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

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 are successful.
After a relapse, the patient must be encouraged and informed that it is not unusual and that a slip could be a 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 patient education resources, see the Mental Health Center. Also, see the patient education articles Barbiturate Abuse, Drug Dependence and Abuse, Narcotic Abuse, and Substance Abuse.

Questions

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Author

David W Dixon, DO Psychiatrist, 2nd Chance Treatment Center, Gilbert, AZ

David W Dixon, DO is a member of the following medical societies: American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ryan P Peirson, MD Aerospace Psychiatry Consultant, Aeromedical Consultation Service, Neuropsychiatry Branch (FECN), US Air Force School of Aerospace Medicine; Assistant Professor of Psychiatry, Chief of Forensic Psychiatry, Assistant Training Director, General Psychiatry Residency, Wright State University, Boonshoft School of Medicine

Ryan P Peirson, MD is a member of the following medical societies: Aerospace Medical Association, American Academy of Psychiatry and the Law, American Psychiatric Association, Ohio Psychiatric Physicians Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Glen L Xiong, MD Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center

Glen L Xiong, MD is a member of the following medical societies: AMDA - The Society for Post-Acute and Long-Term Care Medicine, American College of Physicians, American Psychiatric Association, Central California Psychiatric Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SafelyYou, Blue Cross Blue Shield<br/>book co-editor for: Wolter Kluwer, American Psychiatric Publishing Inc.

Additional Contributors

Barry I Liskow, MD Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

Adrian Preda, MD Professor of Clinical Psychiatry and Human Behavior, University of California, Irvine, School of Medicine

Adrian Preda, MD is a member of the following medical societies: American Association for the Advancement of Science, American Psychiatric Association, International College of Neuropsychopharmacology, International Congress of Schizophrenia Research, Schizophrenia International Research Society, Society of Biological Psychiatry

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Ziaur Rehman, MD, Suzan Khoromi, MD, James E Douglas, MD, Steven A Adelman, MD, and William J Meehan, MD, PhD to the development and writing of this article.