Dependence with opioids

Naltrexone is used to treat persons dependent on opioids. Fhtients receiving naltrexone have been detoxified and are enrolled in a program for treatment of narcotic addiction. Naltrexone, along with other methods of treatment (counseling, psychotherapy), is used to maintain an opioid-free state Fhtients taking naltrexone on a... 

The expected outcomes of the person formerly dependent on opioids may include an optimal response to therapy, which includes compliance with the treatment program, remaining drug free, and an understanding of the drug rehabilitation program. 

Brief experimentation with illicit opioids rarely leads to dependence, but persons who use opioids commonly escalate to daily use, at least once per month for at least a brief period. Among Vietnam War-era soldiers, experimentation with opioids was widespread 73% of the soldiers who used opioids at least five times became dependent however, 88% of enlisted men who became addicted to heroin did not become readdicted at any time in the 3 years after return, and 56% did not use opioids at all during that time (Robins et al. 1975). 

Clinicians have more recently become more aware of elevated rates of posttraumatic stress disorder (PTSD) in both men and women with opioid dependence (Hien et al. 2000). A lifetime prevalence of PTSD of 20% in women and 11% in men was found in one sample of methadone maintenance patients (Villagomez et al. 1995). Patients often deny a PTSD history during initial assessment. They should be reassessed after they have had the opportunity to develop trust in their treating clinicians. 

Neuroimaging of people with opioid dependence shows differences in this population compared to controls (Gerra et al. 1998). However, these differences may be more related to concurrent psychiatric disturbances than the opioid effects (Gerra et al. 1998). Chronic opioid dependence with comorbid depression is associated with decreased perfusion in the right frontal and left temporal lobes. A negative correlation... 

Patients tolerant to or physically dependent on op/o/c/s. Nalmefene may cause acute withdrawal symptoms in individuals who have some degree of tolerance to and dependence on opioids. Closely observe these patients for symptoms of withdrawal. Administer subsequent doses with intervals of at least 2 to 5 minutes between doses to allow the full effect of each incremental dose of nalmefene to be reached. Reversal of postoperative opioid depression Use 100 mcg/mL dosage strength (blue label) refer to the following table for initial doses. The goal of treatment with nalmefene in the postoperative setting is to achieve reversal of excessive opioid effects without inducing a complete reversal and acute pain. This is best accomplished with an initial dose of 0.25 mcg/kg followed by 0.25 mcg/kg... 

Risk of precipitated withdrawal Nalmefene is known to produce acute withdrawal symptoms and, therefore, should be used with extreme caution in patients with known physical dependence on opioids or following surgery involving high uses of opioids. 

Drug dependence Administer cautiously to people who are known or suspected to be physically dependent on opioids, including newborns of mothers with narcotic dependence. Reversal of narcotic effect will precipitate acute abstinence syndrome. Repeat administration The patient who has satisfactorily responded should be kept under continued surveillance. Administer repeated doses as necessary, because the duration of action of some narcotics may exceed that of the narcotic antagonist. Respiratory depression Not effective against respiratory depression due to nonopioid drugs. 

The abuse of opioids falls into two distinct categories of users, those who initiate use solely for recreational purposes and those who become physically dependent as a result of being treated medically with opioids. As discussed in Chapter 26, the primary use of opioids is for the control of moderate to severe pain. However, few... 

Before initiating treatment, careful attention should be paid to the use of any opioid analgesics, since naltrexone may provoke acute withdrawal symptoms. The main contraindications are (1) treatment with opioid analgesics, (2) opioid dependence, (3) acute opioid... 

Non-steroidal antiinflammatory drugs (NSAIDs) are also known as nonopioid analgesics. They relieve pain without interacting with opioid receptors and do not depress CNS and have no drug dependence or drug abuse property and possess antipyretic activity also. They act primarily on peripheral pain mechanisms and also in CNS to raise pain threshold. 

In summary, naltrexone and perhaps other opioid antagonists such as nalmefene are promising agents in the pharmacotherapy of alcohol dependence with or without coexisting psychiatric and addictive disorders (418). 

Naltrexone is generally taken once a day in an oral dose of 50 mg for treatment of alcoholism. An extended-release formulation administered as an IM injection once every 4 weeks is also effective. The drug can cause dose-dependent hepatotoxicity and should be used with caution in patients with evidence of mild abnormalities in serum aminotransferase activity. The combination of naltrexone plus disulfiram should be avoided, since both drugs are potential hepatotoxins. Administration of naltrexone to patients who are physically dependent on opioids precipitates an acute withdrawal syndrome, so patients must be opioid-free before initiating naltrexone therapy. Naltrexone also blocks the therapeutic effects of usual doses of opioids. 

Naltrexone Nonselective competitive antagonist of opioid receptors Reduced risk of relapse in individuals with alcoholism Available as an oral or long-action parenteral formulation Toxicity Gastrointestinal effects and liver toxicity will precipitate a withdrawal reaction in individuals physically dependent on opioids and will prevent the analgesic effect of opioids... 

Use of opioid drugs in acute situations may be contrasted with their use in chronic pain management, in which a multitude of other factors must be considered, including the development of tolerance to and physical dependence on opioid analgesics. 

Portenoy and Payne (1997) insist upon a distinction between physical dependence and addiction. What they mean by physical dependence is roughly what 1 mean, but they define addiction as a condition in which one is unable to abstain "Use of the term addiction to describe patients who are merely physically dependent reinforces the stigma associated with opioid therapy and should be abandoned. If the clinician wishes to describe a patient who is believed to have the capacity for abstinence, the term physical dependency must be used (564). Since my second level of dependency, which I consider to be addiction proper, need not involve this inability, Portenoy and Payne are marking a different distinction. 

Many nonsteroidal anti-inflammatory drugs of different chemical structures (Fig. 5) have been introduced for the treatment of inflammatory and painful conditions. Many years of clinical experience with these drugs have shown that there is no induction of tolerance or dependence and no respiratory depression as seen with opioids. The major side-effects of these compounds with COX-1 selectivity or balanced COX-1 and COX-2 inhibition are damage to the gastric mucosa, prolongation of bleeding time and renal failure. 

Greenwald, M. and Stitzer, M., Butorphanol agonist effects and acute physical dependence in opioid abusers comparison with morphine, Drug Alcohol Depend., 53, 17, 1998. 

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