Psychiatric Nursing

Introduction

More than 20 chemically distinct opioid drugs are in clinical use throughout the world. In the developed countries ,the opioid drug most frequently associated with abuse and dependence is heroin-a drug that is not approved for therapeutic purposes in the United States.

Profile  of the substance

The term opioid refers to a group of compounds include opium, opium derivatives and synthetic substitutes. Opioid exerts both a sedative and an analgesic effect, and their major medical uses are for the relief of pain, the treatment of diarrhea , and the relief of coughing. These drugs have addictive qualities; that is they are capable of inducing tolerance and physiological and psychological dependence.

Opioids are popular drugs of abuse in that they desensitize an individual to both psychological and physiological pain and induce a sense of euphoria. Lethargy and indifference to environment are common manifestations.

Opioids have been used for at least 3,500years, mostly in the from of crude opium or in alcoholic solutions of opium. Morphine was first isolated in 1806 and codeine 1832. Over the next century, pure morphine and codeine gradually replaced crude opium for medicinal purposes, although nonmedical use of opium still persists in some parts of the world.

The opioid induced disorders as defined by DSM IV TR include opioid intoxication, opioid withdrawal, opioid induced sleep disorders and opiod induced sexual  dysfunction .

Opioid abusers usually spend most of the time in nourishing their habit. They are seldom able to hold a steady job that will support their need. They must therefore secure funds from friend, relatives or whomever they have not yet alienated with their dependency related behavior. They may use illegal means of obtaining funds ,such as burglary, robbery, prostitution or selling drugs.

Methods of administration

It include oral, snorting or smoking and by subcutaneous or smoking and by subcutaneous ,intramuscular and intravenous injections .

They are most effective agents known for the relief of pain. They also induce a pleasurable effect on the CNS. So under close supervision , opioids are indispensible in the practice of medicine.

Historical aspects

Opium is the Greek word for "juice ". In its crude form, opium is a brownish black, gummy substance obtained from the ripened  pods of the opium poppy. References  to the use of opiates have been found in the Egyptian, Greek, and Arabian cultures as early as 3000 B.C. The drug became widely used both medicinally and recreationally throughout Europe during the 16^th and 17^th century. Morphine ,the primary active ingredients of opium, was isolated in1803 by the European chemist Frederich Serturner. Since that time ,morphine ,rather than crude opium ,has been used throughout  the world for the medical treatment of pain and diarrhea. This process was facilitated in 1853 by the development of the hypodermic syringe , which made it possible to deliver the undiluted morphine quickly into the body for rapid relief from pain.

This development also created a new variety of opiates user in the United States: one who was able to self administer the drug by injection. During this time , there was also a large influx of Chinese immigrants from the United States, who introduced opium smoking to this country. By the early part of the 20^th century , opium addiction was widespread.

In 1914 the U.S government passed the Harrison Narcotic Act, which created  strict controls on the accessibility of opiates. Until that time these substances were freely available to the public without a prescription. The Harrison Act banned the use of opiates for other than medicinal purposes and drove the use of heroin underground.

Opioid derivatives

• Morphine
• Heroin
• Hydromorphone
• Oxymorphone
• Levorphanol
• Methadone
• Meperidine (Pethedine)
• Fentanyl
• Codine
• Hydrocordone
• Drocode
• Oxycodone
• Propoxyphene
• Buprenorphine
• Pentazocaine
• Nalbuphine
• Butorphanol

Patterns of use and abuse

The development of opioid abuse and the dependence may follow one of two typical behavior patterns. The first occurs in the individual who has obtained the drug by prescription from a doctor for the relief of a medical problem. Abuse and dependency occur when the individual increases the amount of the substance and frequency of use ,justifying the behavior as symptom treatment . He or she becomes obsessed with obtaining increasing amount of the substance, seeking out several physician in order to replenish and maintain supplies.

The second pattern of behavior associated with abuse and dependency of opioids occurs among individuals who use the drugs for recreational purposes and obtain them from illegal sources. Opioid may be used alone to induce the euphoric effects or in combination with stimulants or other drugs to enhance the euphoria or to counteract the depressant effects of the opioid. Tolerance develops and dependency occurs, leading the individual to procure the substance by whatever means is required to support the habit.

