Opioid dependence

Opioid dependence
Classification and external resources
ICD-10	F11.2
ICD-9	304.0
MeSH	D009293

Opioid dependence is a medical diagnosis characterized by an individual's inability to stop using opioids (morphine, heroin, codeine, oxycodone, hydrocodone, etc.) even when objectively it is in his or her best interest to do so. In 1964 the WHO Expert Committee on Drug Dependence introduced "dependence" as "A cluster of physiological, behavioural and cognitive phenomena of variable intensity, in which the use of a psychoactive drug (or drugs) takes on a high priority. The necessary descriptive characteristics are preoccupation with a desire to obtain and take the drug and persistent drug-seeking behaviour. Determinants and problematic consequences of drug dependence may be biological, psychological or social, and usually interact". The core concept of the WHO definition of "drug dependence" requires the presence of a strong desire or a sense of compulsion to take the drug; and the WHO and DSM-IV-TR clinical guidelines for a definite diagnosis of "dependence" require that three or more of the following six characteristic features be experienced or exhibited:

1. A strong desire or sense of compulsion to take the drug;
2. Difficulties in controlling drug-taking behaviour in terms of its onset, termination, or levels of use;
3. A physiological withdrawal state when drug use is stopped or reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms;
4. Evidence of tolerance, such that increased doses of the drug are required in order to achieve effects originally produced by lower doses;
5. Progressive neglect of alternative pleasures or interests because of drug use, increased amount of time necessary to obtain or take the drug or to recover from its effects;
6. Persisting with drug use despite clear evidence of overtly harmful consequences, such as harm to the liver, depressive mood states or impairment of cognitive functioning.

The Walid-Robinson Opioid-Dependence (WROD) Questionnaire was designed based on these guidelines. According to position papers on the treatment of opioid dependence published by the United Nations Office on Drugs and Crime and the World Health Organization, care providers should not mistake opioid dependence for a weakness of character or will. Accordingly, detoxification alone does not constitute adequate treatment.

Causes

It has been demonstrated that most opioid-dependent patients suffer from at least one severe psychiatric comorbidity. Since opioids used in pain therapy rarely cause any of these conditions, they are assumed to have existed prior to the development of dependence.^{[citation needed]} Opioids are known to have strong antidepressive, anxiolytic and antipsychotic effects and thus opioid dependence often develops as a result of self medication.^{[citation needed]} Opioids are excellent acute pain medication, but it is their ability to produce euphoria that makes them attractive to addicts.^{[citation needed]}

Material used for intravenous injection of opiates

Furthermore some studies suggest a permanent dysregulation of the endogenous opioid receptor system after chronic exposure to opioids. A recent study has shown that an increase in BDNF, brain-derived neurotrophic factor, in the ventral tegmental area (VTA) in rats can cause opiate-naive rats to begin displaying opiate-dependent behavior, including withdrawal and drug-seeking behavior. It has been shown that when an opiate-naive person begins using opiates at levels inducing euphoria, this same increase in BDNF occurs.

Another recent study concluded to have shown "a direct link between morphine abstinence and depressive-like symptoms" and postulates "that serotonin dysfunction represents a main mechanism contributing to mood disorders in opiate abstinence". As of 2008, the gateway drug for the youth in USA became opioid drugs instead of marijuana. This is far more dangerous as opioids are more addictive and there is the possibility of dying by overdose, unlike in the case of cannabis.

Symptoms of withdrawal

Symptoms of withdrawal from opiates include, but are not limited to,

Physical symptoms

• Tremors
• Cramps
• Muscle and bone pain
• Chills
• Perspiration (sweating)
• Priapism
• Tachycardia (rapid heart beat)
• Itch
• Restless legs syndrome
• Flu-like symptoms
• Rhinitis (runny, inflamed nose)
• Yawning
• Sneezing
• Vomiting
• Diarrhea
• Weakness
• Akathisia (a profoundly uncomfortable feeling of inner restlessness)

Psychological symptoms

• Dysphoria
• Malaise
• Cravings
• Anxiety/Panic Attacks
• Paranoia
• Insomnia
• Dizziness
• Nausea
• Depression

Other rare but much more serious symptoms include cardiac arrhythmias, strokes, seizures, dehydration and suicide attempts.

Depending on the quantity, type, frequency, and duration of opioid use, the physical withdrawal symptoms last for as little as forty-eight to seventy-two hours (for short-acting opioids such as hydromorphone [Dilaudid] and oxycodone after short duration lower-dose use), and as long as thirty to sixty days or more for long-acting opioids such as buprenorphine and methadone, respectively, after extended high-dose use. When long acting opioids like methadone (Methadone, Physeptone) or buprenorphine (Suboxone [buprenorphine in a 4:1 ratio to naloxone] and Subutex [single-agent buprenorphine]) are used for an extended period, physical withdrawal symptoms can last up to six weeks, while the most severe cases have withdrawal symptoms that can last even longer. This initial withdrawal is characterized by the body attempting to regain homeostasis as a result of the brain's lack of opiate receptor activity. Since the mechanisms of opioid dependence and withdrawal are not fully understood, it is difficult to determine how long withdrawal symptoms will last or how severe they may be for different individuals.

Treatment

Opioid dependence is a complex health condition that often requires long-term treatment and care. The treatment of opioid dependence is important to reduce its health and social consequences and to improve the well-being and social functioning of people affected. The main objectives of treating and rehabilitating persons with opioid dependence are to reduce dependence on illicit drugs; to reduce the morbidity and mortality caused by the use of illicit opioids, or associated with their use, such as infectious diseases; to improve physical and psychological health; to reduce criminal behaviour; to facilitate reintegration into the workforce and education system and to improve social functioning. The ultimate achievement of a drug free state is the ideal and ultimate objective but this is unfortunately not feasible for all individuals with opioid dependence, especially in the short term.

