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Opioid Dependency

For further information, see CMDT Part 25-19: Other Drug & Substance Use Disorders

For further information, see CMDT Part 38-48: Opiate & Opioid Overdose

Key Features

Essentials of Diagnosis

  • Tolerance and withdrawal are major concerns with continued use of opioids

  • Withdrawal causes only moderate morbidity (similar in severity to a bout of "flu")

  • Addicted patients sometimes consider themselves more addicted than they really are and may not require a withdrawal program

General Considerations

  • The terms "opioids" and "narcotics" both refer to a group of drugs with actions that mimic those of morphine

    • The term "opioids" is used when discussing medications prescribed in a controlled manner by a clinician

    • The term "narcotics" is used to connote illicit drug use

  • "Opioids" include a group of drugs with actions that mimic those of morphine

    • Natural derivatives of opium (opiates)

    • Synthetic surrogates (opioids)

    • A number of polypeptides, some of which have been discovered to be natural neurotransmitters

  • The principal opioid of abuse is heroin (metabolized to morphine), which is not used as a legitimate medication

  • Other common opioids are prescription drugs, which differ in milligram potency, duration of action, and agonist and antagonist capabilities (Table 5–6)

  • The incidence of snorting and inhaling heroin ("smoking") is increasing, particularly among cocaine users

Table 5–6.Opioids.
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Table 5–6. Opioids.
Medication  Approximate Equianalgesic Dose (compared to morphine 30 mg orally or 10 mg intravenously/subcutaneously)1  Usual Starting Dose
Adults ≥ 50 kg Body Weight Adults < 50 kg Body Weight
Oral Parenteral Oral Parenteral Oral Parenteral
Opioid Agonists2,3
Buprenorphine parenteral4 (Buprenex)   300 mcg intravenously slowly once, may be repeated after 30–60 minutes once; or 600 mcg intramuscularly once   300 mcg intravenously slowly once, may be repeated after 30–60 minutes once; or 600 mcg intramuscularly once; $14.34/300 mcg    
Buprenorphine transdermal4 (BuTrans) Not available Not available

Not available orally.

Transdermal doses available: 5, 10, and 20 mcg/h. Initiate 5 mcg/h patch for opioid-naïve patients (may currently be using nonopioid analgesics); $114.77/10 mcg/h.

 Not available Not available Not available
Buprenorphine sublingual4 (Belbuca) Sublingual strip approved for pain  

In opioid-naive or opioid-intolerant patients, individualize dose every 12 hours. Start: 75 mcg buccally every 12–24 hours for at least 4 days, then increase to 150 mcg buccally every 12 hours, then may increase by no more than 150 mcg buccally every 12 hours no more frequently than every 4 days.

Maximum: 900 mcg/12 hours;

$7.33/75 mcg.

      
Fentanyl Not available 100 mcg every hour Not available 50–100 mcg intravenously/intramuscularly every hour or 0.5–1.5 mcg/kg/h intravenous infusion; $0.80/100 mcg Not available 0.5–1 mcg/kg intravenously every 1–4 hours or 1–2 mcg/kg intravenously × 1, then 0.5–1 mcg/kg/h infusion
Fentanyl oral transmucosal (Actiq); buccal (Fentora) Not available Not available 200 mcg transmucosal; 100 mcg buccal; $18.80/200 ...

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