Epidemiology : the number of current heroin users in U.S has been estimated to be between 600,000 and 800,000. The male to female ratio of person with heroin dependence is about 3 to 1.

Neuropharmacology :

The primary effects of the opioid are mediated through the opioid receptors, which were discovered in the second half of the 1970s. the µ -opioid receptors are involved in the regulation and mediation of analgesia, respiratory depression ,constipation and dependence; the k -opioid receptors with analgesia ,dieresis and sedation; and the  δ -opioid receptors possibly with analgesia.

In 1974 , enkaphalin an endogenous pentapeptide with opioid like actions was identified. This led to identification of 3 classes of endogenous opioid with in the brain including the endorphins and enkaphalins. Endorphins are involved in neural transmission and pain suppression. They are released naturally in the body when a person is physically hurt.

The opioids have significant effect on the dopaminergic and noradrenergic neurotransmitter system. The properties of opioids are mediated through the activation of the ventral tegmental area dopaminergic neuron that project to the cerebral cortex and the limbic system.

Heroin is the most commonly abused opioid. It is more potent and lipid soluble than morphine. It crosses the blood brain barrier faster and has amore rapid onset than morphine. Heroin was first introduced as a treatment for morphine addiction .codeine is absorbed easily through GI tract and is subsequently transformed into morphine in the body.

Etiology

Psychosocial factors : opioid dependence is not limited to low socioeconomic classes, although the incidence of opioid dependence is greater in these group than the in higher socioeconomic classes. About 50% of urban heroin users are children of single parents and are from families in which at least one other member has a substance related disorder. Children from such settings are at high risk for opioid dependence ,especially if they also evidence behavioral problems in school or other signs of conduct disorders.

Some behavior patterns seem to be especially pronounced in adolescents with opioid dependence. These pattern is called heroin behavior syndrome. It includes depression, often of an agitated type and frequently accompanied by anxiety symptoms, fear of failure ,use of heroin as an antianxiety agent to mask the feelings of low self esteem, hopelessness, aggression etc.

Biological and genetic factors

Monozygotic twins are more likely than dizygotic twins to be concordant for opioid dependence. A  biological predisposition to an opioid related disorder may also be associated with abnormal functioning in either the dopaminergic or the noradrenergic neurotransmitter system.

Psychodynamic theory

Serious ego psychology thought to be associated with substance abuse. In psychoanalytical literature, the behavior of persons addicted to narcotics has been described in terms of libidinal fixation ,with regression to pregenital ,oral or even more archaic levels of psychosexual development.

DIAGNOSIS

OPIOD DEPENDENCE AND OPIOD ABUSE

DSM IV TR DIAGNOSTIC CRITERIA

It is same as the substance dependence and abuse.

Opioid intoxication

The DSM IV TR defines the opioid intoxication as including maladaptive behavioral changes and some specific physical symptoms of opioid use.  In general ,altered mood, psychomotor retardation, drowsiness, slurred speech and impaired memory and attention suggest a diagnosis of opioid intoxication.

Diagnostic criteria for Opioid Intoxication

1. Recent use of an opioid.
2. Clinically significant maladaptive behavioral or psychological changes (e.g., initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, or impaired social or occupational functioning) that developed during, or shortly after, opioid use.
3. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or more) of the following signs, developing during, or shortly after, opioid use:
   1. drowsiness or coma
   2. slurred speech
   3. impairment in attention or memory
4. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Opioid withdrawal

Diagnostic criteria for opioid withdrawal

A.   Either of the following:

1.   cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or longer)

2.   administration of an opioid antagonist after a period of opioid use

B.   Three (or more) of the following, developing within minutes to several days after Criterion A:

1.   dysphoric mood

2.   nausea or vomiting

3.   muscle aches

4.   lacrimation or rhinorrhea

5.   pupillary dilation, piloerection, or sweating

6.   diarrhea

7.   yawning

8.   fever

9.   insomnia

C.   The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D.  The symptoms are not due to a general medical condition and are not    better accounted for by another mental disorder

The general rule about the onset and duration of withdrawal symptoms is that substances with short duration of action tend to produce short, intense withdrawal syndromes and substances with long duration of action produce prolonged but mild symptoms.

