THE OPIOID EPIDEMIC
▪ The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal). ▪ Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms. (Note: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.) Specify if: ○ In early remission (three months of no criteria being met (with the exception of cravings) or sustained remission (12 months or longer (with the exception of cravings). ○ On maintenance therapy. ○ In a controlled environment (where access to opioids is restricted). See the DSM-5 manual for details on specifications. Specify current severity: ○ 305.50 (F11.10) Mild: Presence of 2–3 symptoms. ○ 304.00 (F11.20) Moderate: Presence of 4–5 symptoms. ○ 304.00 (F11.20) Severe: Presence of 6 or more symptoms. Symptoms of opioid intoxication depend on how much of the drug is taken and may include the following: ○ Altered mental status, such as confusion, delirium or decreased awareness or responsiveness. ○ Breathing problems (breathing may slow and eventually stop). ○ Extreme sleepiness or loss of alertness. ○ Nausea and vomiting. ○ Constipation. ○ Small pupil. (Heller, 2017) Symptoms of opioid withdrawal: ○ Early symptoms of withdrawal include: ▪ Muscle aches.
Many individuals with an opioid use disorder began using prescription opioids to treat moderate to severe pain after surgery or injury. Even when taken as prescribed, individuals may suffer from adverse side effects and may develop an opioid use disorder. According to a 2017 report from the Center for Disease Control and Prevention, the United States is in the midst of an opioid overdose epidemic that includes prescription opioids, heroin and fentanyl. In 2017 a record number of 64,000 people died from opioid overdose. Forty percent of all opioid overdose deaths involve a prescription opioid, with 90 to 100 Americans dying every day from an opioid overdose (CDC, 2018). Categories of opioids CDC looks at four categories of opioids: 1. Natural opioid analgesics : Including morphine and codeine, and semi-synthetic opioid analgesics, including drugs such as oxycodone, hydrocodone, hydromorphone and oxymorphone. 2. Methadone : A synthetic opioid. 3. Synthetic opioid analgesics : Other than methadone, including drugs such as tramadol and fentanyl. Fentanyl is a synthetic opioid that is legally made as a pharmaceutical drug to treat pain, or illegally made as a non-prescription drug and is increasingly used to intensify the effects (or “high”) of other drugs, such as heroin. This drug is often mixed with other opioids, unbeknownst to the user, and is extremely powerful. 4. Heroin : An illicit (illegally-made) opioid synthesized from morphine that can be a white or brown powder, or a black sticky substance. (CDC, 2017) The American Psychiatric Association provides the following information in the Diagnostic Manual of Mental Disorders, 5th Edition ( DSM-5 ) (APA, 2013): DSM-5 Criteria for Opioid Use Disorder Description The following are the DSM-5 diagnostic criteria for opioid use disorder: 1. A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: ○ Opioids are often taken in larger amounts or over a longer period than was intended. ○ There is a persistent desire or unsuccessful efforts to cut down or control opioid use. ○ A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects. ○ Craving, or a strong desire or urge to use opioids. ○ Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school or home. ○ Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. ○ Important social, occupational or recreational activities are given up or reduced because of opioid use. ○ Recurrent opioid use in situations in which it is physically hazardous. ○ Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. ○ Tolerance, as defined by either of the following: ▪ A need for markedly increased amounts of opioids to achieve intoxication or desired effect. ▪ A markedly diminished effect with continued use of the same amount of an opioid. (Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.) ○ Withdrawal, as manifested by either of the following:
▪ Agitation, anxiety. ▪ Increased tearing. ▪ Insomnia. ▪ Runny nose.
▪ Sweating. ▪ Yawning. ○ Late symptoms of withdrawal include: ▪ Abdominal cramping, diarrhea. ▪ Dilated pupils. ▪ Goose bumps. ▪ Nausea, vomiting (Heller, 2016). Medication to treat opioid use disorder
The following medications are used to treat opioid use disorder according to the Substance Abuse and Mental Health Services
Administration (SAMHSA, 2016). Medication for opioid use disorders
Medication-assisted treatment with methadone, buprenorphine or extended-release injectable naltrexone plays a critical role in the treatment of opioid use disorders. Opioid agonist therapies with methadone or buprenorphine reduce the effects of opioid withdrawal and reduce cravings. They have been shown to increase retention in treatment and reduce risk behaviors that lead to transmission of HIV and viral hepatitis, such as using opioids by injection. Medication-assisted treatment with extended-release injectable naltrexone reduces the risk of relapse to opioid use and helps control cravings. Extended-release injectable naltrexone is particularly useful for people exiting a controlled setting where abstinence has been enforced such as jail or residential rehabilitation or in situations where maintenance with an opioid agonist is not available or appropriate. People who misuse prescription opioids benefit from medication-assisted treatment as much as people abusing heroin.
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