Opiate use disorders

Nortriptyline (Pamelor). A recent study suggested that the tricyclic antidepressant nortriptyline, like bupropion, is effective in the treatment of smoking cessation. Nortriptyline does not have any significant effect on dopamine reuptake activity, but it does increase norepinephrine availability. Like bupropion, nortriptyline may therefore reduce the physical symptoms of nicotine withdrawal. Because nortriptyline carries the danger of lethality in overdose and has the unfavorable side effect profile of the tricyclics, we do not recommend its use for smoking cessation. However, it does raise the question as to whether other newer antidepressants that increase norepinephrine activity (e.g., venlafaxine, mirtazapine, duloxetine) may also prove to be effective treatments for nicotine withdrawal. 

Smokers who quit are at especially high risk for relapse. A counseling program in lieu of or in addition to medical treatment can be especially helpful in sustaining the patient s success. Therefore, we highly recommend that this be incorporated into the treatment regimen. 

Patients who are especially sensitive to the physical symptoms of nicotine withdrawal may benefit from the addition of a nicotine replacement that is eventually tapered over a period of time (see Table 6.4). It is very important for the patient to abstain from tobacco use (both smoked and chewed) during nicotine replacement therapy. 

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Children of opiate addicts have been shown to have poorer social, educational and health status and to be at higher risk of abuse than their peers (Keen et al., 2000). However, given the high rates of psychiatric comorbidity (in particular, depression) in opiate-dependent patients (Brooner et al., 1997 Khantzian and Treece, 1985), it may be that some of the increased risk in children stems from this greater parental depression. Nunes et al. (1998) reported higher incidence of conduct disorder and global and social impairment for children of addicts with major depression compared to addicts without depression and controls, but not compared with children of depressed patients without substance use disorders. 

When diagnosing a substance use disorder, it is named in accordance with the substance that is being misused. Patients can be said to have alcohol abuse or dependence, cocaine abuse or dependence, opiate abuse or dependence, and so forth. In severe cases when the patient is misusing several substances, (s)he is diagnosed with polysubstance dependence. The complete list of DSM-IV substance use disorders is shown in Table 6.3. Although the diagnostic criteria for the specific substance use disorders are uniform from substance to substance, certain features of the addiction are specihc to the substance being misused. The typical age of onset, the course of the disorder, and the treatment of the disorder vary by substance. Nevertheless, many features of substance abuse and substance dependence are similar across substances. 

Naltrexone (ReVia). Naltrexone is a very potent antagonist of the actions of opiates. It has been used to reduce the rewarding effects of not only opiates but alcohol as well. Like buprenorphine, naltrexone appears to reduce craving for opiates by blocking their pleasurable effects. Naltrexone is not useful for detoxification and in fact worsens withdrawal. Naltrexone can be useful for maintenance treatment in those patients motivated to achieve total abstinence. It is taken at a constant dose of 50mg/day. A sustained-release depot formulation currently under development will likely help to overcome adherence issues that often undermine treatment for substance use disorders. 

Parkinson s disease Postslroke Malignant disease Substance use disorders (including intoxication and withdrawaO Alcoholism Marijuana abuse and dependent Nio)tine dependence Opiate abuse and dependence (eg, heroin) Psychostimulant abuse and dependence (e.g, cocaine)... 

The role of enkephalins and endorphins In learning and memory presents a somewhat confusing picture. It has recently been suggested that the apparent conflicts In the literature may be due to the different doses of opiates used In particular studies high doses appear to facilitate learning while low doses cause a decrement. 28,129 fije effects of the endorphins on animal learning have been recently reviewed, and the proposal made that disturbances In the endorphin system may lead to attentional deficit disorders in children. 

Pharmacological Profiles of Anxiolytics and Sedative—Hypnotics. Historically, chemotherapy of anxiety and sleep disorders rehed on a wide variety of natural products such as opiates, alcohol, cannabis, and kawa pyrones. Use of various bromides and chloral derivatives ia these medical iadications enjoyed considerable popularity early ia the twentieth century. Upon the discovery of barbiturates, numerous synthetic compounds rapidly became available for the treatment of anxiety and insomnia. As of this writing barbiturates are ia use primarily as iajectable general anesthetics (qv) and as antiepileptics. These agents have been largely replaced as treatment for anxiety and sleep disorders. 

Valerian Valeriana officinalis Restlessness, sleep disorders Rare if used as directed. May interact with the barbiturates (eg, phenobarbital), the benzodiazepines (eg, diazepam) and the opiates, (eg, morphine). 

The few controlled studies of pharmacotherapy for AN have largely been disappointing. No class of medication has consistently proved effective in the treatment of AN consequently, pharmacotherapy plays a relatively minor role in the routine management of the disorder. Nevertheless, a review of the medications tested for the treatment of AN is informative. Medications used in the treatment of AN include appetite stimulants, antidepressants, antipsychotics, anxiolytics, trace mineral supplementation, prokinetics, and opiate antagonists. 

Alkaloids such as boldine, codeine, narceine and morphine are active factors in their receptors. Boldine has morphine-like properties and is active on opioid receptors. It may be used to treat stomach disorders and as metabolic stimulant. As it is similar to morphine, boldine can also be considered in the possible development of treatments for narcotic dependence. Codeine also binds to opiate receptors, and specifically functions to reduce bronchial secretions. Codeine can also be used as a cough suppressant when acting on the centre of the medulla oblongata and as a sedative agent. 

Meperidine (Demerol) [C-ll] [Narcotic Analgesic] Uses Moderate/ severe pain Action Narcotic analgesic Dose Adults. 25-50 mg IV, 50-100 mg IM Peds. 1 mg/kg IV/IM (onset w/in 5 min IV and 10 min IM duration about 2 h) Caution [C, ] Contra Convulsive disorders and acute abdomen Disp Prefilled 1 mL syringes 25, 50, 75, 100 mg/mL various amps and vials oral syrup and tabs SE N/V (may be severe), dizziness, weakness, sedation, miosis, resp d ession, xerostomia (dry mouth) Interactions t CNS depression W/ opiates, sedatives/ hypnotics TCNS stimulation W/amphetamines t risk of tox W7 phenytoin EMS Pt should be receiving O2 prior to administration have resuscitation equipment and naloxone available naloxone can be used as an antidote to reverse resp depression aspirate prior to IM administration inadv tent IV admin of IM doses may cause tach and syncope mix w/ NS to make a 10 mg/mL soln and inj very slowly N/V may be sev e may premedicate w/ an antiemetic... 

Comorbid dysthymia and substance disorder. A total of 642 patients were assessed. Thirty-nine had substance-related disorder and dysthymia (SRD-dysthymia) and 308 had SRD only. Data on past use were collected by a research associate using a questionnaire. The patients with SRD-dysthymia and SRD did not differ with regard to use of alcohol, tobacco, and benzodiazepines. The patients with SRD-dysthymia started caffeine use at an earlier age, had shorter use careers of cocaine, amphetamines, and opiates, and had fewer days of cocaine and cannabis use in the last year. They also had a lower rate of cannabis... 

The part played by endogenous opioid systems in the regulation of these various physiological and behavioral functions has led to the experimental application of opiate antagonists in psychiatric disorders. This chapter focuses on autism and self-injury, which are two potential indications for opiate antagonists in pediatric populations. In adults, treatment with opiate antagonists has shown to be useful in the relapse prevention of alcoholism as part of a comprehensive treatment approach (Anton et ah, 1999, 2001). 

It has been shown that after stress or injury, the brain produces and releases its own natural version of opiates to control pain and ease anxiety. People with PTSD continue to produce elevated levels of natural opiates after the trauma has passed. In addition, there exists an increased use of heroin and other opiate-based drugs of abuse among patients with PTSD. Once more, it is difficult to determine whether these elevated natural opiates existed before the disorder developed. 

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