Opioid agonist therapy

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Opioid agonist therapy (OAT) is a treatment in which prescribed opioid agonists are given to patients who live with Opioid use disorder (OUD). [1] In the case of methadone maintenance treatment (MMT), methadone is used to treat dependence on heroin or other opioids, and is administered on an ongoing basis. [2]

Contents

The benefits of this treatment include a more manageable withdrawal experience, cognitive improvement, and lower HIV transmission. [3] The length of OAT varies from one individual to another based on their physiology, environmental surroundings, and quality of life. [3]

The term medication for Opioid Use Disorder (MOUD) is used to describe medication including methadone and buprenorphine, which are used to treat patients with OUD. [4] [5]

Terminology

Other terms that appear in the professional and popular literature include opioid replacement therapy, medication-assisted treatment (MAT) and medications for opioid use disorder (MOUD).

Biological understanding

An opioid is considered a ligand, which is an ion or a molecule. An opioid ligand travels to the brain and attaches itself to an opioid receptor, which begins the effects of opioids. [3]  The mesolimbic system, which is the biological system that moderates the feeling of reward generated by dopamine, is the main system that is effected by opioids. [6] Opioids stimulate the mesolimbic system to release a large amount of dopamine in the brain, which increases the effects of opioids: euphoria and numbness. [6] The difference between an opioid and an opioid agonist is that opioids induce more intense effects and stay in the brain for a short amount of time. [3]  Conversely, an opioid agonist induces minimal effects and stays in the brain for a long time, which prevents the opioid user from feeling the effects of natural or synthetic opioids. [3]  However, the opioid receptors are still being used when an opioid agonist attaches, which prevents the effects of opioid withdrawal and can help prevent relapse. [3] The two most common opioid agonists are methadone and buprenorphine. [3]

Methadone

Methadone is an opioid agonist that binds to the same receptors in the brain as heroin and other opioids. Introduced as an analgesic in the US in 1947, methadone has been used in maintenance treatment—also known as substitution treatment, or drug replacement therapy—since 1964. [7] [8] Methadone treatments usually last for multiple years, although they can last for decades. [8] A dose of methadone often minimizes the effects of withdrawal for approximately 24 hours and the lowest optimal dose is 60 mg. [8] Methadone functions via competitive antagonism; while the prescribed agonist is in the opioid user's body, the use of illicit opioids (illicit heroin or fentanyl) will not produce the effects of illicit opioids. [8] Methadone has a slower onset than illicit opioids and it produces less effects than illicit opioids. [8] Side effects of methadone may include "constipation, weight gain, reduced libido, and irregular menses". [8] (p. 467)

Methadone maintenance reduces the cravings for other opioids, and reduces the risk of fatal overdose from street drugs since the purity and strength of methadone is known, whereas substances obtained from the street vary significantly in strength and purity. [2] [9]

Therapeutic dosing is contingent upon individual patient needs, with a dosage range generally between 20 and 200 mg. Doses are unsafe for opioid-naive individuals, and administration of methadone is gradually increased to reach a therapeutic dose under medical supervision to reduce the risk of overdose. [10] [11] The amount of oral methadone a patient will require is dependent on the amount and power of opioids they consumed prior to initiating treatment, with an assessment in the mid-2000s (prior to the widespread introduction of fentanyl into street heroin supplies in the US) finding that 1 gram of street heroin is roughly equivalent to 50 to 80 mg of methadone. [12] Methadone is taken either orally as a mixture of 1 mg/1ml supplied as a red or clear liquid, or as a mixture containing 10 mg of methadone in 1ml of liquid (green color) or 20 mg in 1ml of liquid (brown color). The latter is often used when a person is on a large amount of methadone, and is rarely permitted for unsupervised consumption. Since the formulations are not as viscous as the 1 mg/1ml mixture, they are more prone to misuse since they are easier to inject, and due to the high risk of overdose if diverted to an individual not accustomed to such a large dose. Methadone also comes in 40 mg dispersible tablets called "diskettes", as well as 5 and 10 mg pills that are round or "coffin" shaped. These pills are only given in hospital settings. Methadone can also be delivered by either IV or IM injection, as well as ampoules which come in various strengths ranging from 10 mg up to 50 mg. This method is often used for individuals who have a "needle fixation" and who would otherwise revert to using IV heroin. [12]

With the emergence of other medications for the treatment of opioid addiction such as buprenorphine and long-acting naltrexone, MMT is no longer the dominant medically assisted addiction treatment. [13]

