Presented in 2009, IMH hyd.

1. OPIOID RELATED DISORDERS
Dr. Srinath G
Dr. Gowri Devi M

2. Plan of Presentation
 Introduction
 Epidemiology
 Psychiatric classification
 DSM Criteria
 Management

3. Introduction
 Opioid= natural opiates+ others
 Narcotic- “stupor”
 Rush/ high
 Oxycodone- Rolls Royce
 Chasing the dragon

4. ENDOGENOUS OPIOIDS
• POMC
Endorphins • ß- Endorphin, MSH, ACTH, LPH
• Preproencephalin
Encephalins • Leu & Met Encephalin
• Preprodynorphin
Dynorphins • Dynorphin A & B
 Opioid motif- Tyr- Gly- Gly- Phe (Leu or Met)

5. Opioids
Semi-
Naturally Semi- synthetics
Synthetic
occurring Synthetic
• Morphine • Heroin • Methadone
• Codeine • Oxycodone • Meperidine
 Full agonists
 Partial agonists
 Antagonists

6. Opioid Receptors
Opioid receptors
µ receptors
DAMGO δ receptors К receptors
CTOP DPDPE Orphanin
Analgesia, DPDTE Nor-
Naltrindole binaltorphimine Nociceptin
Respiration, Analgesia,
GI, Feeding, Analgesia, GI,
Feeding, GH Psychomimetis,
Prolactin,
GH, Ach, Feeding, Sedation
DA, Sedation

7. Neurobiology
 G protein coupled- Gi
 Inhibit Adenyl cyclase, effect potassium channels and calcium
channels during acute administration
 Chronic administration causes superactivation of adenyl
cyclase
 Reward circuit
 Drive/ Motivation
 Emotional circuit
 Executive function
 Learning

9. Functions of Opioids
 Analgesia
 Psychomimesis
 Respiratory depression
 Hormones
 GIT Cornerstone of
pain
 Feeding management Mood altering
properties
 Sedation
 NT

10. EPIDEMIOLOGY
Life time prevalence of
 Opiate use in India- 0.4%
 In US 0.2%

11. Psychiatric co-morbidity
 24% non substance Axis I disorders
 35% Axis II disorders
 47% overall non substance illness
 MC- Mood disorders, Antisocial PD, Anxiety
 Females- BPD, Depression

12. Medical disorders
 CVS effects
 TB
 HIV/AIDS
 Liver disease
 Immune system

13. Special population
 Criminal patients
 Pregnant mothers
 Neonatal Narcotic Abstinence Syndrome
 Hyper excitable CNS
 GIT
 Respiratory system
 ANS

14. Terms
Misuse- incorrect use of a medication
• Amount, Longer time and frequency
Abuse- maladaptive pattern of use leading
to clinical distress or impairment
• Harmful use in ICD-10
Addiction- chronic neurobiologic disease
with various factors
Dependence- set of behaviors, a
neurobiological adaptation
Pseudo addiction- iatrogenically produced
in pain patients

17. Laboratory testing
 Emergency testing, rehabilitation testing, diagnostic testing
 Tested drugs- Opioids, PCP, LSD, Cannabis, Amphetamines
 Tests
 Thin layer chromatography
 Enzyme Immuno Assays
 Medtox Profile II ER
 On Trak TesTCup
 Specimens
 Urine screening
 Oral fluids
 Other

18. Drugs
Methadone
 Full µ agonist
 Very high lipid solubility
 Half life - 15 to 60 hours
 Methadone clinic
Clonidine
 α- 2 agonist
 reduces nausea, vomiting, diarrhea, abdominal cramps, and
sweating
 Not helpful in insomnia, opioid craving

19. Buprenorphine
 Partial agonist at mu and kappa receptors- Ceiling effect
 Poor oral availability- sublingual administration
 Buprenorphine: Naloxone = 4:1
 Less abuse potential
 Office based maintenance
LAAM (l-Alpha Acetyl Methadol)
Opioid antagonists- Naltrexone, Nalmefene

20. Withdrawal
• Dysphoria, nausea & vomiting, lacrimation & rhinorrhoea, Pupillary
dilatation, piloerection, sweating, diarrhea, yawning, fever and insomnia,
cold turkey, aches-kick the habit
Features • Depends upon the half life of the drug
• OWS, SOWS, COWS
Measurement
• Opioid agonists, Non-opioids
• Rapid and Ultra rapid Detoxification, in physician office,
Detoxification

21. Detoxification
• Short term
• Long term
• Rapid
• Ultra Rapid

22. Short term Rate of tapering is 5%
detoxification to 10% per day
• 15-30 mg methadone
• 30 days

23. Long term detoxification
15-30 mg
methadone
Up to 180 days

24. Rapid detoxification
Antagonist administration Precipitate withdrawal
Supportive Treatment
Antiemetics, analgesics, buprenorphine

25. Ultra rapid detoxification
Under general anesthesia
Antagonist precipitated withdrawal
Supportive Treatment

26. Methadone maintenance
Phase Purpose Range
• Initial dose • Relieves abstinence • 20-40 mg
• Early induction • Reach tolerance level • +/- 5- 10 mg q 3-4 hrs
• Late induction • Establish adequate dose • +/- 5- 10 mg q 3-4 hrs
• Maintenance/ • Steady state occupation • 60-120 mg/ day
Stabilization of receptors
• Maintenance to • Medically supervised • 10% q 5- 10 days
abstinence withdrawal
• Medical maintenance • Indefinite management • Adequate dose
in medical setting
 Lapse
 Relapse

27.  Plasma levels of methadone- 150-200ng/ml
 Adequate blockade achieved at 400+ng/ml
 Methadone drug interactions
 ADR- constipation, sweating, transient skin rash, weight gain,
water retention, libido changes
 3 phases-
Vocational Continued
Stabilsation
programs maintenance

28. Psychosocial Treatment
 Narcotic anonymous
 Therapeutic communities
 Relapse Prevention
 Cue prevention
 Harm Reduction
 Psychodynamic/interpersonal
 Group and Family therapy
 Alternate groups- SOS,

29. Narcotic Anonymous

30. Therapeutic communities

31. Relapse prevention- Risk factors, Social
pressure, Cravings
Internal/ Cognitive/ Behavioral/
External Pharmacologic
Self
Management/
Others

32. Relapse process
Stop
Time relapse
Full blown
relapse
 Relapse warning signs- mood, attitude, behavioral, thought
change

33. References
 CTP- Kaplan and Sadock
 Comprehensive text book of substance abuse
 Clinical practice guidelines- IPS
 Tasman Psychiatry