Session 13 Opioids A Comprehensive Review
OPIOIDSA Comprehensive Look
TOPICS OF DISCUSSION§ Definitions§ Opium Poppy§ History of Opium§ Effects of Opioids§ Opiates vs. Opioids§ Rx Opioids and Heroin Abuse Trends in US§ Medication Assisted Treatment§ New Drug Trends§ Testing for Opiates/OpioidsOpioids20172
DEFINITIONS§ Opiates – alkaloids derived directly from the poppy plant§ Opioids – broader class of drugs that are capable of eitherproducing opium like effects or binding to opioid receptors§ Semisynthetic opioid – created by the chemical modification of anopiate§ Synthetic opioid – a chemical compound not derived from anopiate, that is capable of binding to an opioid receptor andproducing opioid effects clinicallyOpioids20173
OPIUM POPPYWhere it all beganOpioids20174
POPPY PLANTOpioids20175
POPPY PLANT§ Papaver somniferum§ Annual herb growing to be about 100 cm§ Origin is possibly the Eastern Mediterranean,extensive cultivation and introduction of the speciesthroughout Europe has obscured its origins§ Opium§ The latex produced by the seed pods§ Contains a class of naturally occurring alkaloidsknown as opiates§ Morphine§ Thebaine§ Codeine§ Papaverine§ Noscapine§ OripavineOpioids20176
HISTORY OF OPIUMOpioids20177
EARLY HISTORY3400 B.C.Earliest Reference Cultivated inMesopatamia Sumerians called itHul Gil, “joy plant”1300 B.C.400 A.DPassing It OnChina Bound SumeriansAssyriansBabyloniansEgyptians Enter the traderoutes to Europe1300’sTaboo Disappears fromEuropean historicalrecords for 200 years During Inquisition itwas tabooIntroduced inChina by ArabtradersOpioids20178
The Dutch exportshipments of Indian opiumto China and the islands ofSoutheast Asia; the Dutchintroduce the practice ofsmoking opium in atobacco pipe to theChinese.17001729Chinese emperor,Yung Cheng, issuesan edict prohibitingthe smoking ofopium and itsdomestic sale, exceptunder license for useas medicine.The British EastIndia Companyassumes controlof Bengal andBihar, opiumgrowing districtsof India. Britishshippingdominates theopium trade outof Calcutta toChina.17501767The British EastIndia Companyestablishes amonopoly on theopium trade. Allpoppy growers inIndia wereforbidden to sellopium tocompetitortradingcompanies.1793The British East IndiaCompany's import ofopium to China reachesa staggering twothousand chests ofopium per year1796The import ofopium into Chinabecomes acontraband trade.Silver was smuggledout to pay forsmuggling opium in.China's emperor,Kia King, bansopiumcompletely,making tradeand poppycultivationillegal.1799Opium Wars1803Mid1800sFriedrich Serturner ofGermany discovers theactive ingredient of opiumby dissolving it in acid thenneutralizing it withammonia. The result:morphine. Physiciansbelieve that opium hadfinally been perfected andtamed. Morphine is laudedas "God's own medicine"for its reliability, longlasting effects and safety.Opioids20179
OPIUM WARS China’s attempt to suppress the opium trade Stop illegal exporting of opium into China§ Widespread addiction§ Social and economic disruption Two Wars§ 1839-42: China and Britain§ 1856-60: China and Britain/France China lost both warsOpioids201710
OPIUM DENS Site to buy and sellopium Chinese immigrantscame to US in mid1800s to work for therailroads and GoldRush They brought thehabit with them and ium dens beganopening up across thecountryOpioids201711
LAWS 1890: U.S. Congress, in its earliest law-enforcement legislation onnarcotics, imposes a tax on opium and morphine. 1905: U.S. Congress bans opium. 1909: The first federal drug prohibition passes in the U.S. outlawing theimportation of opium. 1914: The passage of Harrison Narcotics Act which aims to curb drugabuse and addiction. It requires doctors, pharmacists and others whoprescribed narcotics to register and pay a tax.Opioids201712
CONTROLLED SUBSTANCES ACT 1970 – part of the Comprehensive Drug Abuse Prevention andControl Act Schedule I§ The drug or other substance has a high potential for abuse.§ The drug or other substance has no currently accepted medical use intreatment in the United States.§ There is a lack of accepted safety for use of the drug or othersubstance under medical supervision. Schedule II§ The drug or other substance has a high potential for abuse.§ The drug or other substance has a currently accepted medical use intreatment in the United States or a currently accepted medical usewith severe restrictions.§ Abuse of the drug or other substances may lead to severepsychological or physical dependence.Opioids201713
