Opium withdrawal

Description:

The opium withdrawal is the withdrawal presented by the intensive mental, somatovegetativny and neurologic disturbances arising at the termination of administration of drugs of opium poppy.

Symptoms of the Opium withdrawal:

Rate of development of an opium withdrawal, as well as its duration, are also caused by a number of factors, first of all pharmacokinetic features of opiates. So, at dependence on the methadone entered intravenously abstinence begins in later terms, than at dependence on acetylized drugs of opium poppy. Various psychoactive additives (for example, antihistamines derivative of benzodiazepine, etc.) can prolong effect of opiates considerably. Usually the opium withdrawal develops in 6–18 h after the use of the last dose of drug. In typical cases of heroin drug addiction the maximum development of abstinence signs is fixed in 48–72 h after the last use of drug. In case of treatment of an opium withdrawal its duration fluctuates from 3 to 10 days (rarely 12–15 days) - depending on the nature of therapy; whereas for lack of treatment duration of an opium withdrawal can significantly increase.

Phases of an opium withdrawal (I. N. Pyatnitskaya, 1969). The first phase develops in 8–12 h after the last reception of opiates. Signs of mental dependence of an inclination to drug are conditions of dissatisfaction, tension, they are accompanied by somatovegetativny reactions - a mydriasis (expansion of pupils), yawning, dacryagogue, cold with sneezing, a piloerektion ("goose-pimples"). Also appetite disappears, backfilling disturbance is observed. Signs of the second phase of an opium withdrawal are the most expressed in 30–36 h after the last reception of opiates. Are characteristic the fever which is replaced by feeling of heat, attacks of perspiration and weakness, a constant piloerektion. In back muscles, then legs, a neck and hands the feeling of inconvenience appears. Muscles of a body are strained. There is pain in masseters and temporal and mandibular joints. Symptoms of the first phase remain and amplify: pupils are wide, frequent sneezing (to 50–100 times), intensive yawning and dacryagogue. The third phase of an opium withdrawal develops in 40–48 h after reception of the last dose. The inclination to drug gains compulsive (insuperable) character. Signs of the first two phases amplify. There are muscular pains. Muscles of a back, extremities, are more rare - cramps necks, pulls, twists. Part of patients has spasms of peripheral muscles (sural, foot muscles, etc.), the need to move constantly as in a start of motion of pain weaken, but then amplify. Patients cannot find to themselves the place, lay down, get up, again lay down, turn in a bed. Joint pains are absent. Patients are strained, dissatisfied are spiteful, depressive, have sense of hopelessness and hopelessness. The fourth phase of an opium withdrawal appears on third day from the moment of deprivation of drug and lasts up to 5–10 days. Difference of this phase from previous - in development of a new symptom of the dispeptic phenomena: there are abdominal pains, and then, after several hours, - vomiting and diarrhea in the form of a liquid chair till 10-15 once a day, is followed by tenesmus.

The opium withdrawal at height of the development is characterized, besides, by subfebrile condition, moderate hypertensia (to 120-145/90 – 110 mm of mercury.), tachycardia, to (90 – 100 in 1 min.) and a hyperglycemia ("false diabetes") on an empty stomach from the high and slowed-down sugar curve raised by coagulability of blood – the adrenal signs characteristic and for opium intoxication. Some addicts entering opiates intravenously test a cruel itch of veins in apogee of abstinence – "there are a wish to pull out teeth (this symptom is characteristic of a compulsive inclination).

The symptomatology of a heavy opium withdrawal is usually presented by a strong inclination to drug with the purpose to facilitate the painful state. Frustration from the somatovegetativny sphere (intensive muscular and joint pains, muscular hypertensia and myotonia, a hyperhidrosis, a fever or feeling of heat, nausea, vomiting, lability of the ABP, heart rate) are sharply expressed, psychopathological manifestations (the lowered mood background with a dysphoric shade, alarm, sensation of fear, motive concern, sleeplessness). There are the general weakness, weakness, a capriciousness, malignancy with disforopodobny flashes which, however, quickly come to naught.

