DISCLOSURES MANAGEMENT OF OPIOID USE DISORDERS LECTURE COVERS. SUDs ARE IMPORTANT. I have nothing to declare

Transcription

1 MANAGEMENT OF OPIOID USE DISORDERS DISCLOSURES Marc A Schuckit Distinguished Professor of Psychiatry, UCSD Medical School I have nothing to declare SUDs ARE IMPORTANT Affect > 20% of your patients Are identified by non-experts Alcohol and drug use Rx responses Mimick most psychiatric Dx Deadly: opioid 33k ODs/yr Opoids cost US > $75 billion/yr LECTURE COVERS Drug groups & problems Substance use disorders Criteria Course After you re gone 1

2 LECTURE COVERS Drug groups & problems Substance use disorders Criteria Course After you re gone DRUG GROUPS Based on: Usual effects At usual doses Group then predicts: Pattern of problems DRUG GROUPS Depressants Hallucinogens Stimulants PCP THE GOOD, BAD, & UGLY Good pain, cough, shock, diarrhea euphoria, tranquility, sedation Opioids Cannabinols Solvents Others Bad Tolerance, craving, respirations Ugly: If opioid use disorder Is VERY hard to stop using 2

3 DRUG PROBLEMS LECTURE COVERS Drug groups & problems Overdose Withdrawal Delirium Psychosis Major depression Anxiety Substance use disorders Criteria Course After you re gone SUBSTANCE USE DISORDER In same year 2+ of: Failed roles Hazardous use Social problems Tolerance* Withdrawal* Use longer/more Unable to Lots time use activities Use despite probs Craving * Special re opioids SUD COURSE Fluctuating: Controlled use Problems Abstinence >20% spontaneous remission In richer & poorer Prevention: NEVER USE FOR A HIGH 3

4 LECTURE COVERS Drug groups & problems Substance use disorders Criteria Course After you re gone OVERDOSE Symptoms Awake respirations <12/min*/stupor*/miosis* Also: temp/ gut sounds/pulmonary edema Ventilate Naloxone: 0.04mg IM, IN, IV but not oral If no respiration in 2 min 0.5mg 2mg 5mg 10mg 15mg Yes YES O 2 Naloxone ICU Long Acting Opioid? Continuous IV Naloxone ± Intubate Observe 6hr ~ p IV stop Opioid OD Decisions Resp < 12min when awake NO NO Observe 6hr ~ p last naloxone NO ICU Awake/alert NO Long Acting Opioid? Yes Refer for OP Rx Yes Observe 8+hr STAGES OF RX : drop stereotypes Physical exam & history Enhance motivation Help readjust to life Aftercare Reassurance Relapse prevention Boyer NEJM

5 TO ID: ASK ABOUT PROBLEMS QUESTIONNAIRES Relationships School or job Accidents Legal Health CAGE-AID (2+): Feel need cut down Feel bad or guilty Annoyed by criticisms Eye-opener for relief/steady Drug Use Questionnaire (DAST-10: 3+) Then tie in substances Non-med use/multi drugs/not stop/blackout/guilt/ Complaints/neglect/illegal/withdrawal/med probs MOTIVATIONAL INTERVIEWING Build trust Empathic Avoid resistance Patient is in charge Elicit motivational statements Explore ambivalence Monitor readiness to change STAGES OF RX Physical exam & history Vitamins Enhance motivation Help readjust to life Aftercare Reassurance Relapse prevention 5

6 Depressants Opioids DETOX Stimulants (no specific Rx) DETOX RX Physical exam Rest & education Nutrition Meds for: Opioids KEY MEDICATIONS Methadone (oral): Mu-opioid agonist; ½ life hrs Buprenorphine (SL or buccal) Partial mu agonist; kappa antagonist ½ life 3 hrs (longer recepter occupation) Mu antagonists: Naltrexone ½ life: oral 4-13 hrs IM 5-10 days Naloxone (not oral): onset 2 min; action min OPIOID WITHDRAWAL Symptoms opposite of acute effects Timing depends on drug length action PE, educate, motivate Methadone or Buprenorphene 6

7 CLINICAL OPIOID WITHDRAWAL SCALE (COWS) Pulse > 80 Rhinorrhea Sweating Cramps/naus/vomit Restless Tremor Pupils Yawning Bone/joint pain Anxous/irritable Goosebumps Each scored 1-4 or 1-5 Total: 5-12 = mild = mod/severe = mod > 36 = severe WITHDRAWAL Detox rehabilitation Onset symptoms Naloxone: in 2 minutes Short acting (heroin): ~ 8 hrs, day 4 Long acting (methadone): 1+ days, day 10 Protracted withdrawal: 2 weeks to 2+ months Fatigue appetite insomnia anhedonia LONG ACTING OPIOID TAPER Oral methadone SL buprenorphine PE PE: Rx at mild sympt Initial dose (ck in 1 hr; adjust) 10 mg < current dose 4-8 mg mg/d ( ) Stabilize 7-14 days 2-5 days Taper ~ 0-20% of initial dose Every 1-2 days OPIOID-FREE DETOX Med Dose Target Clonidine mg q 4h Flu-like patch 1 for # Diazepam 2-10mg q 4h Insom/anxiety Imodium 4mg, then 2mg Diarrhea Naproxin 500mg 2x/d Aches/pain Compazine 5-10mg q 4h Naus/vomit 7

8 STAGES OF RX Physical exam & history Vitamins Reassurance REHABILITATION Increase motivation Help rebuild life Enhance motivation Help readjust to life Aftercare Relapse prevention Relapse prevention +/- medications Action: REHAB: NALTREXONE Restriction: Induction: Blocks opioid high/ craving Must be opioid free Test : 12.5mg; in 4 h 25-50mg Day 1: Begin mg/d Maintenance: 100mg Mon & Wed 150mg Fri OR 380mg IM/mo MAINTENANCE GOALS Substitute safer opioid Oral to avoid craving set on by needles Long acting to avoid daytime symptoms Use 1+ years note OD danger when stop Rx includes counseling pain control monitoring Goals: IV dangers Health Crime Work OD Relationships 8

9 Action: REHAB:METHADONE Oral & long ½ life opioid REHAB: BUPRINORPHINE Action: SL/buccal long ½ life opioid & naloxone (4 to 1 ratio) Restriction: Only in special clinics Restriction: Trained pvt doc office OK Induction: 1-2 wk:15-30mg 10-50mg ~q 5d to mg Induction: Wk 1-8: 4-8mg/d up to 16-32mg Maintenance: Consider take-home weekend dose if adherent to Rx at 8 wk Maintenance: Dose on SE and craving CBT dysfunctional thoughts (must have drugs) rational thoughts (I can change) Relapse prevention (risk never ends) Anticipate triggers Learn to cope w/triggers Change behaviors (sober friends; stress) 9