DRUG SCHEDULING Schedule III§ The drug or other substance has a potential for abuse less than thedrugs or other substances in schedules I and II.§ The drug or other substance has a currently accepted medical use intreatment in the United States.§ Abuse of the drug or other substance may lead to moderate or lowphysical dependence or high psychological dependence. Schedule IV§ The drug or other substance has a low potential for abuse relative tothe drugs or other substances in schedule III.§ The drug or other substance has a currently accepted medical use intreatment in the United States.§ Abuse of the drug or other substance may lead to limited physicaldependence or psychological dependence relative to the drugs orother substances in schedule III.Opioids201714
DRUG SCHEDULING Schedule V§ The drug or other substance has a low potential for abuserelative to the drugs or other substances in schedule IV.§ The drug or other substance has a currently accepted medicaluse in treatment in the United States.§ Abuse of the drug or other substance may lead to limitedphysical dependence or psychological dependence relative tothe drugs or other substances in schedule IV.Opioids201715
EFFECTS OF OPIOIDSOpioids201716
Opioid Receptorsµ (mu) receptor: produce central depression – analgesia,respiratory depression, miosis, euphoria, reducedgastrointestinal motility, hypothermia, bradycardia, physicaltolerance and dependenceΚ (kappa) receptor: produce spinal analgesia, sedation, miosis,diuresis, mild respiratory depression and low addiction liabilityδ (delta) receptor: spinal analgesia, dysphoria, delusions,hallucinations, and respiratory and vasomotor stimulationOpioids201717
AGONIST AND ANTAGONIST Opiates/Opioids are classified into three groups§ Full agonist : compounds that have an affinity for opioidreceptors of a certain type§ Mixed agonist-antagonist: compounds with an agonistic effectat one class of receptor and an antagonistic effect at another§ Full antagonist: compounds that inhibit agonist binding ofother compounds; have reduced analgesic effect and areprimarily used for the treatment of opioid intoxicationOpioids201718
EFFECTSCentral Nervous System§ Nervous§§§§EuphoriaAnalgesiaSedationMental clouding and moodswings§ Pulomanary§ Respiratory Depression§ Decreased Responsiveness§ Gastrointestinal§ Nausea§ Vomiting§ Constipation§ Other§§§§§Cough suppressionMiosisTruncal rigidityFlushing and warming of the skinSweating and itchingOpioids201719
EFFECTSHuman Performance§ Driving§§§§§§§§Slow drivingWeavingPoor vehicle controlPoor coordinationSlow response to stimuliDelayed reactionsDifficulty following instructionsFalling asleep at the wheelOpioids201720
WARNINGwww.drugrehab.comOpioids201721
OPIATES VS. OPIOIDSClassificationOpioids201722
OPIATESALKALOIDS DERIVED DIRECTLY FROMTHE POPPY PLANTMorphine Opium§ Morphine, Thebaine, Codeine, Papaverine, Noscapine, Oripavine§ Schedule I Morphine§ Extracted from opium, 1803§ Named after Morpheus, thegod of dreams§ nic whites and non-Hispanic blacksOpioids201733
CDC PRESCRIBING DATAOpioids201734
CDC PRESCRIBING DATAOpioids201735
CDC RX OPIOID OVERDOSE DATA Nearly half of all US opioid overdose deaths involve aprescription opioid (2015 – 15,000 deaths) Most common drugs involved in overdose§ Methadone§ Oxycodone§ Hydrocodone Rates highest among people 25-54 years old Rates higher among non-Hispanic whites, AmericanIndians including Alaskan Natives Men were more likely to die from overdose, but the gapis closingOpioids201736
CDC HEROIN USE DATA Use§ Increasing among men and women, most age groups, and allincome levels§ Greater increase in demographic groups with historically lowrates¡Women, privately insured, higher incomes§ More than doubled in the past decade among young adultsaged 18-25 years Overdose deaths§ More than quadrupled since 2010§ From 2014-2015 death rates increased by 20.6%§ 13,000 people died in 2015Opioids201737
CDC HEROIN USE DATA Risk Factors§ Past misuse of prescription opioids inthe strongest factor¡Especially if the dependency/abuseoccurred within the past year§ 3 out of 4 new heroin users reportedprescription opioid abuse prior tousing heroin§ Increased availability§ Relatively low prices compared to RxopioidsOpioids201738
OPIOID OVERDOSE DEATHSOpioids201739
ARIZONA TAKING ACTION January 2015§ Arizona State University's Walter Cronkite School of Journalismand Mass Communication and the state of Arizona joinedforces to shed light on heroin abuse.§ “Hooked: Tracking heroin’s hold on Arizona.”§ 30 minute program played on all major Spanish and Englishstations in Arizona§ Also played on radio stations.§ Following the program there was a call center staffed with 100professionals that could give advice and refer callers totreatment centers. January 2017§ "Hooked Rx: From prescription to addiction.”Opioids201740