Methadone maintenance has been termed "a first step toward social rehabilitation" because it increases the retention of patients in treatment, relieves them from the need to find, buy, and use multiple daily doses of street opioids, and offers a legal medical alternative. [14] Methadone is one of the most researched treatments for opioid use disorder and has significant research support for its efficacy. [15] [16] [17]

Dispensing

Methadone maintenance generally requires patients to visit the dispensing or dosing clinic daily, in accordance with state-controlled substance laws. Methadone, when administered at constant daily milligram doses, will stabilize patients so they feel a "high" from it and will not require additional street opioids. Most clinics will work with patients to get to a dosing level that will take away all cravings for other opiates without feeling too much of a "high" so they can function correctly throughout their day. [7]

In the U.S., patients that attend methadone clinics regularly and abstain from the use of street opioids or other controlled substances can be permitted to take home doses known as privileges, though this is at the discretion of the clinic's medical staff. Depending on the state's law, some clinics will allow the use of drugs like cannabis and still permit take home doses. [12] Some states allow methadone clinics to close on Sundays and provide take-home medication the day before. Clinics that offer take-home privileges will usually do so by slowly offering more take-home days over a period of time, as long as their standards of clean drug tests are met. In some states, these take-home privileges can work their way to people getting take-home doses that would last them 2–4 weeks maximum. Another way take-homes are permitted is if the clinic puts the patient on a split dose schedule where they take part of their dose in the morning and take home a dose to take later in the day. This is usually given out to people on higher doses, or to help lengthen effectiveness throughout the day. States may mandate drug testing in clinic drug abuse groups and/or outside Narcotics Anonymous meetings. In other countries, dispensing of methadone maintenance by pharmacies, or via prescription from general practitioners rather than specialized clinics, is permitted. [18]

Travel

In the UK, patients on methadone maintenance who wish to travel overseas are subject to certain legal requirements surrounding the exportation and importation of methadone. The prescriber must be provided with details of travel, after which the they will arrange for a Home Office Export License to be provided. This license is only required if the total amount being exported exceeds 500 mg. Granting of the license does not allow for the importation of methadone into any overseas jurisdiction. For importation, the patient should contact the embassy of their destination country and request permission to import methadone onto their shores, although not all countries allow the importation of controlled drugs. The license also allows for the re-importation of any remaining methadone back into the UK. It is normal for patients traveling overseas to be prescribed methadone in a tablet form, as tablets are easier to transport. For patients who expect to be overseas for a prolonged period of time, "courtesy" arrangements can be made at a local clinic which arrange for the prescription of the necessary medication. [12] If traveling throughout the United States, state or city clinics may offer "take home" doses for the period of time patients will be gone. Depending on length of travel or clinic rules, they may opt to have your "courtesy" dose at another clinic that is closer to where they are travelling.

Buprenorphine

Buprenorphine was approved by the United States Food and Drug Administration (FDA) in 2002. [8] The lowest optimal dose of buprenorphine is 8 mg. [8] Buprenorphine has fewer withdrawal symptoms upon discontinuation, lower risk for overdose, and lower potential for abuse; therefore, it is more effective for unsupervised treatment than methadone. [8] Opioid users can take fewer doses per week than methadone. [8] Side effects of buprenorphine may include constipation and disordered sleep. [8]

The manufacturers of naltrexone have marketed it as superior because it is not an opioid. This argument has moved criminal justice officials to prefer the medicine, and has triggered a Congressional investigation about mismarketing. [19] No study has found naltrexone to be superior to methadone or buprenorphine, and a real-world review of patient records suggests that methadone and buprenorphine are superior at reducing overdose risk or the need for acute drug dependence treatment. [20]

Opioid withdrawal

When the body goes through withdrawal, the opioid receptors in the brain are not filled with an adequate amount of opioids, which means that the feelings of euphoria associated with opioids are not felt. [6]  Withdrawal only happens when the body has become accustomed to having opioids in the receptors, which changes the structure and functioning of the brain. [6]  Thus, without opioids, the brain functions differently in comparison to the brain before the user started becoming dependent on opioids. [6]  People who have a dependence on opioids are the only people who experience withdrawal symptoms. [6]

Opioids are commonly prescribed to alleviate symptoms of chronic pain. However, misuse of this pain-killer impacts millions of people worldwide each year. According to WHO, approximately 115,000 people died of opioid overdose in 2017. [21] Addiction is widespread among users and can typically be seen through symptoms such as intense cravings, rejection of previously enjoyed activities, and struggling to fulfill responsibilities due to opioid use. [22] OAT is one suggested treatment for opioid misuse because it is commonly reported to minimize the likelihood of experiencing psychological and physiological symptoms associated with withdrawal (i.e., diarrhea, body pain, vomiting, profound insomnia, sweating, anxiety and depression) and alleviate the intensity of most withdrawal symptoms. [23]

Psychological understanding

There are numerous psychological variables that hold the capacity to influence the effectiveness of opioid agonist therapy (OAT), as explained in Daniel Michael Doleys's 2017 narrative review. [23] Four of these variables include likelihood of opioid withdrawal, conditioning and learning factors, patient-specific factors, and social variables.

