Opioid Use Disorder
Samuel Arthur
Master of Science in Nursing, Walden University
NURS-6630N: Approaches to Treatment
Dr. E Reome BS, PharmD, BCPS, RPh
April 26, 2024
Introduction:
Opioid use disorder (OUD) has emerged as a significant public health concern, affecting individuals
across all demographics. As psychiatric mental health nurse practitioners (PMHNPs), it's crucial to have a
deep understanding of this complex disorder to provide effective care and support for those struggling
with OUD. In this comprehensive guide, we will explore the diagnostic criteria, modes of use and abuse,
symptoms, treatments, and interventions for OUD.
What are Opioids?
Opioids are a class of drugs that include both prescription pain relievers (such as oxycodone,
hydrocodone, codeine, and morphine) and illicit substances like heroin (Kalin, 2022). These substances
are potent central nervous system depressants, and they are notorious for their addictive properties.
Street names for opioids can vary, but some common ones include "heroin," "oxy," "perc," "blues," and
"junk." The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), outlines the
diagnostic criteria for OUD, which include symptoms such as unsuccessful efforts to cut down on opioid
use, cravings, and withdrawal symptoms when not using opioids. These criteria include the presence of
at least two of the following within a 12-month period; Taking opioids in larger amounts or over a longer
period than intended, Persistent desire or unsuccessful efforts to cut down or control opioid use,
Spending a great deal of time obtaining, using, or recovering from the effects of opioids, Craving opioids,
Continued opioid use despite recurrent social or interpersonal problems caused or exacerbated by the
effects of opioids, Recurrent opioid use in situations where it is physically hazardous, Continued opioid
use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely
to have been caused or exacerbated by opioids, Tolerance, as defined by either a need for markedly
increased amounts of opioids to achieve intoxication or desired effect, or a markedly diminished effect
with continued use of the same amount of an opioid (Tiet et al., 2019).
Modes of Use and Abuse
Opioid abuse manifests in various modes, each presenting unique challenges for individuals and
communities. One prevalent form of abuse is the non-medical use of prescription opioids. This often
begins innocently, with individuals using prescription painkillers for legitimate medical reasons but then
escalating to misuse by taking higher doses or using them for non-prescribed purposes, such as to
experience euphoria or numb emotional distress. The accessibility of prescription opioids through
medicine cabinets, friends, or illicit markets contributes to their misuse. Additionally, some individuals
may doctor-shop or engage in prescription fraud to obtain multiple prescriptions, further exacerbating
the issue (Hakansson et al., 2020). Another mode of opioid abuse is the use of illicit opioids like heroin.
Heroin, a highly addictive opioid derived from morphine, is often cheaper and more accessible than
prescription opioids, making it appealing to individuals seeking a potent high. Injection drug use is
common among heroin users, leading to increased risks of infectious diseases like HIV/AIDS and hepatitis
C, as well as overdose fatalities due to variability in purity and potency. Furthermore, the cycle of
addiction to heroin can be particularly challenging to break, as withdrawal symptoms are intense and
can drive individuals to seek more of the drug to alleviate discomfort.
A newer and increasingly concerning mode of opioid abuse is the use of synthetic opioids,
particularly fentanyl and its analogs. These substances are extremely potent, often many times stronger
than heroin or prescription opioids. Illicitly manufactured fentanyl is frequently mixed with other drugs
like heroin or pressed into counterfeit pills, unbeknownst to users, leading to a significant increase in
overdose deaths. The clandestine nature of production and distribution makes it difficult for authorities
to regulate or control, exacerbating the opioid crisis. Moreover, the potency of synthetic opioids
heightens the risk of accidental overdose, as even small amounts can be fatal to unsuspecting users
(Mack et al., 2017). Addressing these modes of opioid abuse requires comprehensive strategies focusing
on prevention, treatment, and harm reduction efforts.
Symptoms of Intoxication
When someone is under the influence of opioids, they may exhibit several symptoms, including
euphoria, drowsiness, confusion, constipation, slowed breathing, pinpoint pupils, and nodding off. In
severe cases, opioid intoxication can lead to respiratory depression, coma, and even death (Sanni et al.,
2023).
