Opioid Use Disorders: Assessment and Treatment (Part 2) 5/2/2019

The last e-weekly discussed the opioid epidemic. This article will discuss more about assessing for opioid use disorders and appropriate treatments.

A person is diagnosed as having an opioid use disorder if he develops symptoms of tolerance and withdrawal to opioids as well as at least two other symptoms in the same year. 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 other symptoms (at least 2) that are required to make a diagnosis of opioid use disorder include: 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 also to relieve withdrawal symptoms. Long-term use becomes established just to feel normal.

Traditional substance abuse programs have separate detoxification then residential inpatient treatment to establish early sobriety then 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. There is a need to develop a treatment method that is more useful for opioid addiction.

Newer opioid treatment programs use a harm reduction approach to try to reduce the hazards that are 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, that there is a biological deficit from chronic use that a maintenance medication can help fill and that opioid use disorder is a chronic disease with a risk of relapse.

Medication is one part of opioid treatment programs. Medication assisted treatment (MAT) is a treatment to reduce opioid use and to ease the withdrawal of stopping opioid use. 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 gastrointestional 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. It must be administered sublingually because it has poor gastric absorption. A patient must be in opioid withdrawal when starting the medication because otherwise the medication will precipitate withdrawal. Side effects include sweating and constipation. Other cons include risk for diversion given that it has a high street value and that it is dangerous if combined with benzodiazepines.

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 arrythymias at higher doses. It requires daily monitoring, which can have a stigma associated with it.

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.

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



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