As no single treatment is effective for all individuals with opioid dependence, diverse treatment options are needed, including psychosocial approaches and pharmacological treatment.

Relapse following detoxification alone is extremely common, and therefore detoxification rarely constitutes an adequate treatment of substance dependence on its own. However, it is a first step for many forms of longer-term abstinence-based treatment. Both detoxification with subsequent abstinence-oriented treatment and substitution maintenance treatment are essential components of an effective treatment system for people with opioid dependence.

Current trends in the US reveal a significant increase of prescription opioid abuse compared to illicit opiates such as heroin. This development has also implications for the prevention, treatment and therapy of opioid dependence.

Methadone

40 mg of Methadone

Main article: Methadone maintenance

MMT (Methadone Maintenance Treatment), a form of opioid replacement therapy, reduces and/or eliminates the use of illicit opiates, the criminality associated with opiate use, and allows patients to improve their health and social productivity. In addition, enrollment in methadone maintenance has the potential to reduce the transmission of infectious diseases associated with opiate injection, such as hepatitis and HIV. The principal effects of methadone maintenance are to relieve narcotic craving, suppress the abstinence syndrome, and block the euphoric effects associated with opiates. Methadone maintenance has been found to be medically safe and non-sedating. It is also indicated for pregnant women addicted to opiates. Methadone maintenance Treatment is given to addicted individuals who feel unable to go the whole way and get clean. For those individuals who wish to completely move away from drugs, a methadone reduction program is indicated, where the individual is prescribed an amount of methadone which is titrated up until withdrawal symptoms subside, followed by a period of stability, the dose will then be gradually reduced until the individual is either free of the need for methadone or is at a level which allows a switch to a different opiate with an easier withdrawal profile, such a Suboxone.

Buprenorphine

Suboxone 8 mg tablet

Main article: Buprenorphine

Studies have shown buprenorphine to be a safer alternative over methadone in opiate replacement therapy, primarily due to its lower instance of overdose related deaths during the course of treatment. Buprenorphine sublingual preparations are often used in the management of opioid dependence (that is, dependence on heroin, oxycodone, hydrocodone, morphine, oxymorphone, fentanyl or other opioids). The Suboxone and Subutex preparations were approved for this indication by the United States Food and Drug Administration in October 2002. This was only possible due to the Drug Addiction Treatment Act of 2000 which overturned a series of 1914–1920 Supreme Court rulings that had found that maintenance and detox treatments were not a form of medical treatment.^{[citation needed]} Although the rulings had the power of legal precedent prior to 2000, it is likely that they were not the intended interpretation of the laws passed originally by congress.^{[citation needed]}

Naltrexone

Main article: Naltrexone

Naltrexone was approved by the FDA in 1984 for the treatment of opioid dependence. It is available both as an oral medication and as a monthly injectable (approved in 2010). Some authors question whether oral Naltrexone is as effective in the treatment of opioid dependence as methadone and buprenorphine mainly due to non-compliance. The monthly injectable naltrexone preparations have been designed to overcome the problems of compliance encountered with the oral formulation.

Diamorphine

See also: Heroin maintenance

In Switzerland, Germany, the Netherlands, and the United Kingdom, longterm injecting drug users who do not benefit from methadone and other medication options are being treated with pure injectable diamorphine that is administered under the supervision of medical staff. For this group of patients, diamorphine treatment has proven superior in improving their social and health situation. Studies show that even after years of homelessness and delinquency and despite severe comorbidities, about half of the patients find employment within the first year of treatment.

LAAM

See also: Levacetylmethadol

LAAM was previously used to treat opioid dependence. In 2003 the drug's manufacturer discontinued production. At this time there are no available generic versions produced.

Experimental treatments

• Clonidine
• Dextromethorphan
• Ibogaine
• Ketamine
• Medical cannabis
• Mitragynine
• Tramadol

12-Step Support Groups

See also: Alcoholics Anonymous and Narcotics Anonymous

While medical treatment may help with the initial symptoms of opioid withdrawal, once an opiate addict overcomes the first stages of withdrawal, an often overlooked method for long-term preventative care is attendance of 12-step groups such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA).

In a 2009, Alexandre B. Laudet presented findings of a study of the benefits of attendance and participation in 12-step groups among primarily inner city minorities who had a "long severe history of (primarily) crack and/or heroin use".

Taken directly from Laudet's presentation of suggested activities in 12-step participation are:

• Having a sponsor
• Sponsoring someone
• Reading recovery literature
• Having a home group
• Considering oneself a 12-step member
• Doing service
• Working the steps
• Contacting 12-step members outside of meetings
• Socializing with other members outside of meetings.

Laudet also presented the odds that continuous attendance at 12-step meetings can result in success at long-term sustained abstinence. It was determined that by simply attending 12-step meetings in the first 6 months, an individual was 8 times more likely to maintain abstinence, while in the much longer term of 3 years or more, an individual who become involved in service with a 12-step group was 8.6 times more likely to have sustained abstinence.

See also

• Opioids
• Opioid receptor
• Opioid replacement therapy
• Benzodiazepine withdrawal syndrome
• Physical dependence
• Doctor shopping
• Prescription drug abuse

External links

• http://www.drugabuse.gov/infofacts/heroin.html
• http://www.licadd.com/drug-alcohol-info/heroin/
• http://www.opioids.net
• Opioid Dependence Treatment and guidelines