a full mu agonist agonist.

Both are high affinity for the mu receptor and will therefore displace any other opioid in the body

Question 5

What can a prescriber give for opioid withdrawal if they are not liscensed to give buprenorphine or methadone?

Answer 5

Clonidine (to reduce sweating, cramps, muscle aches, anxiety)

Dicyclomine (for abdominal cramps)

Loperamide (for diarrhea)

Ibuprofen (for muscle aches)

Ondansetron (for N/V)

Decongestants (for rhinorrhea)

Question 6

Naltrexone for opioid dependency

Answer 6

An opioid antagonist

The oral formulation is not very effective due to noncompliance with therapy, however the injectable formulation is highly effective but cost prohibitive.

Question 7

How long does it take for symptoms of opioid withdrawal to appear?

Answer 7

After hours or 1-2 days

It depends on the specific drug’s half-life and on the user’s tolerance

Heroin is fast on/fast off, with a very rapid and severe withdrawal. Opioids like methadone have a long half life with much less severe and more gradual withdrawal.

Question 8

Recommended treatment for opioid withdrawal

Answer 8

Combination of clonidine (symptomatic treatment) with either slow-tapered methadone or buprenorphine (treating the root cause)

Blood pressure should be carefully monitored while using clonidine for this treatment, as autonomic instability may be present.

Question 9

Mechanism of clonidine in opioid withdrawal

Answer 9

Blocking the alpha-2 adrenergic receptors in the locus ceruleus that share potassium channels with opioids, thereby blunting symptoms of opioid withdrawal.

Question 10

Buprenorphine is usually administered. . .

Answer 10

. . . sublingually

Question 11

If a patient on methadone therapy is experiencing withdrawal symptoms, but u-tox remains negative for any other recent opioid use than methadone, the next step is to. . .

Answer 11

. . . increase the methadone dose

This is preferable to adding clonidine for symptomatic treatment.

Question 12

Patients on methadone for OUD therapy may desire to switch to suboxone therapy due to the inconvenience of daily methadone clinic visits. How should this be handled?

Answer 12

The methadone should be tapered in preparation for the switch.

Since buprenorphine is only a partial agonist and naloxone is a blocker, switching from methadone (a full agonist) can precipitate withdrawal symptoms if there is not a taper period.

Question 13

SLUDGE mnemonic for opioid withdrawal

Answer 13

Salivation

Lacrimation

Urination

Diarrhea

Gastrointestinal symptoms

Emesis

Question 14

Is opioid withdrawal life threatening?

Answer 14

No

It is just extremely uncomfortable.

Opioid overdose, on the other hand, is life threatening due to hypoventilation

Question 15

First symptoms that should raise a red flag for opioid withdrawal

Answer 15

• Dilated pupils
• Sweating
• Anxiety

Question 16

Features unique to opioid withdrawal, among withdrawal syndromes

Answer 16

Rhinorrhea

Lacrimation

Pupillary dilation

These do not occur with stimulant, other sedative, hypnotic, or anxiolytic withdrawals.

Question 17

Efficacy of naloxone

Answer 17

1 or 2 puffs of naloxone no longer regularly gets the job done

This is because the potency of street narcotics have been increasing over the past decades

Question 18

Risks of starting injectable naltrexone for opioid use disorder

Answer 18

For the first week or so they need a washout period, and during this time there is risk of recurrence

If they are on naltrxone stably, it is a great medication.

Question 19

Buprenorphine is basically always given as. . .

Answer 19

. . . a formulation containing naloxone

This reduces the potential for abuse