Opioid dependence

Description:

Use of opioids in the medical purposes, but without observation from workers of health care and any use on not medical indications can lead to serious consequences with dependence development. It is characterized by extremely strong motivation to continuation of reception of opioids, tolerance development when increase in a dose is necessary for achievement of initial effect, and physical dependence which expressiveness amplifies with increase in a dosage and duration of use.
Dependence on opioids quickly increases. Heroin is the most often used substance, use of opium meets seldom. Dependence frequency from the opioid analgetics which are written out by doctors, such as morphine and oxycodone, increases, with a certain increase in a share of the people applying them in the legal medical purposes. Besides, many people find out that the use of opioids allows them to transfer what they consider an intolerable vital stress.

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

The therapeutic dose accepted regularly for 2-3 days can result in a certain tolerance and dependence and when administration of drug stops, the person can have easy symptoms of cancellation which are hardly noticeable or remind flu.

The patients with chronic pain needing prolonged use should not be considered as addikta though they can have some problems with tolerance and physical dependence. Opioids cause cross tolerance therefore patients can replace one drug with another. At people with the developed tolerance symptoms of the use of drug can be expressed slightly, they are capable to act normally in everyday life, but receiving drug is for them constantly existing problem. Tolerance to various effects of these drugs often develops unevenly. For example, consumers of heroin can be high-tolerant to euphoric and lethal effects of heroin, but they keep miotic pupils and a lock.

Symptoms of opioid dependence:

Acute intoxication (overdose) is characterized by euphoria, inflow, an itch (especially for morphine), a miosis, a somnolence, decrease in frequency and depth of breath, hypotension, bradycardia, decrease in body temperature.

It is possible to assume existence of physical dependence if the patient makes 3 and more injections of opioids a day, hot scents from injections metsya, there are symptoms and signs of cancellation or in urine the glucuronide is defined morphine (heroin biotransformirutsya in morphine, it is conjugated with a glucuronide and it is removed). As heroin is often inhaled, the nasal partition can be perforated.

The withdrawal usually includes symptoms and signs of a hyperactivity of TsNS. Weight of a syndrome increases with increase of a dose of opioids and durations of dependence. Symptoms of cancellation begin to be shown in 4 h after drug reception, and for heroin reach peak in 72 h. Against the background of the alarm connected with desire of drug increase of breath at rest (> 16 dykhaniye a minute), usually with yawning, perspiration, dacryagogue and a rhinorrhea follows. The mydriasis, a piloerektion (goose-pimples), a tremor, muscular twitchings, inflows of heat and cold, muscular pains, anorexia belong to other symptoms. The withdrawal at the patients accepting methadone (has longer elimination half-life), develops more slowly and externally less hard, than at heroin cancellation though patients can describe it as heavier.

Complications:

Complications of a heroin adtsiktion are connected with insanitary administration of drug, characteristics of drug, overdose or behavior in a condition of narcotic intoxication. The main complications concern pulmonary, bone and nervous systems; development of hepatitis, immunological changes are possible.

The aspiration pneumonitis, pneumonia, lung abscess, septic pulmonary embolism, atelectases can be observed. Fibrosis because of a talc granulomatosis can develop pulmonary if the tableted opioid analgetics are entered in the form of injections. The chronic heroin addiction leads to decrease in vital capacity of lungs and easy or moderate decrease in diffusion capacity. These effects differ from a fluid lungs which can develop at a heroin injection. Many patients taking heroin smoke 1 pack of cigarettes a day and more that does them especially susceptible to various pulmonary infections.

There can be viral hepatitis And, In, S. Sochetaniye of a viral hepatitis and often considerable consumption of alcohol can matter in big occurrence of hepatic dysfunction.

The most frequent musculoskeletal complication is osteomyelitis (especially lumbar department of a backbone), perhaps, as a result of hematogenous distribution of microorganisms as a result of unsterile injections. Can meet an infectious spondylitis and sakrolit. At an ossifying miositis (administration of drug in elbow veins) the humeral muscle is injured at the wrong manipulations with a needle what substitution of muscular sheaves the kaltsifitsiruyushchy weight (an extra bone metaplasia) follows.

