2016-04-11

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Revision as of 03:36, 11 April 2016

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Opioids work by binding to specific receptors found throughout the body’s nervous and immune system <ref name="2">Substance Use Disorders. Substance Abuse and Mental Health Services Administration. 2015. Available at: http://www.samhsa.gov/disorders/substance-use. Accessed April 8, 2016.</ref>. The receptors are responsible for several functions that include pain, stress, temperature, respiration, endocrine activity, gastrointestinal activity, mood, and motivation. The main intended use is to reduce pain perception, but is associated with causing euphoria, drowsiness, mental confusion, nausea, constipation, and depress respiration (high doses) <ref name="2" />.<br>

Opioids work by binding to specific receptors found throughout the body’s nervous and immune system <ref name="2">Substance Use Disorders. Substance Abuse and Mental Health Services Administration. 2015. Available at: http://www.samhsa.gov/disorders/substance-use. Accessed April 8, 2016.</ref>. The receptors are responsible for several functions that include pain, stress, temperature, respiration, endocrine activity, gastrointestinal activity, mood, and motivation. The main intended use is to reduce pain perception, but is associated with causing euphoria, drowsiness, mental confusion, nausea, constipation, and depress respiration (high doses) <ref name="2" />.<br>

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Commonly used opioids identified in the healthcare setting include codeine, fentanyl (patch), hydrocodone (Hysingla ER, Zohydro ER), hydrocodone/acetaminophen (Lorcet, Lortabe, Norco, Vicodin), hydromorphone (Dilaudid), methadone (Dolophine), morphine (Avinza, Kadian), oxycodone (OxyContin, Roxicodone), oxycodone, and naloxone <ref name="1" />.<br><br>

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Commonly used opioids identified in the healthcare setting include codeine, fentanyl (patch), hydrocodone (Hysingla ER, Zohydro ER), hydrocodone/acetaminophen (Lorcet, Lortabe, Norco, Vicodin), hydromorphone (Dilaudid), methadone (Dolophine), morphine (Avinza, Kadian), oxycodone (OxyContin, Roxicodone), oxycodone, and naloxone <ref name="1" />.<br><br>

== Prevalence<br>  ==

== Prevalence<br>  ==

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<br>Results of the 2014 National Survey on Drug Use and Health reported the impact of opioid use disorders among varying demographics. When examining age, the survey found that roughly 586,000 Americans age 12 or older had a heroin use disorder, with average first use age being 28 <ref name="5">Substance Abuse and Mental Health Services Administration. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf (accessed 04 April 2016).</ref>. An estimated 1.9 million Americans age 12 or older reported a pain reliever use disorder <ref name="5" />. Opioid use disorder is more common with males than females with the highest abuse rates among the Native American population <ref name="6">American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596 (accessed 06 April 2016).</ref>.

<br>Results of the 2014 National Survey on Drug Use and Health reported the impact of opioid use disorders among varying demographics. When examining age, the survey found that roughly 586,000 Americans age 12 or older had a heroin use disorder, with average first use age being 28 <ref name="5">Substance Abuse and Mental Health Services Administration. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf (accessed 04 April 2016).</ref>. An estimated 1.9 million Americans age 12 or older reported a pain reliever use disorder <ref name="5" />. Opioid use disorder is more common with males than females with the highest abuse rates among the Native American population <ref name="6">American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596 (accessed 06 April 2016).</ref>.

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<br>A recent study performed by the Substance Abuse and Mental Health Services Administration found a trend in among non-medical pain reliever use and its initiation of heroin use <ref name="7">Muhuri P, Gfroerer J, Davies M. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States.  http://archive.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.htm (accessed 04 April 2016).</ref>. More research is being done in this area to examine the relationship among these topics.<br><br>

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<br>A recent study performed by the Substance Abuse and Mental Health Services Administration found a trend in among non-medical pain reliever use and its initiation of heroin use <ref name="7">Muhuri P, Gfroerer J, Davies M. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States.  http://archive.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.htm (accessed 04 April 2016).</ref>. More research is being done in this area to examine the relationship among these topics.<br><br>

== Characteristics/Clinical Presentation  ==

== Characteristics/Clinical Presentation  ==

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*Withdrawal symptoms that occur after stopping or reducing use

*Withdrawal symptoms that occur after stopping or reducing use

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Ex: negative mood, nausea or vomiting, muscle aches, diarrhea, fever and insomnia <ref name="2" />

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Ex: negative mood, nausea or vomiting, muscle aches, diarrhea, fever and insomnia <ref name="2" />