Shift of some accents belongs to clinical features of displays of an abstinence syndrome at the use of various derivatives of opium. So, at heroin dependence affective, psychopatholike and dissomnichesky disturbances are much stronger expressed psychopathological, in particular. The painful symptom complex heavy, however is reduced in time (in the conditions of therapy its reduction occurs by 4-5th day). At the use kustarno of the prepared derivatives of opium and natural opiates the leading place in a clinical picture is taken by the expressed painful symptomatology which is followed also much by the expressed vegetative dysfunction. When using methadone the painful symptom complex on severity is equated to arising at use kustarno of the prepared opiates, but will stretch in time (its duration sometimes reaches 2 weeks). At abuse tramaly the painful symptom complex proceeds with dominance of senestopathetic feelings, very burdensome for the patient. Features of a course of an abstinence syndrome are explained by distinctions in pharmacokinetics and a pharmacodynamics of the listed narcotic drugs.

Weight of abstinence is proportional to prescription of an opiizm and the size of a dose. In the summer and in very hard frosts the abstinence syndrome proceeds easier and well. In summertime many addicts try to stop a narcotization independently as an inclination less intensively. "Winter" doses are usually higher than "summer".

I. V. Strelchuk (1956) wrote that abstinence causes an exacerbation of associated diseases. It is necessary to add, as the course of an abstinence syndrome is distorted if the patient suffers from any somatopathy. Abstinence surely reveals locus minoris resistentiae. (Latin the place of the smallest resistance) also causes the corresponding decompensation. Often only in abstinence patients learn about the diseases existing at them. So persons with pulmonary dysfunction (tuberculosis, a bronchoectatic disease) have an asthma, at asthma – attacks become frequent. Trouble of digestive tract (a peptic ulcer, a coloenteritis in the anamnesis) leads to wearisome vomiting and pains not only in intestines е, but also in a stomach. The last can unreasonably direct at suspicion about a polynarcotism. The Dispepsichesky phenomena at such patients can arise in the first days of an opium withdrawal. The cardiovascular decompensation is most dangerous. Exceptional cases of death in opium abstinence are caused usually by it.

The following fact relating not only to iatrogenic drug addiction is curious: if the narcotization the source had the physical sufferings which long ago passed, then in abstinence the corresponding pain comes to life. These peculiar, reminding a phantom syndrome pains are not intensive, they are observed also at the patients who are sincerely wishing to be treated though it is impossible to exclude the functional mechanism of their manifestation.

When weakening an opium withdrawal its symptomatology also disappears the groups corresponding to phases. Order of disappearance of groups of symptoms, with rare exception, the return to an emergence order. Such consecutive appearance of groups of symptoms and their consensual disappearance corresponds to clinic of other drug addiction.

At a change during abstinence patients begin to watch the outward, to smoke, communicate with personnel and other patients, and not just with addicts as happens at abstinence height; become more built, more mobile. The mood is leveled, but its fluctuations are often observed. Appetite improves. Increase of body weight goes slowly, stupeneobrazno, despite special medicamentous purposes (especially at long opium dependence). After full stopping of an abstinence syndrome (at long opium dependence) patients usually does not feel completely healthy yet. They badly eat, are weak physically, it is difficult for them to get to work, "laziness, there are a wish to do nothing", quickly are tired. Are easily distracted. The mood fluctuates, the background of mood is lowered. Hypotension is characteristic (to 90-100/50-70 mm of mercury.). Even after 4 - 6 months there are a low working capacity, high fatigue, reduced mood, the narrowed interests. The recurrence is defined or desire "to become efficient", the "live", or arisen compulsive inclination. Often there is recurrence and under the influence of Wednesday.

Reasons of the Opium withdrawal:

Opium substances are subdivided by origin (Yu. P. Sivolap, V. A. Savchenko, 2005 with changes): natural drugs of somnolent poppy and its separate alkaloids (opium, Omnoponum, morphine, codeine, tebaine), semi-synthetic  (heroin, a hydrocodon, hydromorphone, oxycodone, oxymorphone, buprenorphine, alfentanil, remifentanit, pentazocine, levorphanol, буторфанол, налбуфин), synthetic (Meperidinum, methadone, LAAM, прпоксифен, fentanyl, sufentanil), and also as their pharmacological action: full and partial agonists of opioid receptors, antagonists and drugs mixed (an agonist - antagonistic) actions.

