Opioid Use Disorder

Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project. Top Contributors - Lucinda hampton, Kim Jackson, Lauren Lopez, Sonal Joshi, 127.0.0.1, Ginny Zimlich, WikiSysop, Elaine Lonnemann and Jeanette Lanoire  

Definition/Description

Opioid use disorder is the chronic use of opioids that causes clinically significant distress or impairment. Opioid use disorders affect over 16 million people worldwide and there are over 120,000 deaths worldwide annually attributed to opioids. The opioid crisis was declared a nationwide Public Health Emergency in USA on Oct. 27, 2017.

Opioid use disorder consists of an overpowering desire to use opioids, increased opioid tolerance, and withdrawal syndrome when discontinued.

While opioid use disorder is similar to other substance use disorders in many respects, it has several unique features. Opioids can lead to physical dependence within a short time, as little as 4-8 weeks. In chronic users, the abruptly stopping use of opioids leads to severe symptoms, including generalized pain, chills, cramps, diarrhea, dilated pupils, restlessness, anxiety, nausea, vomiting, insomnia, and very intense cravings. Because these symptoms are severe it creates significant motivation to continue using opioids to prevent withdrawal.

Opioids

Drowsy

Opioids are natural or synthetic (made in laboratories to mimic the properties of natural opioids) chemicals that interact with opioid receptors on the nerve cells in the body and brain and reduce feelings of pain. They are a class of drugs that include prescription pain relievers, synthetic opioids and heroin. Prescription opioids are meant to be used to treat acute pain (such as recovering from injury or post-surgery), chronic pain, active-phase cancer treatment, palliative care and end-of-life care. The main intended use is to reduce pain perception, but is associated with causing euphoria, drowsiness, mental confusion, nausea, constipation, and depress respiration (high doses) .

Commonly used opioids identified in the healthcare setting include: 

• Codeine
• Fentanyl (patch)
• Hydrocodone (Hysingla ER, Zohydro ER)
• Hydrocodone/Acetaminophen (Lorcet, Lortabe, Norco, Vicodin)
• Hydromorphone (Dilaudid) 
• Methadone (Dolophine)
• Morphine (Avinza, Kadian)
• Oxycodone (OxyContin, Roxicodone)
• Oxycodone
• Naloxone

Epidemiology

Opioid Deaths

Over 16 million people worldwide are opioid-dependent and would meet the criteria for opioid use disorder, three million in the USA. Opioid use disorder results in over 120000 and 47000 deaths per year worldwide and in the U.S., respectively.

Etiology

There is not one single cause that will lead someone to develop an opioid use disorder. Although, there are several factors that can increase the risk for developing an addiction including both individual and environmental . Genetic factors have been found to play an important role for predisposition tendencies that can respond to the environment .

Opioids are known to activate the mesolimbic reward system which signals the release of dopamine causing feelings of pleasure. Our brains ability to establish this conditioned association is responsible for the desire to repeatedly use the drug . However, the body is highly specialized to make adaptations to the presence of the drug and will transition from compulsion of seeking pleasure to depending on the drug existence entirely. Therefore, the increased compulsion is related to an individual tolerance and dependence of the drug .

Clinical Presentation

Giving up or reducing activities because of opioid use

Opioids produce high levels of positive reinforcement, increasing the odds that people will continue using them despite negative resulting consequences. Opioid use disorder is a chronic lifelong disorder, with serious potential consequences including disability, relapses, and death. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition describes opioid use disorder as a problematic pattern of opioid use leading to problems or distress, with at least two of the following occurring within a 12-month period:

1. Taking larger amounts or taking drugs over a longer period than intended.
2. Persistent desire or unsuccessful efforts to cut down or control opioid use.
3. Spending a great deal of time obtaining or using the opioid or recovering from its effects.
4. Craving, or a strong desire or urge to use opioids
5. Problems fulfilling obligations at work, school or home.
6. Continued opioid use despite having recurring social or interpersonal problems.
7. Giving up or reducing activities because of opioid use.
8. Using opioids in physically hazardous situations.
9. Continued opioid use despite ongoing physical or psychological problem likely to have been caused or worsened by opioids.
10. Tolerance (i.e., need for increased amounts or diminished effect with continued use of the same amount)
11. Experiencing withdrawal (opioid withdrawal syndrome) or taking opioids (or a closely related substance) to relieve or avoid withdrawal symptoms

Associated Co-morbidities

Depression

As research has shown, there is a high correlation between drug abuse and mental disorders. The most common comorbidities associated with opioid use are anxiety and depression .
Another frequent comorbidity associated with opioid use disorder is chronic pain . 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 .

Treatment

Effective treatments are available, however, only about one in four people with opioid use disorder receive specialty treatment. Medication-assisted treatment is an effective treatment for individuals with an opioid use disorder. It involves use of medication along with counseling and behavioral therapies. Brain chemistry may contribute to an individual's mental illness as well as to their treatment. For this reason medications might be prescribed to help modify one's brain chemistry. Medications are also used to relieve cravings, relieve withdrawal symptoms and block the euphoric effects of opioids.

1. The disease is treated with opioid replacement therapy using buprenorphine or methadone, which reduces the risk of morbidity and mortality.
2. Naltrexone may be useful to prevent relapse. Naloxone is used to treat opioid overdose. Nonpharmacologic behavioral therapy is also beneficial.
3. Patients with opioid use disorder often benefit from twelve-step programs, peer support, and mental health professionals, individual and group therapy

Physical Therapy Management

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 .
On March 15, 2016 the CDC released “Guideline for Prescribing Opioids for Chronic Pain” . In these guidelines it promotes “nonpharmacological therapy and non opioid therapy as preferred treatment for chronic pain” . The CDC found that physical therapy and exercise therapy had a high-quality of evidence to reduce pain and improve function .

Case Reports

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. 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. onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2007.01971.x/full