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Assessment and Clinical Picture
Opioid use disorders can occur at any age, including adolescence and the geriatric years, but most affected persons are between 20 and 45 years. Neonates whose mothers are addicted can experi-ence opioid withdrawal. Rarely, young children are affected with some cases of dependence having been reported in persons who are 8 to 10 years of age. Males are more commonly affected, with the male : female ratio typically being 3 or 4 to 1.
A nonjudgmental and supportive yet firm approach to these patients is especially important. They typically have en-gaged in antisocial or other forms of problematic behavior. They are often embarrassed or afraid to describe the extent of their behavior, and have extremely low self-esteem. At the same time, they are prone to be impulsive, manipulative and to act-out when frustrated. Communicating a feeling of nonjudgmental support in the context of setting limits, along with a clear and informed effort to provide appropriate help will encourage optimum thera-peutic opportunities.
Sclerosed veins (“tracks”) and puncture marks on the lower por-tions of the upper extremities are common in intravenous users. When these veins become unusable or otherwise unavailable, per-sons will usually switch to veins in the legs, neck or groin. Veins sometimes become so badly sclerosed that peripheral edema de-velops. When intravenous access is no longer possible, persons will often inject directly into their subcutaneous tissue (“skin-popping”) resulting in cellulitis abscesses, and circular-appear-ing scars from healed skin lesions. Tetanus is a relatively rare butextremely serious consequence of injecting into the subcutaneous tissues. Infections also occur in other organ systems, including bacterial endocarditis, hepatitis B and C, and HIV infection.
Persons who “snort” heroin or other opioids often develop irritation of the nasal mucosa. Difficulties in sexual function are common, as are a variety of sexually transmitted diseases. Males often experience premature ejaculation associated with opioid withdrawal, and impotence during intoxication or chronic use. Females commonly have disturbances of reproductive function and irregular menses.
During dependence, routine urine toxicology tests are often posi-tive for opioid drugs and remain positive for most opioids for 12 to 36 hours. Methadone and LAAM, because they are longer act-ing, can be identified for several days. Fentanyl is not detected by standard urine tests but can be identified by more specialized procedures. Oxycodone, hydrocodone and hydromorphone are often not routinely included on urine toxicology tests though they can be identified by gas chromatography/mass spectrom-etry. Testing for fentanyl is not necessary in most programs, but needs to be performed in assessing and treating health care pro-fessionals such as anesthesiologists who have access to this drug. Concomitant laboratory evidence of other abuseable substances such as cocaine, marijuana, alcohol, amphetamines and benzodi-azepines is common.
Hepatitis screening tests are often positive, either for hepa-titis B antigen (signifying active infection) or hepatitis B and/or C antibody (signifying past infection). Mild to moderate eleva-tions of liver function tests are common, usually as a result of chronic infection with hepatitis C but also from toxic injury to the liver due to contaminants that have been mixed with injected opioids, or from heavy use of other hepatotoxic drugs such as alcohol. Low platelet count, anemia, or neutropenia, as well as positive HIV tests or low CD-4 cell counts are often signs of HIV infection. HIV is commonly acquired via the practice of sharing injection equipment, or by unprotected sexual activity that may be related to the substance use disorder, for example, exchanging sex for drugs or money to buy drugs.
Individuals who are dependent on “street” opioids are usu-ally easy to diagnose due to the physical signs of intravenous use, drug-seeking behavior, reports from independent observers, the lack of medical justification for opioid use, urine test results, and the signs and symptoms of intoxication or withdrawal.
The signs and symptoms of opioid withdrawal are fairly specific, especially lacrimation and rhinorrhea, which are not as-sociated with withdrawal from any other abuseable substances. Other psychoactive substances with sedative properties such as alcohol, hypnotics, or anxiolytics can cause a clinical picture that resembles opioid intoxication. A diagnosis can usually be made by the absence of pupillary constriction, or by the lack of response to a naloxone challenge. In some cases, intoxication is due to opioids along with alcohol or other sedatives. In these cases the naloxone challenge will not reverse all of the sedative drug effects.
Difficult diagnostic situations are seen among persons who fabricate or exaggerate the signs and symptoms of a painful ill-ness (such as kidney stones, migraine headache, back pain, etc.). Because pain is subjective and difficult to measure, and because some of these individuals can be very skillful and deceptive, diagnosis can be difficult and time-consuming. Drugs that are obtained in such deceptions may be used by the individual in the service of his/her dependence or abuse, or may be sold on the il-licit drug market for profit. These individuals cause problems not only for physicians, but also for patients with disorders that need opioids for pain relief.
Persons with opioid dependence will often present with psychiatric signs and symptoms such as depression or anxiety. Such subjective distress often serves to motivate the patient to seek treatment, and thus can be therapeutically useful. These symptoms can be the result of opioid intoxication or withdrawal, or they might result from the pharmacological effects of other substances that are also being abused such as cocaine, alcohol, or benzodiazepines. They may also represent independent, non-substance-induced psychiatric disorders that require long-term treatment. The correct attribution of psychiatric symptoms that are seen in the context of opioid dependence and abuse follows the principles that are outlined in the substance-related section and other relevant parts of DSM-IV-TR.
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