Treatment of the Opium withdrawal:

On to a hospital stage the doctor of emergency medical service who faced manifestations of a heavy opium withdrawal should notify the patient on need of treatment in the conditions of a profile psychiatric (narcological) hospital. Sick opium drug addiction makes the decision on hospitalization independently. The exception is made by cases when the developed complications threaten the patient's life.

According to authoritative data of domestic researchers, medicamentous ways of correction of an opium withdrawal can be divided into three big groups conditionally: methods of the accelerated and superaccelerated detoxication (rapid and ultrarapid detoxication protocols) of an organism; at the same time antagonists μ – opioid receptors which are entered by a short course (Naloxonum) are used preferential; classical "psychopharmacological" model at which the medicines which are preferential suppressing the TsNS function (neuroleptics, tranquilizers, hypnagogues, anesthetics), and also antidepressants are used; methods of "replacement therapy" with use of the narcotic substances which are μ – opiate agonists.

The most effective remedies of stopping of an opium withdrawal are a clonidine (clonidine) - an agonist of alpha adrenoceptors of TsNS, тиаприд (tiapridat) - an atypical neuroleptic from group of the replaced benzamines and tramat (a tramadola a hydrochloride) - anesthetic of the central action. Complex use of these drugs allows to stop the main displays of an abstinence syndrome most effectively. In the presence of joint pains are used also фенинбутазон (Rheopyrinum), an ibuprofen (Brufenum), and also heat baths, massage, etc. It is possible to apply to stopping of an opium withdrawal геминеврин (хлорметиазол, декстраневрин), normalizing function of katekholaminovy system. Geminevrin exerts impact on such frustration as persistent sleeplessness, psychopatholike disturbances and alarm. For stopping of an opium withdrawal resort to a combination of antagonists of opiates (Naloxonum, naltrexone) with clonidine. Naloxonum accelerates release of metabolites of opium from receptors that reduces terms of stopping of an abstinence syndrome to 5-6 days. In the first days of therapy appoint the maximum doses of clonidine (0,9-1,2 mg) and minimum - Naloxonum hydrochloride (0,2 mg), then gradually reduce doses of the first and increase doses of the second (to 1,8 mg/days) by the end of a course of therapy of the patient received only Naloxonum.

One of the perspective directions in treatment opium drug addiction is use of neuropeptids (Voronin K. E., 1993). Among them it is possible to call cholecystokinin (pancreozymin) close to it on the pharmacological action такус (церулетид), and also the peptide causing a delta dream. For stopping of opium abstinence use drug with adrenoceptor blocking property - Pyrroxanum, (Pyatnitskaya I. N., etc., 1974). A. G. Hoffman and соавт. (1979) for stopping of opium abstinence recommend to use the raised atropine sulfate doses, believing that administration of atropine blocks cholinergic system.

For treatment of opium drug addiction abroad widely use buprenorphine, being the partial antagonist and a partial agonist of opioid receptors. For stopping of acute manifestations of an opium withdrawal buprenorphine is entered intramusculary, an average single dose of 1-2 ml (0,3-0,6 mg). The daily dose depends on individual dosages of the used drug, duration of a narcotization, a somatic condition of the patient. An average daily dose - 3-6 ml (0,9-1,8 mg) on 2-3 injections. In the USA and a number of countries of Western Europe for treatment of heroin drug addiction also methadone - a synthetic agonist of opiates is used. He stops acute manifestations of an opium withdrawal, is means of replacement therapy at the supporting antirecurrent treatment. An initial dose of methadone - 30-40 mg/days. Doses can increase by 10 mg each 2 days or every week up to achievement of stable dosages at which there is no abstinence syndrome. In the late sixties - the beginning of the 70th years researches were conducted is longer acting and related to drug methadone - left-alpha ацетилметадила (LAAM) which it is possible to enter not daily, and 1 time in 2-3 days.