1. Opioids

2. What are opioids?
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Class of drugs which have morphine
like effects
The effects can be reversed by
naloxone
CNS depressants
Powerful analgesics
Prolonged use results in tolerance,
less effective analgesic properties

3. Use & Effects of Opioid
Drugs
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Opioids that bind to receptors & activate
them are “agonist” drugs (such as morphine
& methadone)
Those that bind to receptors but not activate
them are “antagonists” (naloxone &
naltrexone)
Partial agonists (buprenorphine) bind to the
same receptors but have less of an activation
effect

4. Harmful Effects
Dependence
 Amenorrhoea
 Infection
Scarring, thrombosis, thrombophlebitis
Cellulitis, abscess
Septicaemia, infective endocarditis,
osteomyelitis
Blood borne viruses - HIV, HCV(90%), HBV
 Overdose-related morbidity symptoms
Hypoxic brain injury
Rhabdomyolysis
 Poly drug and alcohol use highly prevalent


5. Types of Opioids available
Heroin
 Morphine
 Oxycontin
 Oxycodone
 Methadone
 Buprenorphine


6. History to take
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Name of the drug/s used
Dose of the drug (no. of injections per
day, dollars spent per day)
Route of administration
Frequency of use
Duration of use
Date and time of last use
Other drugs used ?
Alcohol/ Smoking

7. Assessing Opioid Use
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Heroin dosages estimates are difficult - wide
variations in the concentration & purity of
illicit heroin
Oxycontin – More popular than heroin
Consumption may be recorded as:
The no of injections / day
The no of grams ingested
Dollars spent

8. Assessing Opioid Use
Approximate guide to a patient’s level of opioid
use:
Low end
= 1 to 2 injections / day, OR
= 0.5 gram heroin or less / day
High end
= 4 + injections / day, OR
= 1-2 grams heroin or more / day

9. Signs and Symptoms of
opioid intoxication
 Analgesia
 Euphoria
 Miosis
(‘pinned’ pupils)
 Constipation
 Sedation
 Itching, red eyes (histamine release)
 Respiratory depression and reduced cough reflex
 Decreased level of consciousness (‘on the nod’)
 Hypotension/bradycardia

10. Other Clinical Presentations
General – cachexia,
 CV – Murmurs, Pulse pressure,
stigmata of IE
 GE - CLD / hemetemesis
 Respiratory – LRTI /COPD
 Neuro - Septic Embolus /Discitis
 ID – Cellulitis /Abcesses / Sepsis/
BBV


11. Investigations
UDS
 Bloods including FBC, LFTs, UEC,
BBV (consent please)
 BAC
 CXR
 ECG
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12. Opioid Overdose
Drowsy
 Decrease in GCS
 Decrease in O2 saturations
 Respiratory depression
 Rx: 400 mcg of Naloxone initially as
test dose and then further 400 mcg of
naloxone
 Consider alternative dx if failure to
respond
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13. Unplanned Withdrawal
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Patients in hospital, prison or other institutional
care may undergo unplanned opioid withdrawal
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Patients may not always reveal their opioid use

14. Withdrawal Syndrome
Opioid
Time after last dose
Sx appear
Duration withdrawal
syndrome (days)
Heroin / Morphine / IV
oxycontin
6 – 24 hours
5 – 10 days
Pethidine
3 – 4 hours
4 – 5 days
Methadone
36 – 48 hours
3 – 6 weeks
Buprenorphine
3 – 5 days
Up to several weeks
Kapanol / MS Contin
(if intravenous)
8 – 24 hours
7 – 10 days
Codeine PO
8 – 24 hours
5 – 10 days

15. Duration of opioid
withdrawal
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Following acute withdrawal, protracted,
low-grade symptom of discomfort
(psychological & physical) may last many
months

16. Signs & Symptoms of Opioid
Withdrawal
Symptoms
Anorexia & nausea
Abdominal pain
Hot & cold flushes
Bone, joint & muscle pain
Insomnia & disturbed sleep
Cramps
Intense craving
Signs
Restlessness
Yawning
Perspiration
Rhinorrhoea
Dilated pupils
Piloerection
Muscle twitching – restless
legs when lying down
Vomiting
Diarrhoea

17. Course of Opioid withdrawal
NSW Department of Health (2007).

18. Withdrawal Monitoring
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Patients should be monitored regularly & this
may include use of a withdrawal scale
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Frequency of observations should be
determined by the severity of the withdrawal
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Monitoring should be based on observations,
objective signs & subjective Sx

19. Withdrawal Scales
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The Clinical Opiate Withdrawal Scale (COWS)
rates 11 items describing severity of symptoms
from scores of 0 (not present) to > 36 (severe)
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The COWS is considered a reliable & valid
withdrawal scale

20. Withdrawal Scales
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Withdrawal scales do NOT diagnose withdrawal,
but merely guides to the severity of an already
diagnosed withdrawal syndrome
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Re-evaluate the patient regularly to ensure that
it is opioid withdrawal & not underlying medical
condition, especially if the patient is not
responding well to Rx