Symptoms of Withdrawal
Withdrawal from opioids can be extremely uncomfortable and distressing for individuals with OUD.
Symptoms of withdrawal may include agitation, anxiety, muscle aches, insomnia, sweating, abdominal
cramping, diarrhea, dilated pupils, and flu-like symptoms. The intensity and duration of withdrawal
symptoms can vary depending on factors such as the type of opioid used, the duration of use, and the
individual's physiology (Sanni et al., 2023).
First-Line Treatment Options
Treatment for OUD typically involves a combination of pharmacotherapy, psychotherapy, and support
services. First-line pharmacological treatments include opioid agonists such as methadone and
buprenorphine, which help alleviate cravings and withdrawal symptoms while reducing the risk of
overdose. These medications are often used as part of medication-assisted treatment (MAT) programs,
which combine medication with counseling and behavioral therapies to address the multifaceted nature
of OUD (LaGrotta, 2020).
FDA-Approved Medications and Mechanisms of Action
Methadone is a synthetic opioid agonist that acts on the same receptors in the brain as other opioids like
heroin, morphine, and oxycodone. It primarily binds to and activates mu-opioid receptors in the brain,
spinal cord, and digestive tract. By doing so, methadone mimics the effects of opioids, but with a longer
duration of action. This prolonged action helps to alleviate withdrawal symptoms and cravings without
causing the intense euphoria associated with shorter-acting opioids. One key aspect of methadone's
mechanism is its ability to stabilize opioid receptors, effectively blocking the effects of other opioids. This
property makes it useful in managing withdrawal symptoms during opioid detoxification programs. By
occupying opioid receptors for an extended period, methadone prevents the abrupt onset of withdrawal
symptoms that typically occur when opioid use is discontinued. This stabilization also helps to reduce
drug cravings, allowing individuals to focus on their recovery without constantly seeking out opioids to
relieve discomfort. Furthermore, methadone's pharmacokinetic properties contribute to its effectiveness
in opioid withdrawal management. It has a long half-life, meaning it remains active in the body for an
extended duration. This sustained presence helps to smooth out fluctuations in opioid blood levels,
reducing the likelihood of withdrawal symptoms between doses. Additionally, methadone is typically
administered orally, which provides a more controlled and gradual delivery compared to other routes of
administration like injection. Overall, methadone's mechanism of action involves binding to opioid
receptors, stabilizing their activity, and providing sustained relief from withdrawal symptoms, thereby
supporting individuals in their journey towards recovery from opioid addiction (“Methadone,” 2023).
Buprenorphine, a partial opioid agonist, operates through a multifaceted mechanism of action to
mitigate opioid withdrawal symptoms and aid in addiction treatment. When administered,
buprenorphine binds to the same opioid receptors in the brain that traditional opioids target, albeit with
a unique twist. It has a high affinity for these receptors but only partially activates them, which results in
a ceiling effect. This means that even with increasing doses, buprenorphine's opioid effects plateau,
reducing the risk of overdose and abuse compared to full agonists like heroin or morphine.
Buprenorphine's partial agonist activity also serves to displace other opioids from the receptors,
effectively blocking their effects (Martin et al., 2020). This action helps alleviate withdrawal symptoms as
it competes with and gradually replaces the opioids to which the individual is addicted. Consequently,
the individual experiences less severe withdrawal symptoms and cravings, facilitating the transition to
abstinence or maintenance therapy. Moreover, buprenorphine's long duration of action contributes to its
efficacy in managing opioid withdrawal. Its slow dissociation from the opioid receptors means that even
after the initial dose wears off, its effects persist, providing sustained relief from withdrawal symptoms.
This characteristic makes buprenorphine suitable for use in tapering regimens, where the dosage is
gradually decreased over time to wean the individual off opioids while minimizing withdrawal
discomfort. Overall, buprenorphine's unique pharmacological profile makes it a valuable tool in opioid
addiction treatment, offering relief from withdrawal symptoms and aiding in long-term recovery.
