Opioid Abuse and

WithdrawalBY THAER ABUHADID

Instructions for this Power Point

Make sure to play the sound by clicking on play button on the

speaker emblem when going through the power-point

Objectives

Understand why people abuse opioids

List at least 3 signs and symptoms of opioid withdrawal

Identify at least 2 common medications used during opioid

withdrawal

Analyze a case-study for opioid withdrawal signs and symptoms to

measure the individuals withdrawal severity by using a C.O.W.S

scale accurately

Identify which opioids take longer to withdrawal from

Understand Induction and precipitated withdrawal

Opioids and Abuse

Opioids- Class of drugs made from opium, as well as synthetic or

semi-synthetic drugs.

Definition of abuse- When use of opioids harms a persons health or social functioning. It also occurs when a person is addicted to or

physically dependent on opioids.

Causes- Opioids produce a quick, intense feeling of pleasure

(euphoria), followed by a sense of well-being and calm drowsiness.

Symptoms of opioid abuse- Tolerance, drug seeking, and personal

problems

Watch this video about how

people become addicted and

withdrawal symptoms https://www.youtube.com/watch?v=uvPrmQhhRuE

Signs and symptoms of opioid

withdrawal

Short Acting VS Long Acting

Opioids

Short Term- Heroin, Crushed OxyContin, Percocet, Vicodin,

Oxycodone, Codeine, Hydrocodone, Hydromorphone (take shorter

time to withdrawal from)

Long Acting Opioids- Oxycontin, Fentanyl, Methadone, Morphine

(Take a longer time to withdrawal from)

Common Drugs Used For

Withdrawal

Buprenorphine (Subutex)- Semi- synthetic opioid derived from

thebaine, an alkaloid of the poppy Papaver somniferum. It is an

opioid partial agonist.

Benefits- Its maximal effects are less than those of full agonists like heroin

and methadone.

At low doses, it produces increase linearly without increasing doses of

the drug until it reaches a plateau and no longer continues to increase

with further increases in dosage (ceiling effect)

Methadone (Methadose)

It is a synthetic opioid that binds to the mu opiate receptors on the

surfaces of brain cells, which mediate the analgesic and other

effects of opioids.

Therapeutically, appropriate doses of this agonist produce cross-

tolerance for short-acting opioids such as morphine and heroin,

thereby suppressing withdrawal symptoms and opioid craving as a

short-acting opioid is eliminated form the body.

The dose needed to produce cross-tolerance depends on the

patient’s level of tolerance for short-acting opioids

Naltrexone (Depade, ReVia)

Highly effective opioid antagonist that tightly binds to mu opiate

receptors.

It is able to displace other opioids that include heroin, morphine, or methadone and block their effects due to its high affinity level.

It can precipitate withdrawal in patients who have not been

abstinent from short-acting opioids for at least 7 days and have not

been abstinent form long-acting ones, such as methadone, for at

least 10 days

Benefits

Negatives

Precipitated Withdrawal and How

to Avoid It

Precipitated withdrawal is a rapid and intense onset of withdrawal

symptoms initiated by a medication.

Patient education and developing realistic expectations are essential before beginning treatment

To avoid precipitated withdrawal, physically dependent patients

must no longer be experiencing the agonist effects of an opioid.

To avoid this, we observe objective symptoms of withdrawal sufficient to

score a 5-6 on the COWS. Scores of >10 are preferable. Due to patient

individuality, required abstinent times may vary considerable from

patient to patient. Only use the time since last use as an estimate to

anticipate the onset of withdrawal symptoms

Induction and It’s Goal

Induction begins by assessing last use of all opioids, short and long

acting, objective and subjective symptoms and a COWS score

calculation.

The goal of induction

If withdrawal symptoms are mild (5-24), it is in the patients best interest to

wait. Long-acting opioids will require a longer period of abstinence,

than short-acting opioids.

Short-acting opioids (prior to induction)

Long-acting opioids (prior to induction)

Methadone

Using C.O.W.S We use the Clinical Opioid Withdrawal Scale (C.O.W.S) scale to rate

the severity of withdrawal from opioids.

Resting Pulse Rate: Have the patient sit or lay down for at least 1

minute before measuring

0 = Pulse rate 80 or below

1 = Subjective report of chills or flushing

2 = flushed or observable moistness on face

3 = Frequent shifting or extraneous movements of legs/arms

5 = Unable to sit still for more than a few seconds

Sweating: Over Past ½ Hour NOT

Accounted for by Room Temp or Pt

Activity 0 = No report of chills or flushing

1 = subjective report of chills or flushing

2 = flushed or observable moistness on face

3 = beads of sweat on brow or face

4 = sweat streaming off face

Restlessness Observation During

Assessment

0 = able to sit still

1 = Reports difficulty sitting still, but is able to do so

3 = frequent shifting or extraneous movements of legs/arms

5 = Unable to sit still for more than a few seconds

Pupil Size

0 = pupils pinned or normal size for room light

1 = pupils possibly larger than normal for room light

2 = pupils moderately dilated

5 = pupils so dilated that only the rim of the iris is visible

Bone or Joint Aches

If the Patient was having pain previously, only the additional

component attributed to opiate withdrawal is scored

0 = Not present

1 = mild diffuse discomfort

2 = patient reports severe diffuse aching of joints/muscles

4 = Patient is rubbing joints or muscles and is unable to sit still

because of discomfort

Runny Nose or Tearing

Not accounted for by cold symptoms or allergies

0 = not present

1 = nasal stuffiness or unusually moist eyes

2 = nose running or tearing

4 = nose constantly running or tears streaming down cheeks

GI Upset: Over last ½ hour

0 = No GI symptoms

1 = stomach cramps

2 = nausea or loose stool

3 = vomiting or diarrhea

5 = multiple episodes of diarrhea or vomiting

Tremor Observation of

Outstretched Hands

0 = no tremor

1 = tremor can be felt, but not observed

2 = slight tremor observable

4 = gross tremor or muscle twitching

Yawning Observation During

Assessment

0 = no yawning

1 = yawning once or twice during assessment

2 = yawning three or more times during assessment

4 = yawning several times/minute

Anxiety or Irritability

0 = none

1 = patient reports increasing irritability or anxiousness

2 = patient obviously irritable/anxious

4 = patient so irritable or anxious that participation in the assessment

is difficult

Gooseflesh Skin

0 = skin is smooth

3 = piloerection of skin can be felt or hairs standing up on arms

5 = prominent piloerection

SCORE

5-12 = Mild

13-24 = Moderate

25 – 36 = Moderately Severe

More than 36 = Severe Withdrawal

Now Its Your Turn-Case Study

A 24 year old veteran comes in to triage and reports that he has a history of

back pain due to an injury he suffered in Iraq. He also reports that he has

been chronically taking morphine for his back pain. The veteran came in to

triage because he reports experiencing withdrawal symptoms and stuffy nose due to having a cold. The nurse observes that the resting PR is 118

BPM, beads of sweat on brow, the veteran is frequently shifting his position.

The nurse then observes the veteran's pupils and finds that they are so

dilated that only the rim of the iris is visible. The nurse notes that the

veteran’s nose is runny, and the veteran is now experiencing stomach

cramps and the veteran is rubbing joints or muscles and is unable to sit still

because of discomfort. The nurse then tells the veteran to extend his arms

and notices gross tremor and muscle twitching. The nurse also observes that

the veteran is obviously irritable/anxious and prominent pilorection. During the assessment, the veteran yawned four times.

Click to view COWS

SCALE

Click to go back to

Case study

Click to go rate the

veteran

What would you rate this veteran

on C.O.W.S

29-33 40-44

24-28 5-12

Your score is not accurate

Go back to case study.

Your score is accurate enough

As we can see, interpreting withdrawal symptoms can depend on

the observer, but the most important thing to remember is scoring

accurate enough to rate mild, moderate, moderately severe, and severe.

My score is 31, having a score

around this margin is accurate.

This is moderately severe

withdrawal symptoms.

CLICK ON THIS SLIDE TO TAKE

QUIZ

Take the Quiz

Which opioid is a short acting drug?

Why do people abuse Opioids?

Natural endorphins

in the body is

diminished

Tolerance

Euphoric Feeling

and Sense of Well

Being

All answers are

correct

What is an early sign of opioid

withdrawal?

Diarrhea

Hypotension

Dehydration

Diaphoresis

True or False- Withdrawal is

dependent to how much a patient

is using opioids

True False

What is the goal of induction?

Safely suppress opioid

withdrawal as rapidly

as possible with

withdrawal drugs

Safely suppress

opioid withdrawal

slowly as possible

with opioid drugs

Inducing coma None of the above

Nice Job!

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Thank You!

Thank you everyone for learning

about opioids and withdrawal.

Thanks for the AWESOME

experience I had at this site. Thanks

for your kindness and welcoming

attitude. I will not forget the

wonderful team and experience I

had at the VA.

References

References

http://www.naabt.org/documents/cows_induction_flow_sheet.pdf

McCoy, K. M. (2012). Opioid abuse. Salem Press Encyclopedia Of

Health,

http://www.ncbi.nlm.nih.gov/books/NBK64158/

https://www.naabt.org/faq_answers.cfm?ID=2