Opioids

Unless otherwise indicated, the answers are from DSM-IV-TR and APA Practice

Guidelines, AJP Supplement, August, 2006.As of 3Aug06

Treatment of intoxication

Q. Treatment of acute intoxication? Divide into mild to moderate treatment and severe intoxication and its treatment.

Treatment of intoxication

Ans. Mild to moderate intoxication has no specific treatment. Severe overdose, e.g., R down, stupor, or coma requires 24 hour setting and naloxone to reverse.

Naloxone dosing

Q. For severe intoxication, what dosing would you order?

Naloxone dosing

Ans. Depends on how opioid dependent the pt is and how severe the respiratory depression. If R is very depressed, use 2.0 mg IV. If not that severe, use from 0.05-0.4 mg IV, using less for those pts who are opioid dependent. If pt doesn’t respond in 2 minutes, e.g., R improve And pupil size become normal, repeat. Still not adequate response, repeat q 5 minutes two times.

Naloxone failure

Q. After you have had complete failure of the four doses in the previous slide, what to do?

Naloxone failure

Ans. You have only part of the dx as another overdose, e.g., barbiturates overdosage, or head trauma may also be present.

Opioid withdrawal treatment

Q. What meds to use for management of opioid withdrawal?

Opioid withdrawal treatment

Ans. Methadone or buprenorphine.

Methadone dosing

Q. What is the dosing of methadone in opioid withdrawal?

Methadone dosing

Ans. Depending on the objective signs of withdrawal, 10 mg every 2 – 4 hours until withdrawal signs are stabilized, usually means the pt will be on 10 – 40 mg/d.

Once stabilized, taper at 5 mg/d.

As you get below 20 mg/d pt may complain of withdrawal: Manage with clonidine.

Buprenorphine dosing

Q. What is the dosing of buprenorphine for opioid withdrawal?

Buprenorphine dosing

Ans. Stabilization of signs usually occur at a dosage of 8 mg/d in hospitals or 8-32 mg/d in clinics. Tapering over 10-14 days reducing at rate of 2 mg/d.

Clonidine use

Q. What is clonidine useful for as to opioid withdrawal?

Clonidine use

Ans. Clonidine:-- reduces nausea, vomiting, diarrhea,

abdominal cramps, and sweating associated with methadone tapering.

-- not helpful with muscle aches, insomnia, or opioid craving

-- remember, with a few pts, hypotensive crisis. To have an order: “Take BP and if < 90/60, skip next dose.”

Ultra-rapid detox

Q. What is ultra-rapid detoxification and what is its status?

Ultra-rapid detox

Ans. Naltrexone detox while under general anesthesia. Not recommended.

Psychosocial approaches

Q. List the six psychosocial approaches that may be helpful in treating opioid dependence whether the pt is on meds or not.

Psychosocial approaches

Ans.

1] CBT

2] behavioral therapies

3] psychodynamic therapies

4] drug counseling

5] group and family therapies

6] self-help groups

Opioid dependence - FDA

Q. Meds FDA approved for opioid dependence?

Opioid dependence - meds

Ans. FDA approved:

1] methadone

2] buprenorphine

3] LAAM

Methadone maintenance

Q. Methadone maintenance typical dosing?

Methadone maintenance

Ans. 40 – 60 mg/d

Buprenorphine maintenance

Q. Buprenorphine maintenance typical dosing?

Buprenorphine maintenance

Ans. 8-32 mg every two to three days.

Naltrexone maintenance

Q. While not specifically approved for opioid maintenance treatment, what is the typical dosing of those using naltrexone for maintenance?

Naltrexone maintenance

Ans. 100 mg on Mondays, 100 mgs on Wednesdays, and 150 mg on Fridays.

Naltrexone wait time

Q. What is the wait time before beginning the use of naltrexone maintenance?

Naltrexone wait time

Ans. Five days for short-acting opioids and seven days for long-acting opioids.