21. Opioid Withdrawal Rx
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An opioid withdrawal syndrome can be
managed with:
Buprenorphine
Methadone
Symptomatic Meds

22. Buprenorphine
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A partial opioid agonist – an opioid analgesic with
both agonist and antagonist properties
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Available in 2 forms: buprenorphine &
bup/naloxone (Suboxone film)
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Administered sublingually (tab usually take 5
minutes to dissolve, film adheres within 90 secs)
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Less respiratory depression than full agonists

23. Buprenorphine
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Buprenorphine is the principal Rx option for
managing opioid withdrawal
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Well suited in the hospital setting
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Can effectively relieve symptom severity in
opioid withdrawal, meaning that other
symptomatic medication may not be required

24. Buprenorphine
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Buprenorphine binds very tightly to opioid
receptors & can displace other opioids
Buprenorphine can precipitate withdrawal
1st doses bup should be delayed for at least 6 hours after heroin & oxy
24 hours after methadone
NB: buprenorphine is NOT to be administered
until withdrawal is evident

25. Buprenorphine
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If using a withdrawal scale as part of patient
assessment Rx should not begin until:
A COWS score of a least 8 (representing the
mid point of scale)
Give 2mg buprenorphine (test dose)
If tolerated, can give a further 4-8mg in 1
hour
Pt can have a total of 32mg Day 1 if clinically
indicated

26. Methadone
“Gold standard” pharmacotherapy for
opioid dependence for over 30 years
 Synthetic opioid with a long half life
 Administered daily
 Dispensed from a clinic, hospital or
registered pharmacy
 Authorised prescribers
 Clients are registered with NSW
Pharmaceutical Services Unit
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27. Methadone to Treat Opioid
W/D
Maximum initiation dose 40mg/d (in
consultation with D&A Team)
 Usually 15mg BD in hospital in initiation
 Usually increase every 3/7’s
 Commonly used in patients who have opioid
analgesia requirements
 D&A Team always offer to link patient in with
community OST
 Patient may or may not want ongoing OST


28. Symptomatic Mx for Opioid
Withdrawal
Muscles Aches
/ Pains
Paracetamol 1000mg, every 4 hours PRN
(maximum 4000mg in 24 hours OR
Ibuprofen 400mg 6 hourly PRN (if no Hx of
peptic ulcer or gastritis)
Nausea
Metoclopramide 10mg, 4-6 hourly PRN,
reducing to 8th hourly as Sx reduce OR
Prochlorperazine (Stemetil) 5mg, every 4-6
hours PRN, reducing to 8th hourly as Sx
reduce
2nd line Rx for severe nausea/vomiting:
Ondansetron (Zofran) 4-8mg, every 12
hours PRN

29. Symptomatic Mx for Opioid
Withdrawal
Abdominal
cramps
Hyoscine (buscopan) 20mg, every 6 hours PRN
2nd line Rx for severe gastrointestinal Sx:
Octreotide (sandostatin) 0.05-0.1mg, every 812 hours PRN by subcutaneous injection
(hospital setting only)
Diarrhoea
Kaomagma or loperamide (gastro-stop) 2mg
PRN

30. Symptomatic Mx for Opioid
Withdrawal
Sleeplessness
Temazepam 10-20mg nocte. Cease dose after
3-5 nights
Agitation /
Anxiety
Diazepam 5mg QID PRN
Restless legs
Diazepam (as above) OR
Baclofen 10-25mg every 8 hours
Sweating,
sedating
agitation
Clonidine 75mcg every 6 hours

31. Altered tolerance and pain
management
Analgesics should not be withheld unless
medically indicated
 Providing pain relief will not make the patient
more drug dependent
 Methadone patients will not receive pain relief
from their usual daily dose
 First indication of tolerance to opioids is
decreased duration of effect, decreased
analgesia – an involuntary physiological
response
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32. Opioid maintenance treatment
in hospital
Patients who are on methadone or
buprenorphine when admitted to SVH should
remain on their current dose – UNLESS THEY
HAVE MISSED DOSES – PLS RING D&A
• PSU – 9424 5921
 Confirm last dose from the dosing point
 Remove takeaway doses from patient if they
are on their person
 Ensure adequate pain relief is given
 Dosing point will need fax of last dose on D/C
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33. Buprenorphine & Pt’s in
Acute Pain….
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Standard doses of opioid analgesia are not
likely to be effective in any patient who has
taken buprenorphine within the last 3-4 days
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Non opioid analgesia, local anaesthetics
approaches, higher dose opioid prescriptions,
ceasing or increasing bup may be required for
pain relief – Contact D&A & APS

34. Buprenorphine / methadone
prescribing…
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In hospital, doctors can prescribe methadone or
buprenorphine as part of management of opioiddependent people
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Outside hospital, methadone & buprenorphine
may only be used in the treatment of opioid
dependency by authorised medical practitioners

35. Take Home
Take a good substance use history
 Screen for BBV
 Rx with naloxone in suspected od with
400 mcg x 2
 Rx opioid withdrawal with suboxone or
methadone
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