Conditioning and learning

A second psychological factor that can influence the effectiveness of OAT is conditioning and learning. [23] The activity and functioning of opioids are influenced by numerous principles of conditioning and learning such as environmental cues and associations. [23]

Patient-specific factors and social variables

Patient-specific factors such as mood, and overall psychological and neurocognitive status also hold the capacity to influence the effectiveness of OAT. [23] Certain patient characteristics, such as distress intolerance, can result in increased opioid misuse to obtain relief from one's chronic pain. [23] The social environment that the opioid user lives and uses in can also alter the effectiveness of the treatment. [23] A stable positive psychosocial environment aids in the effectiveness of OAT, whereas a negative psychosocial environment can make the effects of OAT difficult for the opioid user. [23] OAT is most effective if the opioid user is compliant and the treatment is consistent. Counseling opportunities are also very helpful with regard to OAT's rehabilitation efforts.

Barriers to access

Stigma

Addiction is highly stigmatized, even in the medical field. [24] Being stigmatized correlates to a decline in an individual's physical and mental health. Thus, stigmatization is a prohibitive factor for addicts who may attempt to seek treatment. [24] Even though opioid agonist therapy (OAT) has been proven to be an effective treatment for Opioid Use Disorder, very few American doctors have undertaken the necessary education and certification to provide the treatment. [24] Most treatment facilities, such as rehabilitation or sobering centers, do not offer OAT, nor do they accept patients who are already receiving Opioid Agonist Therapy. [24]

Due to risks associated with intravenous drug use, such as infections and blood borne illnesses, access to post-acute care is critical. [24] While patients who do not use intravenous drugs may receive post-acute care at home, "healthcare facilities and infusion companies may not allow people with a history of [injection drug use] to have home intravenous antibiotic therapy because of concern that an indwelling intravenous catheter could be used to inject illicit drugs". [24] (p. 17) Moreover, American post-acute care programs rarely accept patients who are receiving OAT. [24]

In the United States, protection from discrimination under the Americans with Disabilities Act (ADA) are more vague for addicts than they are for those living with other disabilities. [24] Active drug users are not protected by the ADA. Only individuals who are in recovery and not actively using drugs qualify for protection. [24] However, individuals receiving OAT are considered to have a disability and are subsequently protected by American law. [24]

Advocates identify the bureaucratic red tape surrounding the prescription and administration of opioid agonists as potential obstructions to fair accessible medical care. [24] Potential solutions include federal incentive or requirement for doctors to be trained to prescribe agonists. Another solution is the amendment of the 2000 Drug Abuse Act, which would remove the requirement of special certification altogether. [24]

Rahul Gupta, director of the White House Office of National Drug Control Policy, identified stigma among doctors as a barrier that patients with OUD. [25]

Similarly, in Canada, research has shown that access to OAT remains low. [26] Despite increasing rates of opioid overdoses, only 1 in 18 people were offered a prescription for OAT within one week of discharge from the emergency department or hospital after an opioid overdose. [26] Older people, people with mental illness, and people living in lower socioeconomic areas were less likely to be started on OAT after an overdose. [26] Despite the benefits of OAT in reducing morbidity and mortality, OAT initiation rates remain low and reveal the missed opportunities to initiate treatment.

Overdose

Higher doses of methadone may cause respiratory depression and/or euphoria in some patients. [27]

Controversy

Methadone maintenance is also known as drug replacement therapy or opiate replacement therapy (ORT), and has been the subject of much controversy since its inception. [28] [13] Opponents note that methadone prescription replaces dependence on one opioid with another, that methadone maintenance does not prevent additional use of heroin or other opioids in addition to methadone, and that the stabilization or "blocking" effect on euphoria can be overridden with the use of other opioids or with benzodiazepines. [29]

In England and Wales, criminal justice drugs workers employed by the 'Drug Interventions Programme' are based in most arrest suites nationwide. Heroin and crack cocaine users are identified either by mandatory urine tests, or by cell sweeps and face-to-face discussions with arrestees. Identified drug use will often trigger a referral to local drug services, whose first-line response to heroin dependence is likely to involve substitute (buprenorphine or methadone) prescribing.