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The older adult population may be harder to identify causative signs and symptoms due to mimicking typical aging characteristics including memory loss, cognitive problems, tremors, falls, weight loss, and muscle wasting <ref name="9">Goodman, CC, Snyder, TEK. Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. St. Louis, MO: Saunders/Elsevier; 2013. (Pg 49-51)</ref>.<br><br>

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The older adult population may be harder to identify causative signs and symptoms due to mimicking typical aging characteristics including memory loss, cognitive problems, tremors, falls, weight loss, and muscle wasting <ref name="9">Goodman, CC, Snyder, TEK. Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. St. Louis, MO: Saunders/Elsevier; 2013. (Pg 49-51)</ref>.<br><br>

== Associated Co-morbidities  ==

== Associated Co-morbidities  ==

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As research has shown, there is a high correlation between drug abuse and mental disorders. The National Institute on Drug Abuse has seen this association through national surveys dating back to the 1980s <ref name="10">National Institute on Drug Abuse. Comorbidity: Addiction and Other Mental Illnesses. https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf (accessed 06 April 2016).</ref>. People that are “diagnosed with mood or anxiety disorders are twice as likely to suffer from a drug use disorder” and vice versa <ref name="10" />. While different mental disorders can bring about opioid use disorder, the most common comorbidities associated with opioid use are anxiety and depression <ref name="11">Gordon A. Australian Government: Department of Health and Aging. Comorbidity of mental disorders and substance use: A brief guide for the primary care clinician. http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/FE16C454A782A8AFCA2575BE002044D0/$File/mono71.pdf (accessed 06 April 2016).</ref>.

As research has shown, there is a high correlation between drug abuse and mental disorders. The National Institute on Drug Abuse has seen this association through national surveys dating back to the 1980s <ref name="10">National Institute on Drug Abuse. Comorbidity: Addiction and Other Mental Illnesses. https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf (accessed 06 April 2016).</ref>. People that are “diagnosed with mood or anxiety disorders are twice as likely to suffer from a drug use disorder” and vice versa <ref name="10" />. While different mental disorders can bring about opioid use disorder, the most common comorbidities associated with opioid use are anxiety and depression <ref name="11">Gordon A. Australian Government: Department of Health and Aging. Comorbidity of mental disorders and substance use: A brief guide for the primary care clinician. http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/FE16C454A782A8AFCA2575BE002044D0/$File/mono71.pdf (accessed 06 April 2016).</ref>.

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<br>Another frequent comorbidity associated with opioid use disorder is chronic pain. Both opioid use disorder and chronic pain are driven by neurophysiological changes that can lead to altered or dysfunctional neural patterns <ref name="12">Substance Abuse and Mental Health Services Administration. A Treatment Improvement Protocol: Managing Chronic Pain in Adults With or in Recovery from Substance Use Disorders. http://store.samhsa.gov/shin/content/SMA12-4671/TIP54.pdf (accessed 06 April 2016).</ref>. Opioids are a common treatment option for those who have recently experienced trauma, surgery, and with chronic pain <ref name="12" />. Opioid use disorder is increasing in chronic pain patients due to the risk of noncompliance with drug use <ref name="13">Sullivan M, Edlund M, Fan M, DeVries A, Braden J, Martin B. Risks for Possible and Probable Opioid Misuse Among Recipients of Chronic Opioid Therapy in Commercial and Medicaid Insurance Plans: the TROUP Study. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897915/ (accessed 06 April 2016).</ref>. The importance of screening an individual with chronic pain for substance use disorder is crucial; this way it can prevent any relapses with previously abused drugs like opioids or set up a strict plan for the individual using the drug <ref name="12" />.<br><br>

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<br>Another frequent comorbidity associated with opioid use disorder is chronic pain. Both opioid use disorder and chronic pain are driven by neurophysiological changes that can lead to altered or dysfunctional neural patterns <ref name="12">Substance Abuse and Mental Health Services Administration. A Treatment Improvement Protocol: Managing Chronic Pain in Adults With or in Recovery from Substance Use Disorders. http://store.samhsa.gov/shin/content/SMA12-4671/TIP54.pdf (accessed 06 April 2016).</ref>. Opioids are a common treatment option for those who have recently experienced trauma, surgery, and with chronic pain <ref name="12" />. Opioid use disorder is increasing in chronic pain patients due to the risk of noncompliance with drug use <ref name="13">Sullivan M, Edlund M, Fan M, DeVries A, Braden J, Martin B. Risks for Possible and Probable Opioid Misuse Among Recipients of Chronic Opioid Therapy in Commercial and Medicaid Insurance Plans: the TROUP Study. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897915/ (accessed 06 April 2016).</ref>. The importance of screening an individual with chronic pain for substance use disorder is crucial; this way it can prevent any relapses with previously abused drugs like opioids or set up a strict plan for the individual using the drug <ref name="12" />.<br><br>

