Opioid-Related Disorders  

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,
                                        Pupillary Constriction

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
                                                                 Yawning
                                                                 Restlessness
                                                                 Insomnia
                                       Grade 2            Dilated Pupils
                                                                Piloerection
                                                                Muscle twitching
                                                                Myalgia
                                                                Arthralgia
                                                                Abdominal pain

Fully Developed Withdrawal
(1-3 days after last use)
                                       Grade 3           Tachycardia
                                                               Hypertension
                                                               Tachypnea
                                                               Fever
                                                               Anorexia or Nausea
                                                               Extreme Restlessness 
                                       Grade 4          Diarrhea and/or vomiting
                                                              Dehydration
                                                              Hyperglycemia
                                                              Hypotension
                                                              Curled-Up Position

     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)
http://www.kap.samhsa.gov

Compiled and Edited By: Deborah Shrira Updated: 19 March 2007