This line of work originated in the mid to late 1990s, as large-scale studies identified significant levels of heroin and crack cocaine use in populations of arrestees. In a large-scale study of drug misuse in arrested populations, 466 'drug misusing repeat offenders' were identified. Of these, 80% declared an 'unmet need for treatment'. [30]

Contemporaneously, the National Treatment Outcomes Research Study (NTORS) found high levels of money-related offenses in populations of people seeking community treatment for drug problems. In a NTORS report, researches found that every £1 spent on drug treatment could yield between £9.50 and £18 of savings in social costs, mostly attributable to reductions in treatment seekers' levels of offenses. [31]

These studies, along with others, [32] [33] [34] were taken on by Tony Blair whilst still Shadow Home Secretary, as Conservative policy regarding drug misuse was relatively undeveloped. Blair disseminated a press release in 1994 entitled 'Drugs: the Need for Action', claiming that drug misuse caused £20bn of money-related crimes each year. This report was dismissed by the Conservative Secretary of State for the Home Department as 'four pages of hot waffle against the Government, with three miserable paragraphs at the end'.

After winning the UK general election of 1997, Blair's first cross-governmental drug strategy established the nationwide development of an integrated drugs and crime strategy as a priority. Drugs workers were in police custody suites nationwide, and saw 50,000 people in 2001. [35] The work of these teams was then formalised in 2003, given an expanded remit (working with prisoners following release, for example), and rebadged the Drug Interventions Programme (DIP).

The founding strapline for DIP was 'out of crime, into treatment', reflecting the crime-reduction philosophy behind criminal justice drug treatment and ongoing methadone (or buprenorphine) maintenance at that time. In their 2010 Drug Strategy, the Conservative/Liberal Democrat coalition stated their continued intention to support DIP.

See also

Related Research Articles

<span class="mw-page-title-main">Methadone</span> Opioid medication

Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid agonist used for chronic pain and also for opioid use disorder. It is used to treat chronic pain, and it is also used to treat addiction to heroin or other opioids. Prescribed for daily use, the medicine relieves cravings and removes withdrawal symptoms. Withdrawal management using methadone can be accomplished in less than a month, or it may be done gradually over a longer period of time, or simply maintained for the rest of the patient's life. While a single dose has a rapid effect, maximum effect can take up to five days of use. After long-term use, in people with normal liver function, effects last 8 to 36 hours. Methadone is usually taken by mouth and rarely by injection into a muscle or vein.

<span class="mw-page-title-main">Harm reduction</span> Public health policies which lessen negative aspects of problematic activities

Harm reduction, or harm minimization, refers to a range of intentional practices and public health policies designed to lessen the negative social and/or physical consequences associated with various human behaviors, both legal and illegal. Harm reduction is used to decrease negative consequences of recreational drug use and sexual activity without requiring abstinence, recognizing that those unable or unwilling to stop can still make positive change to protect themselves and others.

<span class="mw-page-title-main">Opioid</span> Psychoactive chemical

Opioids are a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant. Opioids work in the brain to produce a variety of effects, including pain relief. As a class of substances, they act on opioid receptors to produce morphine-like effects.

<span class="mw-page-title-main">Opioid use disorder</span> Medical condition

Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Opioid withdrawal symptoms include nausea, muscle aches, diarrhea, trouble sleeping, agitation, and a low mood. Addiction and dependence are important components of opioid use disorder.

<span class="mw-page-title-main">Buprenorphine</span> Opioid used to treat pain & opioid use disorder

Buprenorphine, sold under the brand name Subutex among others, is an opioid used to treat opioid use disorder, acute pain, and chronic pain. It can be used under the tongue (sublingual), in the cheek (buccal), by injection, as a skin patch (transdermal), or as an implant. For opioid use disorder, the patient must have moderate opioid withdrawal symptoms before buprenorphine can be administered under direct observation of a health-care provider.

<span class="mw-page-title-main">Naltrexone</span> Medication

Naltrexone, sold under the brand name Revia among others, is a medication primarily used to manage alcohol use or opioid use disorder by reducing cravings and feelings of euphoria associated with substance use disorder. It has also been found effective in the treatment of other addictions and may be used for them off-label. An opioid-dependent person should not receive naltrexone before detoxification. It is taken by mouth or by injection into a muscle. Effects begin within 30 minutes, though a decreased desire for opioids may take a few weeks to occur. Side effects may include trouble sleeping, anxiety, nausea, and headaches. In those still on opioids, opioid withdrawal may occur. Use is not recommended in people with liver failure. It is unclear if use is safe during pregnancy. Naltrexone is an opioid antagonist and works by blocking the effects of opioids, including both opioid drugs as well as opioids naturally produced in the brain.

Physical dependence is a physical condition caused by chronic use of a tolerance-forming drug, in which abrupt or gradual drug withdrawal causes unpleasant physical symptoms. Physical dependence can develop from low-dose therapeutic use of certain medications such as benzodiazepines, opioids, stimulants, antiepileptics and antidepressants, as well as the recreational misuse of drugs such as alcohol, opioids and benzodiazepines. The higher the dose used, the greater the duration of use, and the earlier age use began are predictive of worsened physical dependence and thus more severe withdrawal syndromes. Acute withdrawal syndromes can last days, weeks or months. Protracted withdrawal syndrome, also known as post-acute-withdrawal syndrome or "PAWS", is a low-grade continuation of some of the symptoms of acute withdrawal, typically in a remitting-relapsing pattern, often resulting in relapse and prolonged disability of a degree to preclude the possibility of lawful employment. Protracted withdrawal syndrome can last for months, years, or depending on individual factors, indefinitely. Protracted withdrawal syndrome is noted to be most often caused by benzodiazepines. To dispel the popular misassociation with addiction, physical dependence to medications is sometimes compared to dependence on insulin by persons with diabetes.

Substance dependence, also known as drug dependence, is a biopsychological situation whereby an individual's functionality is dependent on the necessitated re-consumption of a psychoactive substance because of an adaptive state that has developed within the individual from psychoactive substance consumption that results in the experience of withdrawal and that necessitates the re-consumption of the drug. A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioral and drug addictions, but not dependence.

A methadone clinic is a medical facility where medications for opioid use disorder (MOUD) are dispensed-—historically and most commonly methadone, although buprenorphine is also increasingly prescribed. Medically assisted drug therapy treatment is indicated in patients who are opioid-dependent or have a history of opioid dependence. Methadone is a schedule II (USA) opioid analgesic, that is also prescribed for pain management. It is a long-acting opioid that can delay the opioid withdrawal symptoms that patients experience from taking short-acting opioids, like heroin, and allow time for withdrawal management. In the United States, by law, patients must receive methadone under the supervision of a physician, and dispensed through an Opioid Treatment Program (OTP) certified by the Substance Abuse and Mental Health Services Administration and registered with the Drug Enforcement Administration.

<span class="mw-page-title-main">Opioid antagonist</span> Receptor agonist that acts on one or more of the opioid receptors

An opioid antagonist, or opioid receptor antagonist, is a receptor antagonist that acts on one or more of the opioid receptors.

<span class="mw-page-title-main">Lofexidine</span> Medication used for opioid withdrawal

Lofexidine, sold under the brand name Lucemyra among others, is a medication historically used to treat high blood pressure; today, it is more commonly used to help with the physical symptoms of opioid withdrawal. It is taken by mouth. It is an α2A adrenergic receptor agonist. It was approved for use by the Food and Drug Administration in the United States in 2018.

Drug detoxification is variously construed or interpreted as a type of "medical" intervention or technique in regards to a physical dependence mediated by a drug; as well as the process and experience of a withdrawal syndrome or any of the treatments for acute drug overdose (toxidrome). The first definition however, in relation to substance dependence and its treatment is arguably a misnomer and even directly contradictory since withdrawal is neither contingent upon nor alleviated through biological excretion or clearance of the drug. In fact, excretion of a given drug from the body is one of the very processes that leads to withdrawal since the syndrome arises largely due to the cessation itself and the drug being absent from the body; especially the blood plasma, not from ‘leftover toxins’ or traces of the drug still being in the system.

<span class="mw-page-title-main">Opioid overdose</span> Toxicity due to excessive consumption of opioids

An opioid overdose is toxicity due to excessive consumption of opioids, such as morphine, codeine, heroin, fentanyl, tramadol, and methadone. This preventable pathology can be fatal if it leads to respiratory depression, a lethal condition that can cause hypoxia from slow and shallow breathing. Other symptoms include small pupils and unconsciousness; however, its onset can depend on the method of ingestion, the dosage and individual risk factors. Although there were over 110,000 deaths in 2017 due to opioids, individuals who survived also faced adverse complications, including permanent brain damage.

Heroin-assisted treatment (HAT), or diamorphine-assisted treatment, refers to a type of Medication-Assisted Treatment (MAT) where semi-synthetic heroin is prescribed to opiate addicts who do not benefit from, or cannot tolerate, treatment with one of the established drugs used in opiate replacement therapy such as methadone or buprenorphine. For this group of patients, heroin-assisted treatment has proven superior in improving their social and health situation. Heroin-assisted treatment is fully a part of the national health system in Switzerland, Germany, the Netherlands, Canada, and Denmark. Additional trials are being carried out in the United Kingdom, Norway, and Belgium.

