The real voyage of discovery consists of not in seeking new
landscapes but in having new eyes. Marcel Proust
Signs of Opioid Intoxication and Overdose
Syndrome: (1) Opioid Intoxication
Physical Findings: Conscious, Sedated, Drowsy, Slurred Speech,
"Nodding" or Intermittently Dozing, Memory
Impairment, Mood Normal to Euphoric,
Syndrome: (2) Opioid Overdose
Physical Findings: Unconscious, Pinpoint Pupils, Slow Shallow
Respirations: respirations below 10 per minute
Pulse rate below 40 per minute
Overdose triad: apnea, coma, pinpoint pupils,
(with terminal anoxia: fixed and dilated pupils)
Staging And Grading Systems of Opioid Withdrawal
Stage Grade Physical Signs/Symptoms
Early Withdrawal Grade 1 Lacrimation and/or rhinorrhea
(8-24 hours after last use) Diaphoresis
Grade 2 Dilated Pupils
Fully Developed Withdrawal
(1-3 days after last use)
Grade 3 Tachycardia
Anorexia or Nausea
Grade 4 Diarrhea and/or vomiting
DSM-IV-TR Opioid Use Disorders (ICD-9 Code)
Opioid Abuse (305.50)
Opioid Dependence (304.00)
Opioid Intoxication (292.89)
Opioid Withdrawal (292.0)
Opioid Intoxication Delirium (292.81)
Opioid -Induced Psychotic Disorder, With Delusions (292.11)
Opioid -Induced Psychotic Disorder, With Hallucinations (292.12)
Opioid -Induced Mood Disorder (292.84)
Opioid -Induced Sexual Dysfunction (292.89)
Opioid -Induced Sleep Disorder (292.89)
Opioid -Related Disorder NOS (292.9)
Source: International Classification of Diseases, 9th Rev., Clinical Modification: ICD -9 -CM. Volumes 1 and 2. Salt Lake City, UT: Ingenix, Medicode, 2003. 810 pages
Common Comorbid Medical Conditions
Individuals addicted to opioids may have the same chronic diseases seen in the general population and should be evaluated as appropriate for diseases that require treatment (e.g., diabetes, hypertension). In addition, a number of medical conditions are commonly associated with opioid and other drug addictions. During the course of a medical history and physical examination, the possible existence of these conditions should be evaluated.
Infectious diseases are more common among individuals who are addicted to opioids, individuals who are addicted to other drugs, and individuals who inject drugs. For example, in some areas, more than 50 percent of injection drug users may be HIV positive. There are wide variations in the epidemiology of HIV infection, however, and in other areas the prevalence of HIV infection among injection drug users may be less than 10 percent. Because of the potential impact of HIV on the lives of affected patients and the availability of effective treatments, it is important to screen for HIV infection among patients who present for buprenorphine treatment.
Tuberculosis is also a major problem among substance abusers. In 2001, 2.3 percent of tuberculosis cases in the United States occurred in injection drug users, 7.2 percent in noninjection drug users, and 15.2 percent in individuals with excessive alcohol use in the past 12 months (CDC 2002; http://www.cdc.gov/nchstp/tb/surv/surv2001/default.htm. See tables 28, 29, and 30). Individuals who abuse drugs and alcohol are also at increased risk of engaging in high-risk sexual behavior (e.g., exposure to multiple partners, inconsistent use of safe sexual practices) and of contracting syphilis, gonorrhea, and other STDs.
Among individuals who are opioid addicted, other common medical conditions are related to the use of other drugs and to the life disruptions that often accompany addiction. These conditions include nutritional deficiencies and anemia caused by poor eating habits; chronic obstructive pulmonary disease secondary to cigarette smoking; impaired hepatic function or moderately elevated liver enzymes from various forms of chronic hepatitis (particularly hepatitis B and C) and alcohol consumption; and cirrhosis, neuropathies, or cardiomyopathy secondary to alcohol dependence.
Cautions and Circumstances That May Preclude a Patient As A Canditate For Office-Based Buprenorphine Treatment
(1) Comorbid dependence on high doses of benzodiazepines or other central nervous system depressants (including alcohol).
(2) Significant untreated psychiatric comorbidity.
(3) Active or chronic suicidal or homicidal ideation or attempts.
(4) Multiple previous treatments for drug abuse with frequent relapses (except that multiple previous detoxification episodes with relapse are a strong indication for long -term maintenance treatment).
(5) Poor response to previous well -conducted attempts at buprenorphine treatment.
(6) Significant medical complications.
(7) Conditions that are outside the area of the treating physician's expertise.
Note: See Cautions and Contraindications in the following section. The above will be covered more in depth.
References: (1) Clinical Guidelines For The Treatment of Buprenorphine in The Treatment of Opioid Addiction Chapter 3 Patient Assessment (TIP 40)
(2) Quick Guide For Physicans (Buprenorphine Clinical Guide)
Compiled and Edited By: Deborah Shrira Updated: 19 March 2007