The hypergammaglobulinemia, both IgG, and IgM, is observed approximately at 90%ad-dikt. The reasons of it are not clear, but probably reflect the repeating antigen challenge because of infections and daily parenteral administrations of foreign substances. The hypergammaglobulinemia decreases at a maintenance therapy methadone. The patients taking heroin and other intravenous drugs have extremely high risk of HIV infection and AIDS. In communities where use the general needles and syringes, spread of AIDS increases in the menacing scales.

Neurologic frustration at the patients taking heroin usually are noninfectious complications of a coma and a cerebral anoxia. Can be observed a toxic amblyopia (possibly, owing to replacement for the purpose of falsification of heroin by quinine), a cross myelitis, various mononeuropathy and polyneuropathy, a syndrome to Zhuliana-Barra. Cerebral complications include also secondary owing to a bacterial endocarditis (bacterial meningitis, mycotic aneurism, brain abscess, subdural and epidural abscess), owing to a viral hepatitis or tetanus, and also acute cerebral malaria of falciparum. Some neurologic complications can be connected with allergic reactions to mix of heroin and impurity.

Superficial skin abscess, cellulitis can be observed, limfangiit, lymphadenitis and phlebitis because of the contaminated needles. Many patients taking heroin begin with subcutaneous injections and can be returned by this way of introduction when the expressed cicatricial changes do veins unavailable. When addicts reach a condition of a hopelessness, skin ulcerations in atypical places can be found. Kontaminirovanny needles and drug can serve as the reason of a bacterial endocarditis, hepatitis and HIV infection. These complications accompany frequent injections. As heroin force increases recently, more and more people begin to inhale and smoke heroin that can lower the problems connected with microbic contamination.

The complications connected with the heroin use often are transferred to a fruit from mothers taking heroin. As heroin and methadone easily pass through a placental barrier, the child quickly becomes physically dependent. Mothers infected with HIV or hepatitis B can transmit an infection to the child. Early the revealed pregnant patients need to offer transition to a maintenance therapy methadone. Abstention from drugs, undoubtedly, is better for the child, but such mothers usually are returned to the use of heroin and refuse the prenatal help. Late cancellation of heroin or methadone can cause premature births therefore it is better to stabilize pregnant women on big duration of gestation methadone in pregnant women, than to risk in attempt of cancellation of opioids. Mothers who are on a maintenance therapy methadone can raise the child without noticeable clinical problems at the baby as concentration of drug in milk is minimum.

At the babies born from mothers, suffering from dependence on opioids the tremor, loud crying, a shiver, spasms (seldom), can be observed by a tachypnea.

Treatment of an opioid zaisimost:

Acute use. The overdose is usually treated by the opioid antagonist Naloxonum (from 0,4 to 2 mg intravenously) as it has no property to suppress breath. It quickly brings out of the unconsciousness caused by opioids. As some patients become excited, aggressive after they leave coma, physical restriction which needs to be applied before use of antagonists can be required. All patients with overdose have to be hospitalized and be under observation of at least 24 h as action of Naloxonum rather short. Also for several hours there can repeatedly be a breath suppression, especially when using methadone that can demand repeated purpose of methadone to this period in the corresponding dose. The expressed fluid lungs which can lead to death because of a hypoxia usually is not stopped by Naloxonum and its communication with overdose is not clear.

Chronic use. Clinical treatment of addicts, dependent on heroin, is extremely heavy. Epidemic of AIDS provoked the movement on decrease in harm, search of the corresponding ways to reduce the damage brought by drugs without the use termination. For example, providing with pure needles and syringes for injections allows to reduce spread of HIV infection. Despite these data on decrease in harm, federal financing of the USA does not provide with syringes and needles of the addicts using drugs intravenously. Other strategy for harm reduction, such as easy access to programs of substitution by methadone or buprenorphine, the alternative supporting strategy, decrease in restrictions for an extract of psychoactive agents, are more widespread in some European countries, than in the USA where these programs are regarded as inciting to the use of drugs.

The doctor has to be completely informed concerning the federal, regional and local legislation. Treatment is complicated by need to cope with the relation of society to treatment of dependent patients (including the relation of employees of law-enforcement system, other doctors, health care providers). In most cases the doctor has to direct such patient to treatment in the specialized center, but not try to treat him independently.

For legal use of opioid drugs in treatment of an addiction the doctor has to be convinced of existence of physical dependence on opioids. However many patients who are looking for the help use low-grade heroin which can not cause physical dependence. Dependence on low-grade heroin (it can be observed at the people accepting opioid analgetics a long time) it is possible to treat a slow dose decline, substitution by weak opioids (for example, a propoxyphenom) or use of benzodiazepines (which have no cross tolerance with opioids) in the decreasing doses.

