Opiod Use Disorder

 

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Jeanette Lanoire, Ginny Zimlich, 127.0.0.1, WikiSysop, Kim Jackson, Elaine Lonnemann and George Prudden  

Definition/Description

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Prevalence

Drug overdose deaths are on the rise in the United States. The CDC reported that in 2014 overdose deaths increased 6.5% from the previous year (1). The report also stated that since 2000, overdose death rate had risen 137% (1). Of this rise in overdose deaths 61% was attributed to some type of opioid, with synthetic opioid being the leading of categories examined (1). 78 people die per day due to opioid drug abuse (2).

Results of the 2014 National Survey on Drug Use and Health reported the impact of opioid use disorders among varying demographics. When examining age, the survey found that roughly 586,000 Americans age 12 or older had a heroin use disorder, with average first use age being 28 (3). An estimated 1.9 million Americans age 12 or older reported a pain reliever use disorder (3). Opioid use disorder is more common with males than females with the highest abuse rates among the Native American population (4).

A recent study performed by the Substance Abuse and Mental Health Services Administration found a trend in among non-medical pain reliever use and its initiation of heroin use (5). More research is being done in this area to examine the relationship among these topics.

Characteristics/Clinical Presentation

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Associated Co-morbidities

As research has shown, there is a high correlation between drug abuse and mental disorders. The National Institute on Drug Abuse has seen this association through national surveys dating back to the 1980s (6). People that are “diagnosed with mood or anxiety disorders are twice as likely to suffer from a drug use disorder” and vice versa (6). While different mental disorders can bring about opioid use disorder, the most common comorbidities associated with opioid use are anxiety and depression (7).

Another frequent comorbidity associated with opioid use disorder is chronic pain. Both opioid use disorder and chronic pain are driven by neurophysiological changes that can lead to altered or dysfunctional neural patterns (8). Opioids are a common treatment option for those who have recently experienced trauma, surgery, and with chronic pain (8). Opioid use disorder is increased in chronic pain patients due to the risk of noncompliance with drug use (9). The importance of screening an individual with chronic pain for substance use disorder is crucial; this way it can prevent any relapses with previously abused drugs like opioids or set up a strict plan for the individual using the drug (8).

Medications

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Diagnostic Tests/Lab Tests/Lab Values

 The following are screening tools that can be used to test for opioid use disorder.

• Drug Abuse Screening Tool (DAST-10): assesses drug use in the past 12 months. 10-item yes-no questions; high scores indicate drug abuse. (10)
• Diagnostic and Statistical Manual of Mental Disorders (DSM-5): assesses a 12 month period. Can indicate opioid use disorder if the patient fits in the criteria of 2 or more of the 11 criteria examined (ex. craving the substance). (4)
• CAGE-AID Questionnaire: 4 yes-no question tool about drug use. Answering yes to 1 or more questions is a positive test (11).
• RAFFT: Relaxed, Alone, Friends, Family, Trouble. 5 yes-no questionnaire targeting adolescent drug abuse. 2 or more yes answers results in a positive test (12).
• COMM: Current Opioid Misuse Measurement. 17 item, self-reported questionnaire. The higher the score, the increased likelihood of current opioid related deviant behavior (13).

The following are lab tests to test for opioid use disorder.

• Urine/blood toxicology tests: opioids can elicit positive test results 12-36 hours after ingestion (14).
• Screening for Hepatitis A, B, and C, and HIV: opioid abusers have an increased risk for acquiring these diseases from injection or sharing needles (14).
• Liver function tests: increase in ALT and AST can represent signs of acute liver damage; which could be a result from drug use (14).
  

Etiology/Causes

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Systemic Involvement

Opioids reduce the perception of pain by attaching to proteins called opioid receptors that are located in the brain, spinal cord, gastrointestinal tract, and other organs (15). Opioids also affect brain regions involved in reward so they produce a sense of well-being and pleasure (15).

