OPIATE WITHDRAWAL

SYNDROMES
OUTLINE
Opiates
 Introduction
 Definition of Terms
 Types of Opiates
 Indications for Opiate Use
 Side Effects of Opiates
 Opioid Use Disorder
 Risk Factors for Opioid Use Disorder
Opiate Withdrawal Syndrome
 Definition
 Aetiology
 Pathophysiology
 Symptoms
 Withdrawal Timeline
 Diagnosis
OPIATES
INTRODUCTION

 An opiate, in classical pharmacology, is a substance derived

from opium. There is evidence of opiate trade, recreational use
& medical use for pain relief as early as the eighth century.
 Opiates can be consumed as part of a clinically indicated pain
regimen or non-clinically as part of the growing global problem
of opioid use disorder (OUD).
 According to the WHO, about 500,000 deaths are attributable to
drug use worldwide. More than 70% of these deaths are related
to opioids, with more than 30% of those deaths caused by
overdose.
 The WHO also estimates, approximately 115,000 people died of
opioid overdose in 2017. Opioid overdoses that do not lead to
DEFINITION OF TERMS

 Opioid -: A term used to designate all substances, both natural

and synthetic, that bind to opioid receptors in the brain, e.g
Loperamide, Hydrocodone, Oxycodone. It is used
interchangeably with the term opiates.
 Opiate -: These are alkaloid compounds naturally found in the
opium poppy plant and their derivatives, e.g Opium, Codeine,
Morphine, Heroin, Methadone & Fentanyl.
 Use -: This means simple use of a substance. Anyone taking
derivatives of opiates or opioids is a user.
 Opioid Use Disorder -: Opioid use disorder (OUD) is a
substance use disorder characterized by cravings for opioids,
continued use despite physical and/or psychological
deterioration, increased tolerance with use, and withdrawal
symptoms after discontinuing opioids.
TYPES OF OPIATES

 Codeine
 Fentanyl
 Heroin
 Hydromorphone
 Morphine
 Methadone
 Meperidine
 Oxymorphone
INDICATIONS FOR OPIATE USE

 Opiates are mainly used for pain management with

the premise that there will be benefits for both pain
& function that will outweigh the risks to the
patient.
 Another indication is symptomatic relief of shortage
of breath, both in the acute setting (for example,
pulmonary oedema) and in terminally ill patients.
 Other indications include; diarrhoea suppression,
cough suppression, anaesthesia and in the
treatment of opioid withdrawal syndrome.
SIDE EFFECTS OF OPIATES

Side effects associated with opiate use include:

 Sedation
 Nausea
 Vomiting
 Dizziness
 Constipation
 Reduced appetite & libido
 Hyperalgesia
OPIOID USE DISORDER (OUD)

 Opioid use disorder (OUD) is a substance use disorder

characterized by cravings for opioids, continued use despite
physical and/or psychological deterioration, increased tolerance
with use, and withdrawal symptoms after discontinuing opioids.
 Addiction & Dependence are important components of Opioid
Use Disorder.
 Addiction, in this case, refers to the neuropsychological disorder
characterized by a persistent and intense urge to consume
opioids, despite substantial harm and other negative
consequences.
 Dependence, in this case, refers to a biopsychological situation
where an individual's functionality is dependent on the
RISK FACTORS FOR OPIOID USE
DISORDER
 Psychological Factors -: Stress, loneliness, desire to
escape from reality, pleasure seeking, low frustration
tolerance, trauma during childhood, low self esteem,
having a pre-existing psychiatric disorder (such as
depression or anxiety).
 Social Factors -: Peer pressure, religious reasons, poor
social support, broken homes, parental disharmony,
occupational causes (Long distance drivers, labourers,
manual workers, writers, poets or musicians), economic
causes (poverty & unemployment).
 Others -: Easy accessibility
OPIATE WITHDRAWAL
SYNDROME
DEFINITON

 Opiate/Opioid withdrawal syndrome is a life-

threatening condition resulting from opioid
dependence.
 Chronic use of opioids leads to the development of
an incapacitating form of dependence in users.
 Opioid dependence impacts the drug user and
imposes a significant economic burden on society
by increasing health care costs, unemployment
rates, absenteeism, and premature mortality.
Studies in some countries have shown that those
consequences can cost, on average, 0.2% to 2.0%
of a country's gross domestic product.
AETIOLOGY

 Opiate withdrawal syndrome occurs when a patient

who is dependent on opioids suddenly reduces or
stops taking opioids.
 It can also be caused when a patient has an opioid
in his/her system and is given an opioid partial
agonist like buprenorphine or antagonists like
naloxone or naltrexone.
 The aetiology of opioid withdrawal is complex.
Studies from various in vivo and in vitro animal
models have indicated that symptoms of opioid
withdrawal are closely related to pathways of cAMP
superactivation.
PATHOPHYSIOLOGY

 Repeated dosages of opioids can quickly lead to

tolerance and physical dependence.
 Tolerance causes a decrease in opioid sensitivity,
impairing the efficacy of endogenous (our own body's)
opioid molecules that function in multiple brain regions.
Opioids partially signal through the decrease in cellular
cAMP.
 Cells with decreased cAMP adapt to regulate cAMP and
increase production. In the tolerant brain the sudden
withdrawal of opioids coupled with the reduced
sensitivity to inhibitory signals from the endogenous
opioid systems can cause abnormally high levels of cAMP
that may be responsible for withdrawal behaviours.
SYMPTOMS

 Extreme anxiety
 Drug Craving
 Nausea
 Vomiting
 Muscle aches
 Runny nose
 Sneezing
 Diarrhoea
 Sweating
 Fever
 Spontaneous Ejaculation in male patients
WITHDRAWAL TIMELINE
DIAGNOSIS

 Diagnosis is made via the Clinical Opiate Withdrawal

Scale (COWS). It is a method used by registered
practitioners to measure the severity of a patient's opioid
withdrawal symptoms.
 This method consists of a series of 11 topics each
comprising 4 - 5 common symptoms experienced by a
patient undergoing opioid withdrawal.
 In each topic a rank is given depending on what the
patient responds to. Generally, 0 is considered to be no
symptom shown and 4 or 5 is considered to be the most
common and severe symptom shown.
DIAGNOSIS (CONTINUED)

 These results are then added up and a final

diagnosis is made based on the value obtained.
 The results are grouped into 3 categories of mild,
moderately severe and severe.
 Mild consists of 5 to 12 points.
 Moderately severe consists of 13 to 24 points.
 Anything above 36 points is severe and requires
direct medical attention.
DIAGNOSIS (CONT’D)

The parameters assessed are -:

 Resting Pulse Rate
 Gastrointestinal Upset
 Sweating
 Tremor
 Restlessness
 Yawning
 Pupil Size
 Anxiety or Irritability
 Bone or Joint Aches
 Goosebumps
 Runny Nose or Tearing
TREATMENT/MANAGEMENT
 Treatment for opioid withdrawal is based on
underlying diagnostic features. A person with an
acute opioid withdrawal but no underlying opioid
use disorder can be managed by slowly reducing
opioid dosage and treatments aimed at the
symptoms.
 The treatment of withdrawal in people with opioid
use disorder also relies on symptomatic
management and tapering with medications that
replace typical opioids, including buprenorphine,
methadone and naltrexone.
 The principle of managing the syndrome is to allow
the concentration of drugs in blood to fall to near
zero and reverse physiological adaptation.
TREATMENT/MANAGEMENT CONT’D

Other means of treatment include -:

 Cognitive Behavioural Therapy
 Twelve Steps Programmes
 Digital Care Programmes
THANK YOU