Common Side Effects and Administration Guidelines
While methadone and buprenorphine are generally well-tolerated, they can cause side effects such as
constipation, nausea, sedation, and sweating. It is essential to educate patients about these potential
side effects and monitor them closely during treatment. Methadone is typically administered daily under
the supervision of a healthcare provider, while buprenorphine can be prescribed for daily use or as a
monthly injection (Buprenorphine Extended-Release Injectable Suspension) (Martin et al., 2020).
Baseline and Ongoing Assessments
Baseline assessments for patients starting MAT may include a comprehensive physical examination,
laboratory tests (e.g., liver function tests, urine drug screens), and a thorough psychiatric evaluation to
assess for co-occurring mental health conditions. Ongoing assessments should include monitoring for
medication adherence, substance use, withdrawal symptoms, and any adverse effects, with adjustments
to the treatment plan as needed.
Non-Pharmacologic Intervention Recommendations
In addition to pharmacotherapy, non-pharmacologic interventions play a crucial role in the
comprehensive treatment of OUD. Behavioral therapies such as cognitive-behavioral therapy (CBT),
contingency management, and motivational interviewing can help individuals develop coping strategies,
address underlying issues contributing to substance use, and promote long-term recovery. Support
groups such as Narcotics Anonymous (NA) and SMART Recovery offer peer support and encouragement,
facilitating social connectedness and accountability.
Conclusion
Opioid Use Disorder is a complex and challenging condition that requires a multifaceted approach to
diagnosis and treatment. PMHNPs play a vital role in providing compassionate, evidence-based care to
individuals struggling with OUD, incorporating pharmacotherapy, psychotherapy, and support services to
promote recovery and improve quality of life. By staying informed about the latest developments in OUD
treatment and collaborating with interdisciplinary healthcare teams, PMHNPs can make a meaningful
difference in the lives of their patients and communities.
References
Hakansson, A., Schlyter, F., Berglund, M. (2020). Factors Associated with Polysubstance Use Versus Use of
Heroin or Amphetamine: A National Survey of People with Substance Use Disorders in Sweden.
Substance Abuse: Research and Treatment, 14, 1-8.
Kalin, N. H. (2022, October 1). Opioid Use Disorder, Cannabis Use Disorder, and a Mindfulness
Intervention Affecting Pain-Related Neural Substrates. American Journal of Psychiatry, 179(10),
693–695. https://doi.org/10.1176/appi.ajp.20220713
LaGrotta, C. (2020, September 8). Treatment of Opioid Use Disorder in the Elderly. Current Treatment
Options in Psychiatry, 7(4), 531–543. https://doi.org/10.1007/s40501-020-00231-x
Mack, K. A., Jones, C. M., & Ballesteros, M. F. (2017, December). Illicit Drug Use, Illicit Drug Use
Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas—United
States. American Journal of Transplantation, 17(12), 3241–3252.
https://doi.org/10.1111/ajt.14555
Martin, C. E., Shadowen, C., Thakkar, B., Oakes, T., Gal, T. S., & Moeller, F. G. (2020, July 28).
Buprenorphine Dosing for the Treatment of Opioid Use Disorder Through Pregnancy and
Postpartum. Current Treatment Options in Psychiatry, 7(3), 375–399.
https://doi.org/10.1007/s40501-020-00221-z
Methadone. (2023, October 7). Reactions Weekly, 1977(1), 181–181. https://doi.org/10.1007/s40278023-47255-5
Sanni, A., Goble, S., & Linzer, M. (2023, November 28). Opoid Use Disorder and Vaso-Occlusive Crisis
Outcomes: A Retrospective Assesement. Blood, 142(Supplement 1), 3884–3884.
https://doi.org/10.1182/blood-2023-173555
Tiet, Q. Q., Leyva, Y. E., & Moos, R. H. (2019, May). Screen of drug use: Diagnostic accuracy for opioid use
disorder. Drug and Alcohol Dependence, 198, 176–179.
https://doi.org/10.1016/j.drugalcdep.2019.01.044