eMedicine Specialties > Psychiatry > Addiction

Opioid Abuse: Follow-up

Author: William J Meehan, MD, Chief Resident in Clinical Research, Department of Psychiatry, University of Massachusetts Memorial Medical Center, University of Massachusetts Medical School
Coauthor(s): Steven A Adelman, MD, Director, Behavioral Health and Addiction Medicine, Harvard Vanguard Medical Associates
Contributor Information and Disclosures

Updated: Jul 31, 2009

Follow-up

Further Inpatient Care

Detoxification is mostly conducted in an inpatient setting, but a few outpatient clinics for methadone detoxification also exist.

Further Outpatient Care

  • Opioid abuse treatment also is influenced by managed care, and it is changing rapidly.
  • Treatment in outpatient and inpatient settings is equally effective, but significant cost differences exist.
  • The ideal program should be comprehensive enough to target individual patient needs and the severity of the illness.

Complications

In general, the following complications may be observed.

  • Opioid dependence: Constipation, noncardiac pulmonary edema (usually with heroin), and heroin-induced glomerulonephritis may occur. Combination products may lead to acetaminophen or aspirin toxicity. Related to IV drug use, multifocal leukoencephalopathy and myelopathy, which may be related to the parenteral route of administration rather than opioids; HIV; viral hepatitis; and bacteremia may occur. Right-sided endocarditis and valvular damage also may occur.
  • Intoxication - Sedation, respiratory depression, and death

Prognosis

  • Catalino et al found that opioid treatment relapse rates vary from 25-97%. Cigarette smokers have higher rates of relapse than nonsmokers.
  • Success is measured as improvement in following areas:
    • Social functions
    • Reduction of illicit drug use
    • Performance at work and school
  • The prognosis varies according to the type of agent abused and other variables, such as medical care, employment, legal situation, family, and psychological difficulties.
  • In general, the success rate is much better in people who abuse opioids and are professionals than in individuals with a poor education level and low job prospects.

Patient Education

  • Patient and family education: Understanding the nature of the disease helps formulate a strategy to fight against it. Although information may be provided in a single session, generally it is continuous process that begins at the identification of the problem. Statistical evidence may be provided if needed to facilitate the patient's understanding of the disease. The education must cover the following areas:
    • Inform the patient in no unclear terms about their inability to use the substance in a controlled fashion.
    • Treatment alone is hardly ever successful, and rehabilitation is almost always needed for recovery.
    • Will power is not enough to beat the disease, and the role of Narcotics Anonymous must be emphasized.
    • Recovery is possible, and a significant number of people succeed in that.
    • After a relapse, the patient must be encouraged and informed that it is not unusual and that a slip could be valuable experience.
    • Dysphoric effects after abstinence are the main reason of relapse. Patients should be ready and equip themselves with a coping strategy.
    • Tell patient to value recovery and avoid high-risk situations of active drug use.
  • Contrary to the earlier beliefs, most substance abusers are closely tied to their families. In 1972, Levy provided evidence that at 5 years, patients who succeeded in overcoming narcotic abuse most often had family support. Educated family members are likely to provide positive influence without getting frustrated. The following issues must be addressed.
    • Inform the patient about the concept of enabling so that such behaviors may be identified and replaced with assertive but compassionate behaviors.
    • Inform the patient and the family of ways of healthy intrafamily conflict resolution.
    • Keep the expectations reasonable. Relapses may occur often, and it does not mean the patient has to start from zero again.
    • Understand that a patient who abuses opioids and is trying to start life without opioids may develop unacceptable and unfamiliar behaviors, which may be quite painful for family members who are expecting a nice premorbid personality.
    • Inform patients about the availability of family support groups such as spouse support groups.
    • Place emphasis on encouraging patients to attend NA.
  • For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center and Substance Abuse Center. Also, see eMedicine's patient education articles Barbiturate Abuse, Drug Dependence and Abuse, Narcotic Abuse, and Substance Abuse.

Miscellaneous

Medicolegal Pitfalls

Be careful not to accidentally overdose a patient requesting opioids for drug withdrawal symptoms, causing excess sedation or respiratory depression. Close monitoring of vital signs and writing prescriptions of narcotics only against objective symptoms of opioid withdrawal is encouraged.

Special Concerns

  • Signs and symptoms of abstinence in infants exposed to opioids are very nonspecific. Also consider other diagnoses such as sepsis, electrolyte imbalance, and hypoglycemia. The Finnegan scale is used to evaluate opioid abstinence syndrome. Once diagnosed, paregoric (camphorated tincture of opium) or phenobarbital can used to control opiate abstinence symptoms.
  • Pregnant women who are abusing opioids are recommended for treatment with methadone maintenance in almost all cases.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Ziaur Rehman, MD; Suzan Khoromi, MD; and James E Douglas, MD to the development and writing of this article.



More on Opioid Abuse

Overview: Opioid Abuse
Differential Diagnoses & Workup: Opioid Abuse
Treatment & Medication: Opioid Abuse
Follow-up: Opioid Abuse
Multimedia: Opioid Abuse
References
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Further Reading

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Keywords

opioid abuse, narcotic abuse, drug abuse, pain relievers, endorphins, heroin, morphine, opium, PCP, opioid receptors, intravenous drug use, IV drug use, intravenous drug user, IDU, drug dependence, pain reliever abuse

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Contributor Information and Disclosures

Author

William J Meehan, MD, Chief Resident in Clinical Research, Department of Psychiatry, University of Massachusetts Memorial Medical Center, University of Massachusetts Medical School
Disclosure: Nothing to disclose.

Coauthor(s)

Steven A Adelman, MD, Director, Behavioral Health and Addiction Medicine, Harvard Vanguard Medical Associates
Steven A Adelman, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Psychiatric Association, American Society of Addiction Medicine, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Barry I Liskow, MD, Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Residency Program, University of Kansas School of Medicine; Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center
Barry I Liskow, MD is a member of the following medical societies: American Academy of Clinical Psychiatrists, American Academy of Psychiatrists in Alcoholism and Addictions, American Medical Association, American Psychiatric Association, and Research Society on Alcoholism
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eduardo Dunayevich, MD, Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories
Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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