The withdrawal stops independently, and though it is extremely unpleasant, does not pose a threat for life. Small metabolic and physical effects of cancellation can remain up to 6 months. Whether such prolonged withdrawal promotes an aggravation, not clearly. The behavior of the patient on drug search usually begins with the first symptoms of cancellation, and the personnel of hospital need to be on the lookout because the patient will try to get drugs. Visits of visitors have to be limited. Many patients with symptoms of cancellation have the accompanying medical problems which it is necessary to diagnose and treat.

Replacement with methadone is a procedure of choice of cancellation of opioids at hard dependent patients because of a long elimination half-life of methadone and less expressed to sedation and euphoria. Methadone is appointed inside in the minimum quantities (usually 15 - 40 mg once a day) that warns heavy symptoms of cancellation, but everything is not obligatory. Higher doses are appointed if proofs of a withdrawal are observed. Doses of 25 mg can lead to a loss of consciousness also above if at the patient tolerance did not develop. After establishment of the corresponding dose, it has to decrease progressively, but no more than by 20% a day. Patients usually become angry and ask additional appointments. The withdrawal caused by methadone is similar to that at heroin, but the beginning more gradual and later, in 36-72 h after the drug use termination. Acute manifestations of cancellation usually abate in 10 days, but patients often speak about deep muscular pains. Weakness, insomniya, widespread alarm often meet for several months. Cancellation of methadone at dependent, entering the program of replacement therapy by methadone, can be especially difficult as the dose of methadone can reach 100 mg/days. Generally the detoxication has to begin with a dose decline to 60 mg of 1 times a day for several weeks before attempt of a full detoxication.

The central adrenergic drug a clonidine can stop practically all signs of opioid cancellation. Possibly, it reduces the central adrenergic exchange for the second time through stimulation of the central receptors (on the similar mechanism the clonidine reduces arterial pressure). However the clonidine can cause hypotension and drowsiness, and its cancellation can provoke concern, an insomniya, irritability, tachycardia and a headache. The clonidine can help patients with cancellation of heroin or methadone before they begin peroral treatment by naltrexone. The mixed opioid agonist antagonist buprenorphine can also successfully be used at cancellation.

The program of the supporting treatment:

There is no consensus concerning long-term therapy of patients, dependent on opiod. In the USA thousands of the patients dependent on opioids are in the methadone replaceable program which is designed to control the solution of problems of patients, providing them with high doses of peroral methadone, giving the chance to be socially productive. Methadone blocks effects of injection heroin and facilitates passionate desire of drug. This program works for many patients. However wide use of methadone provokes social and political discontent, and many people doubt usefulness of such treatment.

Buprenorphine, agonist antagonist, is available to the supporting treatment of patients, dependent on opioids, and there is more preferable, than a methadone. It blocks receptors, in this regard interferes with the illegal use of heroin or other opioid analgetics. Buprenorphine can be appointed by specially trained doctors certified by the federal government. The usual dose makes 8 or 16 mg in a tablet once a day. This option is more preferable than the methadone program as saves from need of visit of the clinic which is engaged in replacement methadone therapy to many opioid addicts.

Levometadil acetate (LAAM) is is long the operating opioid close to methadone. Disturbances of an interval of QT are found in some patients accepting LAAM. Therefore its use is not approved, and it is better to transfer the patients receiving it to methadone therapy. LAAM is applied 3 times a week that reduces the cost and a problem of daily visits of the client or drug intake of the house. The dose in 100 mg 3 times a week is comparable to methadone in a dose of 80 mg once a day.

Naltrexone, the opioid antagonist, bioavailable at intake, blocks effects of heroin. Most of the patients dependent on opioids has weak properties of an agonist, and, voluntarily do not accept it. The usual dose makes 50 mg once a day or 350 mg/week divided into 2 or 3 receptions.

The concept of therapeutic community which pioneers were Daytop Village and Phoenix House includes non-drug treatment at accommodation in the public centers where the people using drugs study and reoriented that allows them to build new life. Accommodation in the center usually lasts 15 months. These communities help, will even transform some patients. However the level of initial leaving is very high. How well these communities as much they have to be open as far as them society has to subsidize work, remains not clear.