Common side effects associated with taking opioid include the following (7):
• Drowsiness
• Confusion
• Nausea and vomiting
• Constipation
• Sweating
• Pruritus

For those that inject opioids, the following complications can be seen (7):
• Scarred/collapsed veins
• Abscesses
• Bacterial infections
• Blood borne viruses
• Thrombophlebitis
• Intravascular sepsis
• Endocarditis
• Accidental arterial injection
• Peripheral ischemia

For those with long-term opioid abuse, the following can be seen (7):
• Gonadal suppression
• Reduced bone density
• Increase risk of osteoporotic fractures
• Decreased decision making ability
• Decreased ability to regulate behaviors
• Decreased management of stressful situations
• Addiction/dependence

Signs of opioid overdose include (7, 15):
• Respiratory depression
• Cardiovascular depression
• Loss of consciousness/coma
• Hypoxia

Signs of patients having withdraw symptoms include (7, 15):
• Restlessness
• Muscle and bone pain
• Insomnia
• Vomiting
• Diarrhea
• Cold flashes
• Involuntary leg movements
• Agitation
• Flu-like symptoms

Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

Physical therapists are not qualified to manage opioid use disorders. Physical therapists should be able to recognize signs and symptoms of this disorder, but need to refer patients out for treatment. Physical therapists need to advocate for their patients to get them the treatment and help they deserve. Once treatment plans for the opioid use disorder are in place with a physician and patients began receiving medical treatment, if physical therapy treatment is needed to help recover functional deficits than physical therapy management is appropriate. The physical therapy role mainly applies in opioid use disorders to get patients the appropriate care and begin advocating for nonopioid therapy through research in order to help decrease the prevalence of opioid abuse. The APTA has called to action of physical therapists and physical therapist assistances to focus on their role in pain management with the use of fewer or no drugs, such as opioids (17).

As the epidemic of opioid overuse has increased, the CDC has been working on guidelines to decrease risks of abuse and deaths in the United States. On March 15, 2016 the CDC released “Guideline for Prescribing Opioids for Chronic Pain” (16). In these guidelines it promotes “nonpharmacological therapy and nonopioid therapy as preferred treatment for chronic pain” (16). The CDC found that physical therapy and exercise therapy had a high-quality of evidence to reduce pain and improve function (16). The CDC also states that the risks are much lower with nonopioid treatment plans, but in situations that opioids are prescribed they should always be combined with nonopioid therapies, such as physical therapy (16). The movement is toward physical therapy affects in pain management to prevent opioid use disorder.

Differential Diagnosis

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Case Reports/ Case Studies

1. Sullivan M, Edlund M, Fan M, DeVries A, Braden J, Martin B. Risks for Possible and Probable Opioid Misuse Among Recipients of Chronic Opioid Therapy in Commercial and Medicaid Insurance Plans: the TROUP Study. Pain. 2010 Aug; 150(2): 332–339. www.ncbi.nlm.nih.gov/pmc/articles/PMC2897915/
   
2. Niesters M, Overdyk F, Smith T, Aarts L, Dahan A. Opiod-induced respiratory depression in paediatrics: a review of case reports. Br. J. Anaesth. (2013) 110 (2): 175-182. bja.oxfordjournals.org/content/110/2/175.short
3. 5. Maloney E, Degenhardt L, Darke S, Mattick R, Nelson E. Suicidal behaviour and associated risk factors among opioid-dependent individuals: a case–control study. Addiction. December (2007) 102 (12) 1933–1941. [[ http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2007.01971.x/full |onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2007.01971.x/full ]]
4. 4. Ives T, Chelminski P, Hammett-Stabler C, Malone R, Perhac J, Potisek N, Shilliday B, DeWalt D, Pignone M. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Services Research 2006, 6:46. bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-6-46
5. Muhuri P, Gfroerer J, Davies M. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBASQ Data Review. 2013 August. archive.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.htm

Resources

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Recent Related Research (from Pubmed)

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References

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