DISCLOSURES MANAGEMENT OF OPIOID USE DISORDERS Marc A Schuckit I - PDF document

DISCLOSURES MANAGEMENT OF OPIOID USE DISORDERS Marc A Schuckit I have nothing to declare Distinguished Professor of Psychiatry, UCSD Medical School LECTURE COVERS SUDs ARE IMPORTANT Drug groups & problems Affect > 20% of your patients Substance use disorders Are identified by non-experts Criteria Course Alcohol and drug use ↓ Rx responses Treatment Mimick most psychiatric Dx Identification/intervention Deadly: opioid 33k ODs/yr Detoxification Rehabilitation Opoids cost US > $75 billion/yr After you’re gone 1

LECTURE COVERS DRUG GROUPS Drug groups & problems Substance use disorders Based on: Criteria Usual effects Course Treatment At usual doses Identification/intervention Group then predicts: Detoxification Rehabilitation Pattern of problems After you’re gone DRUG GROUPS THE GOOD, BAD, & UGLY Hallucinogens Depressants Good ↓ pain, cough, shock, diarrhea PCP ↑ euphoria, tranquility, sedation Stimulants Solvents Bad Opioids Tolerance, craving, ↓ respirations Others Cannabinols Ugly: If opioid use disorder Is VERY hard to stop using 2

LECTURE COVERS DRUG PROBLEMS Drug groups & problems Substance use disorders Psychosis Overdose Criteria Course Major depression Treatment Withdrawal Identification/intervention Anxiety Detoxification Delirium Rehabilitation After you’re gone SUBSTANCE USE DISORDER SUD COURSE In same year 2+ of: Fluctuating: Tolerance* Failed roles  Controlled use Withdrawal* Hazardous use Use longer/more  Problems Social problems Unable to ↓  Abstinence Lots time use >20% spontaneous remission ↓ activities Use despite probs In richer & poorer Craving Prevention: NEVER USE FOR A HIGH * Special re opioids 3

LECTURE COVERS OVERDOSE Drug groups & problems Symptoms Substance use disorders Awake respirations <12/min*/stupor*/miosis* Also: ↓ temp/↓ gut sounds/pulmonary edema Criteria Course Treatment Treatment Ventilate Identification/intervention Naloxone: 0.04mg IM, IN, IV— but not oral Detoxification If no ↑ respiration in 2 min →0.5mg Rehabilitation → 2mg → 5mg → 10mg → 15mg After you’re gone Opioid OD Decisions STAGES OF RX Resp < 12min when awake Identification/intervention: drop stereotypes YES NO | O 2 Naloxone Long Acting Opioid? Detoxification Long Acting Opioid? Reassurance Physical exam & history Yes NO Medications Observe 8+hr Yes NO Rehabilitation ICU Observe 6hr ~ p last naloxone Relapse prevention Enhance motivation Continuous Awake/alert Medications IV Naloxone Help readjust to life ± Intubate NO Yes Aftercare Observe 6hr ICU ~ Refer for OP Rx p IV stop Boyer NEJM 2012 4

TO ID: ASK ABOUT PROBLEMS QUESTIONNAIRES Legal Relationships CAGE-AID (2+): Feel need cut down Feel bad or guilty Health School or job Annoyed by criticisms Eye-opener for relief/steady Accidents Drug Use Questionnaire (DAST-10: 3+) Then tie in substances Non-med use/multi drugs/not stop/blackout/guilt/ Complaints/neglect/illegal/withdrawal/med probs MOTIVATIONAL INTERVIEWING STAGES OF RX Build trust Identification/intervention Empathic Detoxification Avoid ↑ resistance Physical exam & history Reassurance Vitamins Medications Patient is in charge Rehabilitation Elicit motivational statements Enhance motivation Relapse prevention Help readjust to life Explore ambivalence Medications Monitor readiness to change Aftercare 5

DETOX RX DETOX Physical exam Rest & education Depressants Nutrition Opioids Meds for: Stimulants (no specific Rx) Opioids KEY MEDICATIONS OPIOID WITHDRAWAL Methadone (oral): Symptoms opposite of acute effects Mu-opioid agonist; ½ life 15-20 hrs Timing depends on drug length action Buprenorphine (SL or buccal) Partial mu agonist; kappa antagonist PE, educate, motivate ½ life 3 hrs (longer recepter occupation) Methadone or Mu antagonists: Naltrexone ½ life: oral 4-13 hrs IM 5-10 days Naloxone (not oral): onset 2 min; action 20-90 min Buprenorphene 6

CLINICAL OPIOID WITHDRAWAL WITHDRAWAL SCALE (COWS) Detox ≠ rehabilitation Pulse > 80 Rhinorrhea Sweating Cramps/naus/vomit Onset symptoms Restless Tremor Naloxone: in 2 minutes Pupils ↑ Yawning Short acting (heroin): ~ 8 hrs, ↓ day 4 Bone/joint pain Anxous/irritable Long acting (methadone): 1+ days, ↓ day 10 Goosebumps Each scored 1-4 or 1-5 Protracted withdrawal: 2 weeks to 2+ months Total: 5-12 = mild 25-36 = mod/severe Fatigue ↓ appetite insomnia anhedonia 13-24 = mod > 36 = severe LONG ACTING OPIOID TAPER OPIOID-FREE DETOX Med Dose Target Oral methadone SL buprenorphine Clonidine 0.1-0.2mg q 4h Flu-like PE PE: Rx at mild sympt patch 1 for 100-200 # Initial dose (ck in 1 hr; adjust) 10 mg < current dose 4-8 mg Diazepam 2-10mg q 4h Insom/anxiety 10-30 mg/d (÷) Stabilize Imodium 4mg, then 2mg Diarrhea 7-14 days 2-5 days Taper Naproxin 500mg 2x/d Aches/pain ~ 0-20% of initial dose Compazine 5-10mg q 4h Naus/vomit Every 1-2 days 7

STAGES OF RX REHABILITATION Identification/intervention Increase motivation Detoxification Physical exam & history Reassurance Help rebuild life Vitamins Medications Rehabilitation Relapse prevention Enhance motivation Relapse prevention Medications Help readjust to life +/- medications Aftercare REHAB: NALTREXONE MAINTENANCE GOALS Action: Blocks opioid high/↓ craving Substitute safer opioid Oral to avoid craving set on by needles Restriction: Must be opioid free Long acting to avoid daytime symptoms Use 1+ years— note OD danger when stop Induction: Test : 12.5mg; in 4 h 25-50mg Rx includes counseling pain control Day 1: Begin 50-100mg/d monitoring Goals: ↓ IV dangers ↑ Health Maintenance: 100mg Mon & Wed Crime Work 150mg Fri OD Relationships OR 380mg IM/mo 8

REHAB: BUPRINORPHINE REHAB:METHADONE Action: SL/buccal long ½ life opioid Action: Oral & long ½ life opioid & naloxone (4 to 1 ratio) Restriction: Only in special clinics Restriction: Trained pvt doc office OK Induction: 1-2 wk:15-30mg Induction: Wk 1-8: 4-8mg/d up to 16-32mg ↑ 10-50mg ~q 5d to 50-100mg Maintenance: Dose on SE and craving Maintenance: Consider take-home weekend dose if adherent to Rx at 8 wk CBT ↓ dysfunctional thoughts (must have drugs) ↑ rational thoughts (I can change) Relapse prevention (risk never ends) Anticipate triggers Learn to cope w/triggers Change behaviors (sober friends; ↓ stress) 9