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The Opioid Crisis: Treating Opioid Withdrawal in the EDDave Vearrier MD and Rich Hamilton MDIntroductionsOpioid PharmacodynamicsMu, kappa, delta receptorsU47,700 – example of a selective kappa agonist used in US and Europe with fatalities (including non-fatal case at HUH)Opioid PharmacokineticsSpeed of CNS penetration intensity of euphoriaExample of diacetylmorphine Speed of metabolism, presence of active metabolites timing and intensity of withdrawalReceptor – ligand interactionsAgonists (morphine etc)Neutral antagonist (naltrexol)Inverse agonists (naloxone, naltrexone, methylnaltrexone)Partial agonists (buprenorphine)By Boghog - Own work, CC BY-SA 4.0, of the Opioid EpidemicMore deaths than MVCs91 deaths/day in US due to opioid overdoseNearly half of all overdose deaths involve an opioidEpidemic is the worst in the deep South and Midwest, PA is pretty severeYounger adults more likely to die of heroin, older more likely to die of Rx opioidsWhites are affected more than any other raceDefinitionsToleranceDependencePhysiological PsychologicalAddictionMechanisms of ToleranceOpioid Withdrawal SyndromeNon-Opioid Management of Opioid WithdrawalNSAIDs, APAPMyalgias, arthalgias, but not cravingClonidineFunctional overlap btwn alpha2 and mu receptors in CNSMost effective for autonomic effects, but not cravingOctreotideGI effects, but not cravingOpioid Replacement TherapyIntroductionHarm Reduction PhilosophyOpioid Treatment Programs May use methadone, LAAM, or buprenorphineIncludes medical maintenance, medically supervised withdrawal, and detoxificationSettings include intensive outpatient, residential, and hospital DEA regulationsInitially all doses administered on site but over time may get take-home dosingMethadone in the emergency departmentOffice-Based Opioid TreatmentDrug Addiction Treatment Act of 2000OBOT designed as alternative to OTPBuprenorphine Buprenorphine induction in the Emergency DepartmentPatient suitabilityCOWS scoringPrecipitated withdrawalDosingObservation ................
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