Summary
Definition
History and exam
Key diagnostic factors
- maladaptive pattern of opioid use
- high Addiction Severity Index (ASI) score
- blunting of pleasurable opioid effects
- miosis
- dilated pupils
- shallow/slow respirations or apnea
- needle marks, scars, or necrosis on skin near veins
- unconsciousness
- pulse <40 bpm
Other diagnostic factors
- chronic constipation
- weight loss
- nausea/vomiting
- sedation
- restless sleep/insomnia
- memory impairment
- sneezing
- yawning
- abdominal cramps
- diarrhea
- backache/muscle spasms
- hot and cold flashes
- hypotension
- sedation
- confusion
- slurred speech
- aggressive behavior
- excess perspiration or lacrimation
- rhinorrhea
- restlessness
- piloerection
- tachypnea
- hypertension
- arrhythmias
- seizures
Risk factors
- male gender
- young age
- history of mental illness
- history of substance abuse
- long-term opioid therapy
- family history of substance abuse
Diagnostic investigations
1st investigations to order
- urine drug screen
- gas chromatography-mass spectroscopy (GC-MS)
- serum electrolytes
- CBC
- BUN/creatinine
- LFTs
- rapid plasma reagent
- hepatitis serology
- HIV serology
- PPD skin test
- blood cultures
- beta-hCG
Treatment algorithm
Contributors
Authors
Ashwin A. Patkar, MD, MRCPsych
Associate Professor
Medical Director
Duke Addictions Program
Department of Psychiatry and Behavioral Sciences
Duke University Medical Center
Durham
NC
Disclosures
AAP is a consultant/member of the advisory board for Cubist Pharma, Biodelivery Sciences (BDSI), Kaleo, Forest Research Institute, and Titan Pharma; is on the speaker’s bureau and received honoraria from Otsuka, Alkermes, Sunovion, and BDSI; and is a shareholder in Ironwood Sciences LLC and Patkar Medical Consultants. AAP's institution has received grant support from National Institutes of Health (NIDA, NIAAA), SAMHSA, AstraZeneca, Bristol-Myers Squibb, Cephalon, Daiichi Sankyo, Envivo Pharma, Forest, J & J, Jazz Pharmaceuticals, Lundbeck, Merck, Organon, Pfizer, Sunovion, Shire, and Titan. AAP holds unpaid positions on the Board of Directors of Southlight Inc, the Board of Advisors of People's Medical Care, the Executive Committee of Triangle Indian American Physicians Society, and also as President of Indo American Psychiatric Association.
Jonathan C. Lee, MD
Medical Director
The Farley Center at Williamsburg Place
Williamsburg
VA
Affiliate Assistant Professor
Department of Psychiatric Medicine
East Carolina University
Greenville
NC
Community Assistant Professor
Department of Family Medicine
Eastern Virginia Medical School
Norfolk
VA
Disclosures
JCL is a full-time employee at The Farley Center at Williamsburg Place.
Douglas M. Burgess, MD
Assistant Professor
Department of Psychiatry
University of Missouri - Kansas City
Medical Director
Outpatient Behavioral Health
Truman Medical Centers
Kansas City
MO
Disclosures
DMB declares that he has no competing interests.
Acknowledgements
Dr Ashwin A. Patkar, Dr Jonathan C. Lee, and Dr Douglas M. Burgess would like to gratefully acknowledge Dr Kamal Bhatia and Dr Srilakshmi Musham, previous contributors to this monograph. KB declares that he has received grant support from National Institutes of Health, Lundbeck Pharmaceuticals, Pfizer, and Titan Pharmaceuticals. SM declares that she has received grant support from Pfizer, Titan Pharmaceuticals, Shire Pharmaceuticals, and the Forest Research Institute.
Peer reviewers
Andrew Stolbach, MD
Assistant Professor
Department of Emergency Medicine
Johns Hopkins University Hospital
Baltimore
MD
Disclosures
AS declares that he has no competing interests.
F. Gerard Moeller, MD
Professor
Department of Psychiatry and Behavioral Sciences
University of Texas
Health Science Center
Houston
TX
Disclosures
FGM declares that he has no competing interests.
Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD
Consultant Psychiatrist and Honorary Senior Lecturer
Institute of Psychiatry
King's College London
London
UK
Disclosures
CK declares that he has no competing interests.
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