Opioid intoxication is characterized by maladaptive
and clinically significant behavioral changes developing within minutes to a
few hours after opioid use (see DSM-IV-TR for substance intoxication on general
approaches to substance abuse disorder. Symp-toms include an initial euphoria
sometimes followed by dysphoria or apathy. Psychomotor retardation or
agitation, impaired judgment, and impaired social or occupational functioning
are commonly seen. Intoxication is accompanied by pupillary constriction unless
there has been a severe overdose with consequent anoxia and pupillary
dilatation. Persons with intoxication are often drowsy (described as being “on
the nod”) or even obtunded, have slurred speech, im-paired memory and
demonstrate inattention to the environment to the point of ignoring potentially
harmful events. Dryness of secre-tions in the mouth and nose, slowing of
gastrointestinal activity and constipation are associated with both acute and
chronic opioid use. Visual acuity may be impaired as a result of pupillary
constriction. The magnitude of the behavioral and physiologic changes depends
on the dose as well as individual characteristics of the user such as rate of
absorption, chronicity of use and tolerance. Symptoms of opioid intoxication
usually last for several hours, but are dependent on the half-life of the
particular opioid that has been used. Severe intoxication following an opioid
overdose can lead to coma, respira-tory depression, pupillary dilatation,
unconsciousness and death.
Opioid withdrawal is a clinically significant,
maladaptive behav-ioral and physiological syndrome associated with cessation or
re-duction of opioid use that has been heavy and prolonged (see DSM-IV-TR
criteria for substance withdrawal from general approaches to substance abuse
disorders p. 410. It can also be precipitated by administration of an opioid
antagonist such as naloxone or naltrex-one. Patients in opioid withdrawal
typically demonstrate a pattern of signs and symptoms that are opposite the
acute agonist effects. The first of these are subjective and consist of
complaints of anxiety, rest-lessness and an “achy feeling” that is often
located in the back and legs. These symptoms are accompanied by a wish to
obtain opioids (sometimes called “craving”) and drug-seeking behavior, along
with irritability and increased sensitivity to pain. Additionally, patients
typically demonstrate three or more of the following: dysphoric or depressed
mood; nausea or vomiting; diarrhea; muscle aches; lacri-mation or rhinorrhea;
increased sweating; yawning; fever; insomnia; pupillary dilatation; fever; and
piloerection. Piloerection and with-drawal-related fever are rarely seen in
clinical settings (other than prison) as they are signs of advanced withdrawal
in persons with a very significant degree of physiologic dependence;
opioid-dependent persons with “habits” of that magnitude usually manage to
obtain drugs before withdrawal becomes so faradvanced. For short act-ing drugs
such as heroin, withdrawal symptoms occur within 6 to 24 hours after the last
dose in most dependent persons, peak within 1 to 3 days and gradually subside
over a period of 5 to 7 days. Symp-toms may take 2 to 4 days to emerge in the
case of longer acting drugs such as methadone or levo-alpha-acetylmethadol
(LAAM). Less acute withdrawal symptoms are sometimes present and can last for
weeks to months. These more persistent symptoms can include anxiety, dysphoria,
anhedonia, insomnia and drug craving.
Opioid dependence is diagnosed by the signs and
symptoms associated with compulsive, prolonged self-administration of opioids
which are used for no legitimate medical purpose, or if a medical condition
exists that requires opioid treatment, are used in doses that greatly exceed
the amount needed for pain relief. Persons with opioid dependence typically
demonstrate continued use in spite of adverse physical, behavioral and
psychological consequences. Almost all persons meeting criteria for opioid
de-pendence have significant levels of tolerance and will experience withdrawal
upon abrupt discontinuation of opioid drugs. Persons with opioid dependence
tend to develop such regular patterns of compulsive use that daily activities
are typically planned around obtaining and administering drugs.
Opioids are usually purchased on the illicit
market, but they can also be obtained by forging prescriptions, faking or
ex-aggerating medical problems, or by receiving simultaneous pre-scriptions
from several physicians. Physicians and other health care professionals who are
dependent will often obtain opioids by writing prescriptions or by diverting
opioids that have been prescribed for their own patients.
Opioid abuse is a maladaptive pattern of
intermittent use in haz-ardous situations (driving under the influence, being
intoxicated while using heavy machinery, working in dangerous places, etc.), or
periodic use resulting in adverse social, legal, or interpersonal problems (see
DSM-IV-TR criteria on p. 409). All of these signs and symptoms can also be seen
in persons who are dependent; abuse is characterized by less regular use than
dependence (i.e., compulsive use not present) and by the absence of significant
tolerance or withdrawal. As with other substance use disorders, opioid abuse
and dependence are hierarchical and thus persons diagnosed as having opioid
abuse must never have met criteria for opioid dependence.
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