lecture 22b: opiates, heroin, benzos, barbiturates

opioid analgesic

risk factors of ____________ prescription drug abuse•Hx of legal problems or incarceration

•Age < 40-45 yo

•White race (compared to black race)

•More severe pain

•Co-occurring mental disorders

•Depression, PTSD, anxiety

•Hx of childhood maltreatment

sedative hypnotics

risk factors of _______ prescription drug abuse

White race

Female

Uninsured

Unemployed

Panic sx

Other psychiatric symptoms

Alcohol abuse or dependence

Morphine

Codeine

Thebaine

examples of natural opioids

Heroin

Hydromorphone

Oxymorphone

Oxycodone

Buprenorphine

examples of semisynthetic opioids

Methadone

Fentanyl

Meperidine

Tramadol

Tapentadol

examples of synthetic opioids

heroin

•Used to be the most abused illicit opioid drug

•Made from morphine by adding acetyl groups (structurally known as diacetylmorphine)

White or brown powder, or a black sticky substance

heroin

-opioid that enters brain RAPIDLY and binds to opioid receptors on cellls

-VERY lllipophilic

heroin

-has a more intense euphoric sensation compared to prescription opioids

-Rx opiioid pain med misuse is a risk factor

fentany

______ induced rigid chest

•Flushing, miosis, slurred speech, respiratory depression, hypotension, hypothermia, bradycardia

•Constipation, nausea, and vomiting also frequently occur

physical signs of opioid use

miosis and constipation

tolerance to the effects of opioids develops in all side effects EXCEPT

•Sexual interest decreases

Females may stop menstruating

sexual dysfunction associated with opioid use

CPR

-depressed Consciouness

-pinpoint pupils

-respiratory depression

mnemonic for overdose effects of opioids

respiratory rate <12/min

best predictor of opioid intoxication

naloxone

drug of choice, opioid antagnoist treatment for overdose

-IV preferred in hospital

-rescue kit nasal sprays and IM in the fielld

administration of naloxone in overdose

mass spectrometry

test that may be used for confirmation and quantification of opioid use

•Urine drug screen by itself does not confirm a diagnosis of OUD:

•Immunoassay (antibody-based) may be used for screening

•Mass spectrometry may be used for confirmation and quantification:

diagnostic tools for opioid use disorder

anxiety, nausea, muscle aches, and abdominal cramps

signs of opioid withdrawal in first 8 hours

•yawning, rhinorrhea, lacrimation, sweating, piloerection (gooseflesh, “going cold turkey”), dilated pupils, diarrhea, insomnia, elevated temperature, heart rate, blood pressure, and respirations

signs of opioid withdrawal in 8-24 hours

meperidine

_________ withdrawal may cause seizures

severe craving, abdominal cramps, diarrhea, and painful cramps and muscle spasms ("kicking the habit")

signs of severe stage of opioid withdrawal, can last up to 3 days

methadone

-used in opioid withdrawal treatment

-long acting opioid receptor agonist

-gradually taper at a rate that prevents severe withdrawal

buprenorphine

-long actin partial opioid agonist used to treat opioid withdrawal

-HIGH affinity for mu opioid receptor

a2 agonists, benzos, NSAIDs

non-opioid treatments used in symptomatic relief of of opioid withdrawal

clonidine

alpha 2 agonist used for relief of autonomic symptoms in opioid withdrawal (lacrimation, rhinorrhea)

postural hypotension

common side effect of alpha 2 agonists clonidine and lofexidine

buprenorphine or buprenorphine/naloxone

•: ideal tx for patients with mild withdrawal symptoms

naltrexone

Blocks opioid effects (euphoria) and discourages people, with physiologic dependence to opioids, from substance seeking behavior to decondition this behavior

buprenorphine and methadone

treatments of choice for opioid use disorder in pregnancy and lactation

7 day supply

when issuing a 1st time opioid rx to an adult for outpatient use, limit supply to

immediate release formulation

-faster acting and shorter duration of action

-star at lowest effective dose

if initiating an opioid start with this formulation

benzodiazepines

•Polydrug users may use to reduce irritability and anxiety associated with cocaine or amphetamine use

•thiopental (induction of anesthesia), phenobarbital (seizures), butalbital (headaches; tension/migraine- last resort)

medical uses of barbituates today

•Increased sedation, respiratory depression, coma, hypotension

presentation of benzo overdose:

•Sedation, slurred speech, nystagmus, confusion, ataxia, blisters

•CNS depression, hypotension (myocardial depression) and CV collapse; exacerbated by co-ingestants

•SEVERE: coma, respiratory depression and arrest, decreased myocardial contractility, hypothermia, death

presentation of barbiturates overdose

Flumazenil

drug that reverses CNS effects of benzos, used in overdose treatment

potentiate seizures

use flumazenill with caustion as it may

NONE

reversal agent for barbiturate overdose

-supportive care

-activated charcoal if within one hour of ingestion; AVOID if depressed mental status due to increased risk of asphyxiation

treatment of barbitruate overdose

•Tremors, anxiety, perceptual disturbances, dysphoria, psychosis, seizures, autonomic instability

symptoms of BZD and barbiturate withdrawal

HTN, tachy, hyperthermia, agitation, confusion, hallucination, diaphoriesis, tremor

define autonomic instability seen in BZD and barbiturate withdrawal

•suppress acute withdrawal, followed by gradual dose reduction

treatment of BZD and barbiturate withdrawal

•switch to longer acting BZD

•e.g., chlordiazepoxide, diazepam, clonazepam

treatment of BZD withdrawal

•witch to phenobarbital a longer acting barbiturate

•Adjunctive clonidine/propranolol may suppress sympathetic overactivity (tachycardia, hypertension, anxiety)

treatment of barbiturate withdrawal

BZD and barbiturate witdrawal

Signs and symptoms may resemble those of alcohol withdrawal, including the potential lethality

opiates (morphine, heroin, meperidine)

sedative hypnotics: benzo, barbiturates

alcohol

If the patient appears lethargic or is in a coma, suspect intoxication from the following: