Opioids: dependence, symptoms and treatment

The use of opioids for medical purposes, but without supervision by health professionals and any use of non-medical indications, can lead to severe consequences with the development of dependence. It is characterized by an extremely strong incentive to continue taking opioids, developing tolerance when it is necessary to increase the dose to achieve the initial effect, and physical dependence, the severity of which increases with increasing dosage and duration of application.

Dependence on opioids is rapidly increasing. Heroin is the most commonly used substance, the use of opium is rare. The frequency of dependence on prescription opioid analgesics, such as morphine and oxycodone, increases with a certain increase in the proportion of people who use them for legal medical purposes. In addition, many people find that the use of opioids allows them to tolerate what they consider an intolerable stress of life.

Physical dependence inevitably leads to the continuation of the use of the same opioid or related to it for the prevention of cancellation. The abolition of the drug or the appointment of an antagonist causes the development of a characteristic withdrawal syndrome.

The therapeutic dose taken regularly for 2-3 days can lead to a certain tolerance and dependence, and when taking the drug stops, a person may have mild withdrawal symptoms that are hardly noticeable or resemble the flu.

Patients with chronic pain who need long-term use should not be considered addicts, although they may have some problems with tolerance and physical dependence. Opioids cause cross tolerance, so patients can replace one drug with another. In people with developed tolerance, the symptoms of drug use can be expressed slightly, they are able to function normally in everyday life, but getting a drug is a constant problem for them. Tolerance to the various effects of these drugs often develops unevenly. For example, heroin users may be highly tolerant of the euphoric and lethal effects of heroin, but they have narrowed pupils and constipation.

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Symptoms of dependence on opioids

Acute intoxication (overdose) is characterized by euphoria, tidal, pruritus (especially for morphine), miosis, drowsiness, lowering of frequency and depth of breathing, hypotension, bradycardia, lowering of body temperature.

It is possible to presume the presence of physical dependence if the patient produces 3 or more injections of opioids per day, fresh injections are torn, there are signs and signs of withdrawal, or morphine glucon-ronide is detected in urine (heroin is biotransformed into morphine, conjugated with glucuronide and excreted). Since heroin is often inhaled, a nasal septum can be perforated.

The withdrawal syndrome usually includes symptoms and signs of hyperactivity of the central nervous system. The severity of the syndrome increases with the increase in the dose of opioids and the duration of dependence. Symptoms of withdrawal begin to appear 4 hours after taking the drug, and for heroin reach a peak after 72 hours. Against the background of anxiety associated with the desire for a drug, breathing should be increased at rest (> 16 breaths per minute), usually with yawning, sweating, lacrimation and rhinorrhea. Other symptoms include mydriasis, piloection (goosebumps), tremors, muscle twitchings, hot flashes and colds, muscle pains, anorexia. The withdrawal syndrome in patients taking methadone (has a longer half-life) develops more slowly and externally less painfully than with heroin abolition, although patients can describe it as more severe.

Complications of heroin addiction

Complications of heroin addiction are associated with unsanitary drug introduction, characteristic features of the drug, overdose or behavior in the state of drug intoxication. The main complications concern pulmonary, bone and nervous systems; possible the development of hepatitis, immunological changes.

There may be aspiration pneumonitis, pneumonia, lung abscess, septic pulmonary embolism, atelectasis. It may develop pulmonary fibrosis due to talc granulomatosis, if tableted opioid analgesics are injected. Chronic heroin addiction leads to a decrease in the vital capacity of the lungs and to an easy or moderate decrease in diffusion capacity. These effects are different from pulmonary edema, which can develop with heroin injection. Many heroin users smoke one pack of cigarettes a day or more, which makes them particularly susceptible to various pulmonary infections.

There may be viral hepatitis A, B, C. The combination of viral hepatitis and often significant alcohol consumption may be important in the large occurrence of hepatic dysfunction.

The most frequent osteomuscular complication is osteomyelitis (especially the lumbar spine), possibly as a result of hematogenous spread of microorganisms as a result of non-sterile injections. Infectious spondylitis and sacrolitis can occur. With ossifying myositis (injection of the drug into the ulnar veins), the shoulder muscle is damaged by incorrect manipulation of the needle, followed by the replacement of the muscular ligaments with a calcifying mass (extraosteal metaplasia).

Hypergammaglobulinemia, both IgG and IgM, is observed in approximately 90% of the ad-dictations. The reasons for this are not clear, but probably reflect repetitive antigenic stimulation due to infections and daily parenteral injections of foreign substances. Hypergammaglobulinemia decreases with maintenance therapy with methadone. Patients who use heroin and other intravenous drugs have an extremely high risk of HIV infection and AIDS. In communities where shared needles and syringes are used, the spread of AIDS is rampant.

Neurological disorders in patients who use heroin are usually non-infectious complications of coma and cerebral anoxia. There may be toxic amblyopia (probably due to the substitution of heroin for quinine for falsification), transverse myelitis, various mononeuropathies and polyneuropathies, Julian-Barre syndrome. Cerebral complications also include secondary due to bacterial endocarditis (bacterial meningitis, mycotic aneurysm, brain abscess, subdural and epidural abscess), due to viral hepatitis or tetanus, as well as acute falciparum cerebral malaria . Some neurological complications may be associated with allergic reactions to a mixture of heroin and impurities.

There may be a superficial cutaneous abscess, cellulitis, lymphangitis, lymphadenitis and phlebitis due to contaminated needles. Many heroin users start with subcutaneous injections and can return to this mode of administration, when pronounced cicatricial changes make the veins inaccessible. When drug addicts reach a state of despair, skin ulceration can be detected in atypical sites. Contaminated needles and drugs can cause bacterial endocarditis, hepatitis and HIV infection. These complications are accompanied by frequent injections. Since the strength of heroin has recently increased, more people are beginning to inhale and smoke heroin, which can reduce the problems associated with microbial contamination.

Complications associated with the use of heroin are often transmitted to the fetus from mothers who use heroin. Since heroin and methadone easily pass through the placental barrier, the child quickly becomes physically dependent. Mothers infected with HIV or hepatitis B can transmit the infection to the child. Early detection of pregnant women should suggest a switch to maintenance therapy with methadone. Abstinence from drugs is certainly better for the child, but such mothers usually return to heroin use and refuse prenatal care. Late removal of heroin or methadone in pregnant women can cause premature birth, so pregnant women at a longer gestation period are better able to stabilize with methadone than risk taking an attempt to abolish opioids. Mothers on methadone maintenance therapy can breastfeed their child without significant clinical problems in the infant, since the concentration of the drug in milk is minimal.

Infants born to mothers who are addicted to opioids may experience tremors, loud crying, trembling, convulsions (rarely), tachypnea.

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Treatment of dependence on opioids

Acute use. Overdose is usually treated with an opioid antagonist naloxone (from 0.4 to 2 mg intravenously), since it has no property to suppress respiration. It quickly removes from the unconscious state caused by opioids. Since some patients become agitated, aggressive, after they leave comatose state, a physical restriction may be required, which must be applied before the use of antagonists. All patients with an overdose should be hospitalized and under observation for at least 24 hours, since the action of naloxone is relatively short. Also, for several hours, respiratory depression may reoccur, especially when methadone is used, which may require a re-appointment of methadone for this period at the appropriate dose. Pronounced pulmonary edema, which can lead to death due to hypoxia, is usually not stopped by naloxone and its association with an overdose is unclear.

Chronic use. The clinical treatment of heroin addicts is extremely difficult. The AIDS epidemic has provoked a movement to reduce harm, finding appropriate ways to reduce the damage caused by drugs, without stopping consumption. For example, providing clean needles and syringes for injecting can reduce the spread of HIV infection. Despite these data on harm reduction, US federal funding does not provide for the provision of syringes and needles to drug users who inject drugs intravenously. Other harm reduction strategies, such as easy access to methadone or buprenorphine substitution programs, alternative support strategies, and reduced restrictions on the release of psychoactive substances, are more common in some European countries than in the US, where these programs are regarded as inciting drug use.

The doctor should be fully aware of federal, regional and local legislation. Treatment is complicated by the need to cope with the attitude of society towards the treatment of dependent patients (including the attitude of law enforcement officers, other doctors, health workers). In most cases, the doctor should send such a patient to a specialized center for treatment, rather than try to treat it himself.

For the legal use of opioid drugs in the treatment of addiction, the physician must ascertain the existence of a physical dependence on opioids. However, many patients seeking help use low-grade heroin, which may not cause physical dependence. Dependence on low-grade heroin (can be observed in people taking opioid analgesics for a long time) can be treated with slow dose reduction, substitution with weak opioids (for example, propoxyphene) or benzodiazepines (which do not have cross-tolerance with opioids) in decreasing doses.