<span class="mw-page-title-main">Opiate</span> Substance derived from opium

An opiate is an alkaloid substance derived from opium. It differs from the similar term opioid in that the latter is used to designate all substances, both natural and synthetic, that bind to opioid receptors in the brain. Opiates are alkaloid compounds naturally found in the opium poppy plant Papaver somniferum. The psychoactive compounds found in the opium plant include morphine, codeine, and thebaine. Opiates have long been used for a variety of medical conditions, with evidence of opiate trade and use for pain relief as early as the eighth century AD. Most opiates are considered drugs with moderate to high abuse potential and are listed on various "Substance-Control Schedules" under the Uniform Controlled Substances Act of the United States of America.

<span class="mw-page-title-main">Buprenorphine/naloxone</span> Opioid treatment

Buprenorphine/naloxone, sold under the brand name Suboxone among others, is a fixed-dose combination medication that includes buprenorphine and naloxone. It is used to treat opioid use disorder, and reduces the mortality of opioid use disorder by 50%. It relieves cravings to use and withdrawal symptoms. Buprenorphine/­naloxone is available for use in two different forms, under the tongue or in the cheek.

<span class="mw-page-title-main">Opioid epidemic in the United States</span> Ongoing overuse of opioid medication in the US

There is an ongoing opioid epidemic in the United States, originating out of both medical prescriptions and illegal sources. The epidemic began in the United States in the late 1990s, according to the Centers for Disease Control and Prevention (CDC), when opioids were increasingly prescribed for pain management, resulting in a rise in overall opioid use throughout subsequent years.

Clinical Opiate Withdrawal Scale (COWS) is a method used by registered practitioners to measure the severity of a patient's opioid withdrawal symptoms. This method consists of a series of 11 topics each comprising 4 - 5 common symptoms experienced by a patient undergoing opioid withdrawal. In each topic a rank is given depending on what the patient responds to. Generally, 0 is considered to be no symptom shown and 4 or 5 is considered to be the most common and severe symptom shown. These results are then added up and a final diagnosis is made based on the value obtained. This test is crucial as it allows the practitioner to assess the physiological and psychological behaviours of the patient as well as the severity of each symptom during the duration of the examination. The results are grouped into 3 categories of mild, moderately severe and severe. Mild consists of 5 to 12 points, moderately severe consists of 13 to 24 points and anything above 36 points is severe and requires direct medical attention.

<span class="mw-page-title-main">Opioid withdrawal</span> Withdrawal symptoms of opiates

Opioid withdrawal is a set of symptoms arising from the sudden withdrawal or reduction of opioids where previous usage has been heavy and prolonged. Signs and symptoms of withdrawal can include drug craving, anxiety, restless legs, nausea, vomiting, diarrhea, sweating, and an increased heart rate. Opioid use triggers a rapid adaptation in cellular signalling pathways that means, when rapidly withdrawn, there can be adverse physiological effects. All opioids, both recreational drugs and medications, when reduced or stopped, can lead to opioid withdrawal symptoms. When withdrawal symptoms are due to recreational opioid use, the term opioid use disorder is used, whereas when due to prescribed medications, the term prescription opioid use disorder is used. Opioid withdrawal can be helped by the use of opioid replacement therapy, and symptoms may be relieved by the use of medications including lofexidine and clonidine.

<span class="mw-page-title-main">Prescription drug addiction</span> Medical condition

Prescription drug addiction is the chronic, repeated use of a prescription drug in ways other than prescribed for, including using someone else’s prescription. A prescription drug is a pharmaceutical drug that may not be dispensed without a legal medical prescription. Drugs in this category are supervised due to their potential for misuse and substance use disorder. The classes of medications most commonly abused are opioids, central nervous system (CNS) depressants and central nervous stimulants. In particular, prescription opioid is most commonly abused in the form of prescription analgesics.

References

  1. "Opioid Agonist Therapy" (PDF). Center for Addiction and Mental Health (CAMH). 2016. Retrieved 2021-02-02.
  2. 1 2 "Clinical guidelines and procedures for the use of methadone in the maintenance treatment of opioid dependence", Pharmacotherapies for the Treatment of Opioid Dependence, CRC Press, pp. 370–405, 2009-03-25, doi:10.3109/9780203414088-14, ISBN   978-0-429-23119-3 , retrieved 2023-04-10
  3. 1 2 3 4 5 6 7 Making the Choice, Making It Work: Treatment for Opioid Addiction. Toronto, Canada: Center for Addiction and Mental Health (CAMH). 2016. p. 19. ISBN   978-1-77114-357-8.
  4. Miele K, Kim SY, Jones R, Rembert JH, Wachman EM, Shrestha H, Henninger ML, Kimes TM, Schneider PD, Sivaloganathan V, Sward KA, Deshmukh VG, Sanjuan PM, Maxwell JR, Seligman NS, Caveglia S, Louis JM, Wright T, Bennett CC, Green C, George N, Gosdin L, Tran EL, Meaney-Delman D, Gilboa SM (2023). "Medication for Opioid Use Disorder During Pregnancy — Maternal and Infant Network to Understand Outcomes Associated with Use of Medication for Opioid Use Disorder During Pregnancy (MAT-LINK), 2014–2021". Surveillance Summaries. Morbidity and Mortality Weekly Report . 72 (3): 1–14. doi: 10.15585/mmwr.ss7203a1 . ISSN   1546-0738. PMC   10154076 . PMID   37130060.
  5. Archibald, Luke (20 December 2022). "Telemedicine for opioid addiction saves lives. Let's make sure it continues". Washington, D.C. (United States): AAMC . Retrieved 18 January 2024.
  6. 1 2 3 4 5 6 Kosten TR, George TP (July 2002). "The neurobiology of opioid dependence: implications for treatment". Science & Practice Perspectives. 1 (1): 13–20. doi:10.1151/spp021113. PMC   2851054 . PMID   18567959.
  7. 1 2 DOLE, VINCENT P.; NYSWANDER, MARIE E.; KREEK, MARY JEANNE (1966-10-01). "Narcotic Blockade". Archives of Internal Medicine. 118 (4): 304–309. doi:10.1001/archinte.1966.00290160004002. ISSN   0003-9926. PMID   4162686.
  8. 1 2 3 4 5 6 7 8 9 10 11 Berglund M, Thelander S, Jonsson E, eds. (2003). Treating Alcohol and Drug Abuse: An Evidence Based Review. Hoboken, New Jersey, United States: John Wiley & Sons. ISBN   978-3-527-30682-4.
  9. Volkow, Nora D.; Wargo, Eric M. (2018-08-07). "Overdose Prevention Through Medical Treatment of Opioid Use Disorders". Annals of Internal Medicine. 169 (3): 190–192. doi:10.7326/M18-1397. ISSN   0003-4819. PMID   29913514. S2CID   49300767.
  10. Baxter, Louis E. Sr; Campbell, Anthony; DeShields, Michael; Levounis, Petros; Martin, Judith A.; McNicholas, Laura; Payte, J. Thomas; Salsitz, Edwin A.; Taylor, Trusandra; Wilford, Bonnie B. (November–December 2013). "Safe Methadone Induction and Stabilization: Report of an Expert Panel". Journal of Addiction Medicine. 7 (6): 377–386. doi:10.1097/01.ADM.0000435321.39251.d7. ISSN   1932-0620. PMID   24189172. S2CID   44251671.
  11. Sordo, Luis; Barrio, Gregorio; Bravo, Maria J.; Indave, B. Iciar; Degenhardt, Louisa; Wiessing, Lucas; Ferri, Marica; Pastor-Barriuso, Roberto (2017-04-26). "Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies". BMJ. 357: j1550. doi:10.1136/bmj.j1550. ISSN   0959-8138. PMC   5421454 . PMID   28446428.
  12. 1 2 3 4 http--www.rcgp.org.uk-PDF-drug_meth%20guidance.pdf
  13. 1 2 California Alcohol and Drug Programs. "Narcotic Treatment Programs". FAQ's Re: Licensing (Online Website). CA.gov. Retrieved 17 June 2012.
  14. Anderson, Ilene B; Kearney, Thomas E (January 2000). "Use of methadone". Western Journal of Medicine. 172 (1): 43–46. doi:10.1136/ewjm.172.1.43. ISSN   0093-0415. PMC   1070723 . PMID   10695444.
  15. Kuehn, B. M. (2005-08-24). "Methadone Treatment Marks 40 Years". JAMA: The Journal of the American Medical Association. 294 (8): 887–889. doi:10.1001/jama.294.8.887. ISSN   0098-7484. PMID   16118372.
  16. "Management of Narcotic-Drug Dependence by High-Dosage Methadone HC1 Technique". JAMA. 201 (12): 956. 1967-09-18. doi:10.1001/jama.1967.03130120064016. ISSN   0098-7484.
