Chapter 234. Opioids

1. Is this patient opioid dependent?

2. Is this patient in opioid withdrawal?

3. How should opioid withdrawal be managed?

4. How can pain be managed in an opioid-dependent patient?

5. What discharge planning should take place for opioid-dependent patients?

Opioid misuse, primarily in the form of heroin, has been a longstanding problem in the urban United States. Opioids are now among the most commonly prescribed medications in the U.S. As a result, problems related to opioids are frequently seen in hospitalized patients. The admitting diagnosis may be related directly to opioids, or opioid related problems may complicate the hospital course. Regardless of the source or severity of the problem, all Hospital Medicine specialists must understand the evaluation and management of patients who are regularly taking opioids.

The term opiate traditionally refers to those drugs that are naturally derived from the poppy plant, and opioid generally refers to synthetic and semisynthetic drugs that are structurally similar to morphine, the prototypic opiate. In this chapter, the term opioid is preferentially used to encompass the broad category of morphine-like analgesics (Table 234-1).

The clinical management of opioid-related problems requires the use of both clear terminology and clinical definitions. Tolerance, dependence, and addiction are sometimes used inappropriately due to lack of understanding or lack of clinical clarity. In this chapter, the terms addiction and opioid addiction refer to the pathologic syndrome of opioid dependence with uncontrolled use despite consequences. Hospitalized patients may also present with pseudoaddiction, which is drug-seeking behavior that occurs in response to inadequate treatment of pain.

Opioid use and problems associated with opioid use have increased dramatically in the United States over the last 15 years. Although there is significant regional variation in the types of opioids used and the patterns of use, several trends are worth noting. Epidemiologic surveys from the United States indicate that over 5 million people used opioids for nonmedical purposes in 2007. U.S. data from 2005 indicate there were more than ...