== Medications  ==

== Medications  ==

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*Clonidine (alpha 2 adrenergic agonists) - May reduce norepinephrine release, Most effective in suppressing autonomic signs/symptoms (withdrawal), Less effective for subjective symptoms <ref name="14" />

*Clonidine (alpha 2 adrenergic agonists) - May reduce norepinephrine release, Most effective in suppressing autonomic signs/symptoms (withdrawal), Less effective for subjective symptoms <ref name="14" />

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“Medication-assisted treatment with methadone, buprenorphine, or extended-release injectable naltrexone plays a critical role in the treatment of opioid use disorders. According to the latest survey of opioid treatment providers more than 300,000 people received some form of medication-assisted treatment for an opioid use disorder in 2011” <ref name="2" />. <br><br>

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“Medication-assisted treatment with methadone, buprenorphine, or extended-release injectable naltrexone plays a critical role in the treatment of opioid use disorders. According to the latest survey of opioid treatment providers more than 300,000 people received some form of medication-assisted treatment for an opioid use disorder in 2011” <ref name="2" />. <br><br>

== Diagnostic Tests/Lab Tests/Lab Values  ==

== Diagnostic Tests/Lab Tests/Lab Values  ==

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There is not one single cause that will lead someone to develop an opioid use disorder. Although, there are several factors that can increase the risk for developing an addiction including both individual and environmental <ref name="1" />. Genetic factors have been found to play an important role for predisposition tendencies that can respond to the environment <ref name="1" />.

There is not one single cause that will lead someone to develop an opioid use disorder. Although, there are several factors that can increase the risk for developing an addiction including both individual and environmental <ref name="1" />. Genetic factors have been found to play an important role for predisposition tendencies that can respond to the environment <ref name="1" />.

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Opioids are known to activate the mesolimbic reward system which signals the release of dopamine causing feelings of pleasure. Our brains ability to establish this conditioned association is responsible for the desire to repeatedly use the drug <ref name="19">Kosten TR, George TP. The Neurobiology of Opioid Dependence: Implications for Treatment. Science & Practice Perspectives. 2002;1(1):13-20.</ref>. However, the body is highly specialized to make adaptations to the presence of the drug and will transition from compulsion of seeking pleasure to depending on the drug existence entirely. Therefore, the increased compulsion is related to an individual tolerance and dependence of the drug <ref name="19" />.<br><br>

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Opioids are known to activate the mesolimbic reward system which signals the release of dopamine causing feelings of pleasure. Our brains ability to establish this conditioned association is responsible for the desire to repeatedly use the drug <ref name="19">Kosten TR, George TP. The Neurobiology of Opioid Dependence: Implications for Treatment. Science &
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amp; Practice Perspectives. 2002;1(1):13-20.</ref>. However, the body is highly specialized to make adaptations to the presence of the drug and will transition from compulsion of seeking pleasure to depending on the drug existence entirely. Therefore, the increased compulsion is related to an individual tolerance and dependence of the drug <ref name="19" />.<br><br>

== Systemic Involvement  ==

== Systemic Involvement  ==

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Medical management for individuals with opioid use disorder begins treatment with detoxification followed by pharmaceutical maintenance therapy, psychotherapy, and treatment of acute pain in patients already on maintenance therapy <ref name="14" />.

Medical management for individuals with opioid use disorder begins treatment with detoxification followed by pharmaceutical maintenance therapy, psychotherapy, and treatment of acute pain in patients already on maintenance therapy <ref name="14" />.

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Pharmacologic methods of detoxification typically include the use of methadone, burprenorphine, and alpha-2 agonists <ref name="14" />. Other medications (listed in Medication section) are used for treating associated signs/symptoms from opioid intoxication, opioid overdose, and/or opioid withdrawal. Cognitive behavior psychotherapy works by focusing on the individual’s thoughts/behaviors and establishes techniques used to resist substance abuse and reduce factors related to drug use <ref name="14" />. Treatment of acute pain in these individuals should include education on how to aggressively treat their pain with conventional opioid analgesics and reassurance of previous addiction history not hindering from adequate pain management <ref name="14" />.<br><br>

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Pharmacologic methods of detoxification typically include the use of methadone, burprenorphine, and alpha-2 agonists <ref name="14" />. Other medications (listed in Medication section) are used for treating associated signs/symptoms from opioid intoxication, opioid overdose, and/or opioid withdrawal. Cognitive behavior psychotherapy works by focusing on the individual’s thoughts/behaviors and establishes techniques used to resist substance abuse and reduce factors related to drug use <ref name="14" />. Treatment of acute pain in these individuals should include education on how to aggressively treat their pain with conventional opioid analgesics and reassurance of previous addiction history not hindering from adequate pain management <ref name="14" />.<br><br>

== Physical Therapy Management (current best evidence)  ==

== Physical Therapy Management (current best evidence)  ==

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Physical therapists are not qualified to manage opioid use disorders. Physical therapists should be able to recognize signs and symptoms of this disorder, but need to refer patients out for treatment. Physical therapists need to advocate for their patients to get them the treatment and help they deserve. Once treatment plans for the opioid use disorder are in place with a physician and patients began receiving medical treatment, if physical therapy treatment is needed, it would be utilized to help recover functional deficits. The physical therapy role mainly applies in opioid use disorders to get patients the appropriate care and begin advocating for nonopioid therapy through research in order to help decrease the prevalence of opioid abuse. The APTA has called to action for physical therapists and physical therapist assistances to focus on their role in pain management with the use of fewer or no drugs, such as opioids <ref name="21">PT in Motion News. APTA's Role in Opioid Abuse Initiative Reflects Wide Scope of White House Efforts. http://www.apta.org/PTinMotion/News/2015/10/23/OpioidInitiative/ (accessed 07 April 2016).</ref>. <br>

Physical therapists are not qualified to manage opioid use disorders. Physical therapists should be able to recognize signs and symptoms of this disorder, but need to refer patients out for treatment. Physical therapists need to advocate for their patients to get them the treatment and help they deserve. Once treatment plans for the opioid use disorder are in place with a physician and patients began receiving medical treatment, if physical therapy treatment is needed, it would be utilized to help recover functional deficits. The physical therapy role mainly applies in opioid use disorders to get patients the appropriate care and begin advocating for nonopioid therapy through research in order to help decrease the prevalence of opioid abuse. The APTA has called to action for physical therapists and physical therapist assistances to focus on their role in pain management with the use of fewer or no drugs, such as opioids <ref name="21">PT in Motion News. APTA's Role in Opioid Abuse Initiative Reflects Wide Scope of White House Efforts. http://www.apta.org/PTinMotion/News/2015/10/23/OpioidInitiative/ (accessed 07 April 2016).</ref>. <br>

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As the epidemic of opioid overuse has increased, the CDC has been working on guidelines to decrease risks of abuse and deaths in the United States. On March 15, 2016 the CDC released “Guideline for Prescribing Opioids for Chronic Pain” <ref name="22">Move Forward: Physical Therapy Brings Motion to Life. Health Center on Opioid Use for Pain Management.  http://www.moveforwardpt.com/Opioids (accessed 07 April 2016).</ref>. In these guidelines it promotes “nonpharmacological therapy and nonopioid therapy as preferred treatment for chronic pain” <ref name="22" />. The CDC found that physical therapy and exercise therapy had a high-quality of evidence to reduce pain and improve function <ref name="22" />. The CDC also states that the risks are much lower with nonopioid treatment plans, but in situations that opioids are prescribed they should always be combined with nonopioid therapies, such as physical therapy <ref name="22" />. The movement is toward physical therapy affects in pain management to prevent opioid use disorder. <br><br>

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As the epidemic of opioid overuse has increased, the CDC has been working on guidelines to decrease risks of abuse and deaths in the United States. On March 15, 2016 the CDC released “Guideline for Prescribing Opioids for Chronic Pain” <ref name="22">Move Forward: Physical Therapy Brings Motion to Life. Health Center on Opioid Use for Pain Management.  http://www.moveforwardpt.com/Opioids (accessed 07 April 2016).</ref>. In these guidelines it promotes “nonpharmacological therapy and nonopioid therapy as preferred treatment for chronic pain” <ref name="22" />. The CDC found that physical therapy and exercise therapy had a high-quality of evidence to reduce pain and improve function <ref name="22" />. The CDC also states that the risks are much lower with nonopioid treatment plans, but in situations that opioids are prescribed they should always be combined with nonopioid therapies, such as physical therapy <ref name="22" />. The movement is toward physical therapy affects in pain management to prevent opioid use disorder. <br><br>

== Differential Diagnosis  ==

== Differential Diagnosis  ==

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== Resources <br>  ==

== Resources <br>  ==

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<references />
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== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])<br>  ==

== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])<br>  ==

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