An abstinence syndrome can be precipitated by administration of an opioid antagonist. The symptom can begin within seconds of such an IV injection and peak in about one hour. Opioid craving rarely occurs in the context of analgesic administration for pain from physical disorders or surgery. The  full withdrawal syndrome, including intense craving for opioids usually occurs only secondary to abrupt cessation of use in persons with opioid dependence.

Morphine and heroine : the withdrawal symptoms begin 6 to8 hors after the last dose, usually 1 to 2 week period of continuous use or after the administration of a narcotic antagonists. The withdrawal symptoms reaches it peak during the second or third day and subsides during the next 7 to 10 days, but some symptoms may persists for 6months or longer.

Meperidine: withdrawal symptoms begins quickly, reaches a peak in 8 to 12 hours and ends in 4 to5 days .

Methadone : withdrawal symptoms begins 1 to 3 days after the last dose and ends in 10-14 days.

Symptoms: it includes severe bone aches, profuse diarrhea, abdominal cramps, rhinorrhea, lacrimation, piloerection or goose flesh, yawning, papillary dilatation, hypotension ,tachycardia and temperature dysregulation including hypothermia and hyperthermia. Residual symptoms such as insomnia, bradycardia, temperature dysregulation and a craving for opioids -can persists for months after withdrawal.  Associated features of opioid withdrawal include restlessness, irritability, depression, tremor, weakness, nausea and vomiting. At any time during the abstinence syndrome, a single injection of morphine or heroine eliminates all the symptoms.

Opioid intoxication delirium

It is more likely to happen when opioids are used in high doses ,are mixed with other psychoactive compounds or  are used by a person with preexisting brain damage or CNS disorder like epilepsy.

Opioid induced psychotic disorders :It can begin during opioid intoxication. Clinicians can specify whether hallucinations or delusions are the predominant symptoms.

Opioid induced mood disorders : it can begin during intoxication. the symptom can have manic, depressed or mixed nature ,depending on a persons response to opioids. A person coming to psychiatric attention with opioid mood disorder usually has mixed symptoms ,combining irritability ,expansiveness and depression.

Opioid induced sleep disorder and opioid induced sexual dysfunction

The most common sexual dysfunction is impotence.

Opioid related disorder not otherwise specified

The DSM IV TR includes diagnoses for opioid -related disorders with symptoms of delirium , abnormal mood ,psychosis, abnormal sleep and sexual dysfunction. Clinical situation that do not fit into those will be placed under this category.

Clinical features :

Opioids can be taken orally ,snorted intranasally and injected intravenously or subcutaneously. Opiods are subjectively addictive because of the euphoric high that users experience ,especially those who takes the substances IV. The associated symptoms include a feeling of warmth, heaviness of the extremities, dry mouth, itchy face especially the nose and facial flushing. The initial euphoria is followed by a period of sedation ,known in street parlance as nodding off. Opioid can induce dysphoria, nausea and vomiting in opioid naïve persons.

The physical effects of opioid include respiratory depression ,papillary constriction ,smooth muscle contraction ,constipation ,and changes in blood pressure ,heart rate and body temperature.

Adverse effects

The most common and serious adverse effect of is the potential transmission of hepatitis and HIV through the use of contaminated needles by more than one person.

Persons can develop idiosyncratic allergic reactions to opioids which result in anaphylactic shock, pulmonary edema and death if they do not receive prompt and adequate treatment.

Another adverse effect is an idiosyncratic drug interaction between meperidine and MAOI, which can produce gross autonomic instability, severe behavioral agitation ,coma, seizures and death. Opioids and MAOI should not be given together.

Opioid overdose

Death from an overdose of an opioid is due to respiratory depression. The  symptoms of overdose include marked unresponsiveness, coma, slow respiration ,hypothermia, hypotension and bradycardia. When presented with the clinical triad of coma, pinpoint pupils and respiratory depression ,clinician should consider opioid overdose as a primary diagnosis.

