Opioid Use Disorders: Assessment and Treatment 9/17/21

A person can be diagnosed as having an opioid use disorder if he or she develops symptoms of tolerance and withdrawal to opioids in association with various behavioral profiles, described below. Tolerance is defined as either needing a larger amount to achieve the same effect or having less effect from the same amount. Withdrawal is defined as either experiencing a withdrawal syndrome or needing to take the drug in order to avoid withdrawal effects. The withdrawal syndrome includes: anxiety, sad mood, insomnia, nausea, vomiting, diarrhea, “bone pain”, lacrimation, rhinorrhea, enlarged pupils and sweating. The associated behavioral symptoms that are required to make a diagnosis of opioid use disorder include at least two of the following: using larger amounts, spending longer time using, spending more time trying to get more drug, attempting to cut down, neglecting major work and home commitments, having interpersonal problems, having medical or psychiatric problems, and experiencing cravings.

Chronic opioid users describe a cycle of use. When they first use, they typically experience only euphoria, “the high”. After early repeated use, there is still some euphoria but the use is more profoundly driven to avoid the pain of withdrawal symptoms. Long-term use becomes established just to feel normal.

Traditional substance abuse treatment programs have focused on detoxification (withdrawal management) followed by residential treatment to establish early sobriety and then followed by outpatient programs to build support to maintain recovery. While this method works for some people, for people with opioid use disorder there is a high rate of relapse within 6 months.  In recent years with the increased availability of medically assisted treatment (MAT), more treatment is being provided directly in outpatient settings.

The newer MAT-facilitated outpatient opioid treatment programs use a harm reduction approach to try to reduce the hazards associated with drug use and help prevent harm. This comprehensive approach ideally includes mental health services and integration with other medical care. Therapy services that are helpful in this context include motivational interviewing, cognitive behavioral therapy, group-based therapy and support groups. The need for maintenance programs is based on two notions– first, that there is a biological deficit from chronic use that a maintenance medication can help fill and, second, that opioid use disorder is a chronic disease with a substantial risk of relapse.

Medication is one part of opioid treatment programs. Medication assisted treatment is an important tool in reducing opioid use that can ease the withdrawal of stopping opioid use and provide a chemical blockade of the euphoria produced by misuse of opioids. Naltrexone is an opioid receptor antagonist that blocks other opioids. It can be taken orally or as a monthly injection (Vivitrol). Side effects include headache and gastrointestinal upset. There is no special setting or special license to be able to prescribe it.

Buprenorphine is a long-acting opioid receptor partial agonist. It reduces the cravings for opioids and there is a substantially lower risk for euphoria and overdose. A patient must be in partial opioid withdrawal when starting the medication because otherwise the medication can precipitate a full withdrawal syndrome. Side effects include sweating and constipation.  Although buprenorphine can be associated with risks for diversion can be dangerous if combined with benzodiazepines, its use can be life changing for many addicted to opioids and it can be used for pain management patients with lower risk of tolerance and dependency developing.

Methadone, which is a long-acting opioid agonist, is the most well-known medication used for maintenance treatment and has been around the longest. It reduces cravings and has less of a euphoria and overdose risk associated with it. Side effects include sweating, constipation and arrhythmias at higher doses. It typically requires daily monitoring which can be a barrier to treatment but the level of involvement may also be a positive for many patients.

Both methadone and buprenorphine improve outcomes and decrease the use of opioids. Methadone has a greater patient retention in treatment, likely due to the need for daily attendance. The requirement of daily attendance allows for patients to be more easily referred to other services as well. On the other hand, buprenorphine is more widely available and safer in terms of side effects. Both have shown positive outcomes when it comes to reduced risk of HIV, decrease in criminal behavior, increase in the ability to engage in work and improved relationships. Retention in MAT is associated with substantial reductions in the risk of all cause and overdose mortality in people dependent on opioids. The longer a patient stays in a MAT, the better the outcome.

Finally, and of particular relevance in relation to opioid medication given the increased street availability of highly potent opioid agents such as fentanyl that is implicated in many overdoses, it is important to comment on the importance of naloxone (Narcan) which can be lifesaving in preventing loss of life through its action of blocking the opioid receptors.

In summary, opioid use disorder is a chronic and deadly illness. There are now good available treatments for opioid use disorders. Treatment for opioid use disorders using MAT improves quality of lives.

 

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