MEDICATION ASSISTED TREATMENTOpioids201741
ABSTINENCE SYNDROME 8-12 ion 12-14 hours§§§§§§§§IrritabilityPiloerection (“goose flesh”)Restless sleepWeaknessMydriasisTremorLoss of appetiteMuscle twitchingOpioids201742
ABSTINENCE SYNDROME 48-72 hours§§§§§§§Increased irritabilityIncreased heart rateInsomniaHypertensionLoss of AppetiteHot and cold flashesSneezing§ Alternating sweating andflushing§ Nausea and vomiting§ Piloerection§ Body temperature increases§ Rapid breathing§ Abdominal cramps§ Aching muscles§ Syndrome duration 7-10 daysOpioids201743
MAT - METHADONE Methadone§ Started to be used in 1964 as a response to post-World War IIheroin epidemic§ Reduces and/or eliminates the use of heroin§ Reduces the death rates and criminality associated with heroinuse§ Allows patients to improve health and social productivity§ Potential to reduce the transmission of infectious diseasesassociated with heroin IV use, like hepatitis and HIVOpioids201744
MAT - METHADONE How does it work?§§§§§§Oral effectivenessModerately long-lasting effectRelieve narcotic cravingSuppress the abstinence syndromeBlock the euphoric effects associated with heroinMajority of patients require 80-120 mg/d to achieve theseeffects and require treatment for indefinite amount of timeOpioids201745
MAT - BUPRENORPHINE Used as treatment over the last 10-15 years Developed for office-based treatment due to a lack ofOpioid Treatment Programs FDA approved use in 2002 after formal trials proved to besuccessful Office-based treatment does not guarantee the patient isreceiving counseling or drug testing Doctors are required to go through certification processto prescribe buprenorphineOpioids201746
MAT - BUPRENORPHINE In 2010 there was an increase in buprenorphine abuse Suboxone§ Buprenorphine with naloxone§ Prevents people from getting high by dissolving and injectingbuprenorphine tabletsOpioids201747
MAT - NALTREXONE VivitrolPrevent relapse to opioid dependence after detox.Taken once a month as an injectable.Must be opioid-free for a minimum of 7-14 days.§ Can cause severe withdrawal symptoms otherwise. Can be used to treat alcohol dependence. Must be used in conjunction with drug or alcoholrecovery programs. Can be prescribed by HCP.Opioids201748
MAT - NALOXONE Opioid Antagonist Rapidly reverses opioid overdose Three FDA-approved formulations§ Injectable: professional training required§ Autoinjectable: EVZIO¡¡¡www.evzio.comOnce activated device provides verbal instruction to userInjected into outer thigh2 doses supplied§ Nasal Spray: NARCAN¡¡¡No assembly requiredSpray into one nostril2 doses suppliedwww.narcan.comOpioids201749
MAT - NALOXONE Who can give naloxone?§ Injectable version is given by medical professional§ Depending on the state citizens may use the auto injector andnasal spray on someone who has overdosed§ Some states require a physician to prescribe naloxone§ In other states pharmacies can distribute naloxone tocommunity without a physician prescription§ Check the Prescription Drug Abuse Policy System for the lawsin your state¡http://www.pdaps.org/Opioids201750
CURRENT TRENDSOpioids201751
2017Opioids52
KROKODIL Desomorphine First recognized in Russia in 2002 Doctors noticed dark and scaly patches of skin on somedrug addicts Codeine derivative§ Mixed with chemicals such as paint thinners, hydrochloric acidand red phosphorus§ Murky yellow liquid with an acrid smell Mimics the effect of heroin at a fraction of the cost Blood vessels burst at injection site and flesh dies, fallingoff the bone in large chunksOpioids201753
KRATOM Mitragynine and 7-hydroxymitragynine§ Extract from tropical tree Mitragyna speciosa, native to SoutheastAsia§ Currently not scheduled¡¡¡DEA put a temporary ban in place Fall of 2016, which it liftedDEA asked public to comment on proposed ban, 99% opposed itDEA is currently waiting on FDA analysis on potential harms and healthbenefits§ At low doses produces stimulant effect¡Increased energy, sociability, alertness§ At high doses produces opioid effect¡Sedation, pleasure, decreased painOpioids201754
LOPERAMIDE ImodiumSchedule Vµ agonist in the myenteric plexus of the large intestineExcessive dosing (10 times higher than recommended)§ At high concentrations loperamide can cross the blood-brainbarrier§ Attempt to get high§ Treat opioid withdrawal symptoms§ Can fatally disrupt the heart’s rhythm Insufflation may be attemptedOpioids201755