The withdrawal syndrome ceases on its own, and, although extremely unpleasant, does not pose a threat to life. Minor metabolic and physical cancellation effects can persist up to 6 months. Whether such prolonged withdrawal syndrome aggravates, it is not clear. The patient's behavior in search of a drug usually begins with the first symptoms of withdrawal, and hospital staff need to be on guard because the patient will try to get drugs. Visits of visitors should be limited. Many patients with withdrawal symptoms have concomitant medical problems that need to be diagnosed and treated.

Methadone replacement is the preferred method for the abolition of opioids in severely dependent patients because of the long half-life of methadone and less pronounced sedation and euphoria. Methadone is administered internally in minimal amounts (usually 15-40 mg 1 time per day), which prevents severe withdrawal symptoms, but not necessarily all. Higher doses are given if evidence of withdrawal is observed. Doses of 25 mg or higher can lead to a loss of consciousness if the patient does not develop tolerance. After setting an appropriate dose, it should progressively decrease, but not more than 20% per day. Patients usually become irritated and ask for additional appointments. The withdrawal syndrome caused by methadone is similar to that of heroin, but the onset is more gradual and later, 36-72 hours after stopping the use of the drug. Acute withdrawal symptoms usually subsided in 10 days, but patients often talk about deep muscle pain. Weakness, insomnia, common anxiety often occur for several months. The abolition of methadone in addicts who are part of the methadone substitution program can be particularly difficult, since the dose of methadone can reach 100 mg / day. In general, detoxification should begin with a dose reduction of up to 60 mg 1 time per day for several weeks before attempting full detoxification.

Central adrenergic drug clonidine can stop almost all signs of opioid withdrawal. Probably, it reduces the central adrenergic exchange again through stimulation of the central receptors (according to a similar mechanism, clonidine reduces blood pressure). However, clonidine can cause hypotension and drowsiness and cancellation can trigger anxiety, insomnia, irritability, tachycardia and headache. Clonidine may help patients with heroin or methadone withdrawal before they begin oral naltrexone treatment. A mixed opioid agonist-antagonist buprenorphine can also be used successfully for cancellation.

Supportive treatment for dependence on opioids

There is no consensus on long-term therapy for opioid-dependent patients. In the United States, thousands of opioid dependent patients are on the methadone substitution program, which is designed to monitor patients' problems by providing them with large doses of oral methadone, enabling them to be socially productive. Methadone blocks the effects of injectable heroin and facilitates the passionate desire for a drug. In many patients this program works. However, the widespread use of methadone provokes social and political discontent, and many people question the usefulness of such treatment.

Buprenorphine, an antagonist agonist, is available for maintenance treatment of opioid-dependent patients and becomes more preferable than methadone. It blocks receptors, therefore it prevents the illegal use of heroin or other opioid analgesics. Buprenorphine may be prescribed by specially trained doctors certified by the federal government. The usual dose is 8 or 16 mg per tablet 1 time per day. For many opioid addicts, this option is preferable to the methadone program, as it eliminates the need to visit a clinic dealing with methadone replacement therapy.

Levometadil acetate (LAAM) is a long-acting opioid, close to methadone. In some patients receiving LAAM, violations of the QT interval are detected . Therefore, its use is not approved, and patients receiving it, it is better to translate into methadone therapy. LAAM is applied 3 times a week, which reduces the cost and problem of daily visits to the client or taking medication at home. The dose of 100 mg 3 times a week is comparable to methadone at a dose of 80 mg once a day.

Naltrexone, an orally bioavailable opioid antagonist, blocks the effects of heroin. Has a weak agonist properties, and most patients who are dependent on opioids voluntarily do not take it. The usual dose is 50 mg once daily or 350 mg / week, divided into 2 or 3 doses.

The concept of the therapeutic community, pioneered by Daytop Village and Phoenix House, includes non-drug treatment for living in community centers where people who use drugs are trained and reoriented, which allows them to build a new life. Accommodation in the center usually lasts 15 months. These communities help, even transform some patients. However, the level of initial retirement is very high. How well these communities work, how many of them should be open, how much they should be subsidized by society, remains unclear.