MPTP -induced Parkinsonism

In 1976, after ingesting an opioid contaminated with methylphenyltetrahydropyridine (MPTP), several persons developed a syndrome of irreversible parkinsonism. The mechanism for neurotoxic effect is as follows :MPTP is converted into 1-methyl-4-phenylpyridinium(MPP+) by the enzyme monoamineoxidase and is then taken up by dopaminergic neurons.because MPP+ binds to melanin in sustantia nigra neurons,MPP+ is concentrated in this neurons and eventually kills the cells. PET studies of persons who ingested MPTP but remained asymptomatic have shown a deceased number of dopamine binding sites in the sustantia nigra. This decrease reflects a loss in the number of dopaminergic neurons in that region.

Treatment and rehabilitation

Overdose treatment

• Ensure an adequate airway: tracheopharyngeal secretions should be aspirated, an airway may be inserted.
• The patient should be ventilated mechanically until naloxone is given
• Naloxone is administered IV at a slow rate -initially about .8mg per 70 kg of body weight. Signs of improvement (increased respiratory rate and papillary dilation )should occur promptly. In opioid patient too much naloxone may produce signs of withdrawal as well as reversal of overdose. If no response to the initial dose of ,naloxone administration may be repeated after intervals of a few minutes. The  duration of action of naloxone is short compared with that of many opioids, such as methadone and levomethadyl acetate and repeated administration may be required to prevent recurrence of opiod toxicity.

Medically supervised withdrawal and detoxification

Opioid agents for treating opioid withdrawal

Methadone : it is a synthetic narcotic that substitutes for heroin and can be taken orally. A daily doses of 20 to 80mg is sufficient to stabilize the patient although daily dose of 120mg can be given. The duration of action exceeds 24 hours : thus once a daily dose is enough. Methadone maintenance is continued until the patient can be withdrawn from methadone, which itself causes dependence. An abstinence syndrome occurs with methadone withdrawal  but patients are detoxified methadone more easily than from heroin. Clonidine (.1 to .3mg three to four time a day) is usually given during the detoxification period.

Advantages :

• It frees the persons with opioid dependence from using injectable heroin and reduces the chance of spreading HIV infection through contaminated needles.
• methadone produces minimal euphoria and rarely causes drowsiness or depression when taken for a long time
• It allows patients to engage in gainful employment instead of criminal activity.

Disadvantage : patient remain dependent on methadone.

Other opioid substitutes

Levomethadyl (LAAM): it is an opioid agonist that suppresses opioid withdrawal. It  is no longer used because some patients developed prolonged QT interval with arrhythmias

Buprenorphine: it can be dispensed on an outpatient basis but prescribing physician must  demonstrate that they have revived special training in its use. It is effective in thrice weekly dosing . daily use of 8-10mg appears to reduce heroin use. After repeated administration ,it blocks the subjective effect of parenterally administered opioid such as heroin or morphine. A mild withdrawal syndrome occurs if the drug is abruptly discontinued after chronic administration.

Opioid antagonists

Opioid antagonists block the effects of opioids. They do not exert narcotic effects and do not cause dependence. Opioid antagonists include naloxone which is used to treat opioid overdose because it reverse the effects of narcotics and naltrexone .

The theory for using an antagonists is that it blocks the agonist effect ,particularly euphoria, discourages the person with opioid dependence from substance seeking behaviors and thus deconditions  this behavior.

Psychotherapy

Individual psychotherapy, behavioral therapy ,cognitive behavioral therapy ,family therapy, support groups(Narcotic Anonymous, NA) and social skill training are effective for specific patients.

Therapeutic community

Therapeutic communities are residences in which all members have a substance abuse problem. The goal are to effect a complete change of life style, develop personal honesty, responsibility and useful social skills and it eliminate an antisocial attitude and criminal behavior.

Education and needle exchange

Encourage the person to abstain from opioid. Education about the transmission of HIV must receive equal attention. persons with opioid dependence  who use IV or subcutaneous

Narcotic Anonymous

Narcotic Anonymous is a self help group of abstinent drug addicts modeled on the 12 step principles of Alcoholic Anonymous (AA). the outcome for patients treated in 12 step program is good.

References :

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