PINK U-47700 Synthetic opioid§ First identified in 1978, Upjohn§ Scientific literature in the early 1980’s reported it behaved likemorphine in animal models§ No approved medical use§ Not approved for human consumption – FDA µ agonist Analgesic Potency 7.5 DEA temporary Schedule I ban November 2016§ 46 confirmed fatalities between October 2015-September 2016§ Temporary ban good for 24 months and can be extended foradditional 12 monthsOpioids201756
PINK Drug seizures have resulted in powder form andcounterfeit tablets that mimic pharmaceutical opioids Abuse often happens unknowingly Single substance or mixed with heroin or fentanyls Street Names: Pink, Pinky, U4 Sold online as research chemicalsOpioids201757
FENTANYL DERIVATIVES Carfentanil (Wildnil)§§§§§Schedule IIAnalgesic Potency 10,000Intended for large-animal use“Heroin laced with elephant tranquilizers”DEA Issues public warning in September 2016¡¡¡2 mg could be lethalPowder, blotter paper, tablets, sprayCan be absorbed through skin or inhaled Sufentanil§ Analgesic Potency 500-1000§ Schedule IIOpioids201758
DEA WARNINGS July 2016§ Counterfeit Prescription Pills Containing Fentanyls: A GlobalThreat October 2016§ DEA warns public that drug cartels are selling lethal doses offentanyl disguised as street heroin and counterfeit OxyContinpills Officer Safety Alert – Carfentanil: A Dangerous NewFactor in the U.S. Opioid Crisis§ YouTube – DEA Warns of Fentanyl RiskOpioids201759
DEA WARNS OF FENTANYL RISKOpioids201760
DRUG TESTING FOR OPIOIDSOpioids201761
SCREENING TESTLooking neHerointest)MethadoneBuprenorphine (Suboxone)TramadolTest ForOpiatesOxycodoneHeroin 62
GCMS INTERPRETATIONPrescription/DrugOpiateParent Drug/MetaboliteHeroinDiacetylmorphine6-MAM, Morphine, CodeineTylenol #3, #4CodeineCodeine, MorphineMS Contin,RoxanolMorphineMorphine, HydromorphoneVicodin, Vicoprofen,Tussionex, H-CTussiveHydrocodoneHydrocodone, contin, Percodan,Percoset, RoxicetOxycodoneOxycodone, 3
12 LAWS 1890: U.S. Congress, in its earliest law-enforcement legislation on narcotics, imposes a tax on opium and morphine. 1905: U.S. Congress bans opium. 1909: The first federal drug prohibition passes in the U.S. outlawing the importation of opium. 1914: The passage of Harrison Narcotics Act which aims to curb drug abuse and
Opioid Overdose Deaths by Drug Type In 2019, synthetic opioids were involved in the greatest proportion of opioid overdose deaths. Type of Opioid Number of Deaths Commonly-prescribed opioids* 143 Heroin 106 Synthetic opioids 309 Note: overdose deaths may involve more than one drug. They also include unintentional
Tennessee –Principles to Initiating Opioids Opioids used for acute pain severe enough to require opioids - 3 days or less often sufficient; more than 7 days in some instances is appropriate –need to be documented in medical record PCP starting opioids for chronic pain should generally prescribe immediate-release at
01 17-19 YEAR OLDS Session 1: Getting to know each other and getting to know yourself Session 2: Social and gender norms Session 3: Responsibility, choices and consent Session 4: Romantic relationships Session 5: Gender and human rights Session 6: Conception and contraception Session 7: Early and unintended pregnancy Session 8: Sexual health, STIs and HIV Session 9: Talking online
Mind Matters is a series that explores the ways that different drugs affect your brain, body, and life. In this issue we are going to talk about opioids. You may have heard a lot about opioids lately. It’s possible you know them as . . opioid c
Taking Opioids Responsibly Because opioid medications can be dangerous, your provider can only prescribe them safely if you follow these “DO’s and DON’Ts” for taking opioids responsibly. 1. DO take your opioid and non-opioid pain medicines as prescribed. Make sure
challenges linking patients who request opioids prescrip-tions to a FP [10], little is known about the association between requiring opioids and acceptance as a new patient into family practice. Opioid management by family physicians The current opioid crisis has grown in Canada over the past several decades, and there were nearly 4000 opioid
Outline (cont.): Session 9: Animal Abuse and Substance Abuse Session 10: Effects of Animal Abuse on Children Session 11: Family Hierarchy Session 12: Infallibility Fallacy Session 13: Anger Control Session 14: Animal Abuse and Self Talk Session 15: Stress Management Session 16: Communication Skills
One individual midterm case report due session 9. Class Reflection Journal: Do each session . on previous session’s case/s and discussion. Put it all together , broken by session, and post as ONE word document before last class session. No need for journal write up on content of midterm case session and the last session. One take-home final .