  17. Axel Johansson, Björn; Berglund, Mats; Lindgren, Anna (January 2007). "Efficacy of maintenance treatment with methadone for opioid dependence: A meta-analytical study". Nordic Journal of Psychiatry. 61 (4): 288–295. doi:10.1080/08039480701415251. ISSN   0803-9488. PMID   17763122. S2CID   9230037.
  18. International Harm Reduction Development Program (2010). Lowering the Threshold: Models of Accessible Methadone and Buprenorphine Treatment (PDF). New York: Open Society Foundations.
  19. Wolfe, Daniel; Saucier, Roxanne (2021-02-01). "Biotechnologies and the future of opioid addiction treatments". International Journal of Drug Policy. 88: 103041. doi:10.1016/j.drugpo.2020.103041. ISSN   0955-3959. PMID   33246267. S2CID   227191111.
  20. Wakeman, Sarah E.; Larochelle, Marc R.; Ameli, Omid; Chaisson, Christine E.; McPheeters, Jeffrey Thomas; Crown, William H.; Azocar, Francisca; Sanghavi, Darshak M. (2020-02-05). "Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder". JAMA Network Open. 3 (2): e1920622. doi: 10.1001/jamanetworkopen.2019.20622 . ISSN   2574-3805. PMID   32022884. S2CID   211035316.
  21. "Opioid overdose". www.who.int. Retrieved 2021-02-20.
  22. "20118 Opioid Addiction". Center for Addiction and Mental Health. Retrieved 2021-02-20.
  23. 1 2 3 4 5 6 7 8 Doleys DM (November 2017). "Philosophical Issues and Psychological Variables that Influence the Determination of Opioid Effectiveness: A Narrative Review". Pain Physician. 20 (7): E1091–E1105. PMID   29149154.
  24. 1 2 3 4 5 6 7 8 9 10 11 12 Wakeman SE, Rich JD (January 2017). "Barriers to Post-Acute Care for Patients on Opioid Agonist Therapy; An Example of Systematic Stigmatization of Addiction". Journal of General Internal Medicine. 32 (1): 17–19. doi:10.1007/s11606-016-3799-7. PMC   5215148 . PMID   27393486.
  25. Facher, Lev (2022-09-02). "Rahul Gupta, first physician to serve as drug czar, says stigma among doctors is key culprit in addiction crisis". STAT. Retrieved 2023-07-06.
  26. 1 2 3 Hu T, McCormack D, Juurlink D, Campbell TJ, Bayoumi AM, Leece P, Kent JT, Gomes T (December 2023). "Initiation of opioid agonist therapy after hospital visits for opioid poisonings in Ontario". CMAJ. 195 (49): E1709–E1717. doi:10.1503/cmaj.231014. PMC   10727793 . PMID   38110219.
  27. Wang, Shaocheng (2018-11-13). "Historical Review: Opiate Addiction and Opioid Receptors". Cell Transplantation. 28 (3): 233–238. doi:10.1177/0963689718811060. ISSN   0963-6897. PMC   6425114 . PMID   30419763.
  28. Schwartz, Harvey (April 7, 1973). "County methadone clinic controversy continues" (PDF). The New York Daily Press. Retrieved 12 June 2012.
  29. Ausubel, David P. (1983-01-01). "Methadone Maintenance Treatment: The Other Side of the Coin". International Journal of the Addictions. 18 (6): 851–862. doi:10.3109/10826088309033052. ISSN   0020-773X. PMID   6629582.
  30. Katy Holloway; Trevor Bennett (2004). The results of the first two years of the NEW-ADAM programme (PDF). Home Office. ISBN   978-1-84473-258-6. Archived from the original (PDF) on 2009-12-07.
  31. Godfrey, Christine; Stewart, Duncan; Gossop, Michael (1 June 2004). "Economic analysis of costs and consequences of the treatment of drug misuse: 2-year outcome data from the National Treatment Outcome Research Study (NTORS)". Addiction. 99 (6): 697–707. doi: 10.1111/j.1360-0443.2004.00752.x . PMID   15139868.
  32. Arun Sondhi; Joanne O'Shea; Teresa Williams (2002). Arrest referral: emerging findings from the national monitoring and evaluation programme (PDF). HR. ISBN   978-1-84082-860-3.
  33. http://www.nationalarchives.gov.uk/ero/details.aspx?seriesid=64444&deliverableUnitId=520&entrypoint=HO/421/2/P2/DPAS/CDPUR23.PDF [ dead link ]
  34. Michael Hough (1996). Drugs misuse and the criminal justice system: a review of the literature (PDF). Home Office. ISBN   978-1-85893-440-2.
  35. "Updated Drug Strategy 2002" (PDF). 2002. Retrieved February 18, 2017.