Heroin/Opioid misuse

Question 1

Definition of opioid abuse?

Answer 1

Continuous opioid use despite physical, psychological or social harm to the user

Question 2

What are examples of opioids?

Answer 2

Heroin, morphine, methadone, buprenorphine

Question 3

What are the main effects of opioid?

Answer 3

Analgesia
Euphoric effect (the main reason why it is abused)

Question 4

By which routes can opioids be taken?

Answer 4

IV, SC, intranasally, smoked

Question 5

What are characteristic features of opioid dependence?

Answer 5

• Drug craving / compulsion to take substance
• Maladaptive behaviour focused on obtaining opioids at any cost
• Difficulty in controlling use
• Physiological withdrawal state
• Tolerance (need increased dose for same effect)
• Neglect of alternative pleasures and interests
• Persistence of use despite harm to themselves or others

Question 6

What are the three major symptoms of opioid overdose?

Answer 6

• pinpoint pupils
• unconsciousness
• respiratory depression

Question 7

What are symptoms of acute opioid withdrawal?

Answer 7

• Sweating
• Watering eyes
• Rhinorrhoea and coughing
• Yawning
• Feeling hot/cold
• Anorexia
• Abdominal cramps
• Nausea, vomiting and diarrhoea
• Tremor
• Goosebumps
• Tachycardia and HTN
• Insomnia, restlessness, anxiety and irritability
• Generalised aches and pains
• Dilated pupils
• Increased bowel sounds

Question 8

How soon can acute heroin withdrawal symptoms start to improve?

Answer 8

after 5 days

Question 9

How soon can methadone withdrawal symptoms start to ease?

Answer 9

10-12 days

Question 10

How long can opioid cravings last for after withdrawal?

Answer 10

Up to 6 months

Question 11

What health complications are there with opioid dependence?

Answer 11

• Death  overdose, suicide accidents, health-related complications
• Skin infection at injection sites (can be serious e.g. necrotising fasciitis)
• Sepsis
• Infective endocarditis
• HIV infection
• Hepatitis A, B, C infection
• TB
• Venous and arterial thromboses (due to poor injecting techniques)
• Poor nutrition and dental disease

Question 12

What social complications can occur with opioid dependence?

Answer 12

• Crime
• Relationship problems
• Child protection issues
• Homelessness and deprivation
• Working in sex industry

Question 13

What psychological complication scan occur with opioid dependence?

Answer 13

• Craving
• Guilt
• Anxiety
• Cognitive impairment and memory loss

Question 14

How may opioid dependence present in primary care?

Answer 14

• Direct request for help with their dependence
• Medical complication due to their dependence
• Clinical signs of opioid intoxication or withdrawal
• Social problems including forensic history
• Disclosing their opioid abuse whilst presenting for another problem

Question 15

How would you assess for current opioid drug use?

Answer 15

Drug testing:

• Screening test - immunoassay and dipstick (these are quick, easy and cheap)
• confirmatory tests - gas or liquid chromatography and mass spectrometry
• oral fluid testing ( however, this only detects drug use in past 24-48 hours)
• hair testing - can detect drug use over past few months ( but can’t tell between continuous and sporadic use)

Question 16

Which risks need to be assessed in opioid drug users?

Answer 16

Overdose risk
Polydrug and alcohol misuse
Unsafe injecting practices
Unsafe sexual practices
Risk of self harm or harm to others
Risk to dependent children

Question 17

What needs to be looked at in order to assess social functioning?

Answer 17

• partners, family, support
• housing
• education/employment
• domestic violence
• Benefits and financial problems
• childcare issues - pregnancy, parenting and child protection

Question 18

What should be assessed in opioid users?

Answer 18

current drug use
risk ( to self and others)
Social functioning
criminal involvement and offending
physical and psychological health

Question 19

What is the treatment of opioid intoxication?

Answer 19

1) ABCDE
2) Naloxone (is. pure opioid antagonist to reverse opioid intoxication) (route: IV best, IM or SC if venous access difficult)
3) supportive measures - maintain airway, ventilation, IV fluids

Question 20

What is the treatment of opioid dependence?

Answer 20

detoxification

induction and maintenance substitute prescribing

Question 21

How long does it take to lose tolerance to methadone?

Answer 21

3 days

Question 22

If someone stopped taking methadone and wanted to restart it after 3 or more days what would you do?

Answer 22

Prescribe them a lower dose than before to reduce risk of overdose

Question 23

what are the two main treatment options for heroin detox?

Answer 23

Methadone

Buprenoprhine

Question 24

What else should be delivered alongside the medication during detox?

Answer 24

Psychological interventions - CBT

keyworker support

Question 25

When an opioid user asks for detox, what has to be considered when assessing suitability?

Answer 25

* Patient COMMITTED and fully informed?? * Does patient understand the physical and psychological aspects of withdrawal and how they can be managed? * Understand increased risk of overdose and death if use illicit drug whilst on detox medication * High risk of relapse been explained? * Adequate social support available post detox??

Question 26

What are the aims of pharmacological treatment for opioid detoxification?

Answer 26

* Reduce or prevent withdrawal symptoms * Provide opportunity to stabilise drug intake whilst breaking with illicit drug use and associated unhealthy risk behaviours

Question 27

Which medication is first line for opioid detox (despite them both appearing to be equally effective)?

Answer 27

methadone

Question 28

What does treatment with a. drug substitute help protect against?

Answer 28

Risk of overdose Bloods-borne infection Risk of offending

Question 29

With methadone - when is the risk highest for overdose?

Answer 29

On induction and during the first 2 weeks of treatment

Question 30

What increases the risk of overdose when on methadone for detoxification?

Answer 30

``` o Low opioid tolerance o Other CNS Depressants e.g. alcohol, benzos o Initial dose is too high o Slow methadone clearance o Polysubstance abuse ```

Question 31

How do you reduce the risk of toxicity with methadone?

Answer 31

- Identifying high-risk patients - Avoid starting the patient on too a low a dose - avoid rapid increases of dose - explain and educate patients and careers on the early signs of overdose

Question 32

Why does buprenorphine have reduced risk of overdose during induction of the medication for detoxification?

Answer 32

As it has mixed agonist and antagonist properties at opioid receptors, so an increased dose does not produce more intense opioid effects

Question 33

What are downsides with using buprenorphine for opioid detox?

Answer 33

- May interact with any HIV medications | - More risk of misuse than methadone

Question 34

What pharmacological medications can be used to treat any withdrawal symptoms that may be experienced?

Answer 34

- Antidiarrhoeals (Loperamide) for diarrhoea - Metoclopramide, Prochlorperazine for nausea, vomiting and stomach cramps - Mebeverine for stomach cramps - Diazepam or Zopiclone for agitation, anxiety and insomnia - Paracetamol and NSAIDs for muscle pains and headaches

Question 35

What medication can be prescribed to prevent replaces of opioid use?

Answer 35

Naloxone