Opioid Dependence 

Case Study: Opioid Dependence

Patient: Sarah, 32-year-old Female

Presenting Complaint:

Sarah visits the clinic complaining of severe cravings, withdrawal symptoms, and difficulty stopping opioid use despite repeated attempts.

History of Presenting Illness:

• Prescribed oxycodone two years ago after a back injury.
• Began taking higher doses without medical supervision due to increased tolerance.
• Started seeking multiple prescriptions and later switched to heroin when prescriptions ran out.
• Reports intense cravings, anxiety, sweating, nausea, and muscle aches if she misses a dose.
• Lost her job due to frequent absences and strained relationships with family.

Examination Findings:

• Pupils: Pinpoint pupils (suggesting opioid use).
• Skin: Track marks on arms (suggesting IV drug use).
• Behavior: Restless, anxious, requesting medication.
• Vitals: Mild tachycardia, sweating.

Diagnosis:

Sarah meets the DSM-5 criteria for Opioid Use Disorder, characterized by compulsive opioid use, loss of control, and withdrawal symptoms.

Management:

1. Medication-Assisted Treatment (MAT) – Buprenorphine or Methadone to reduce cravings and withdrawal.
2. Psychosocial Support – Cognitive Behavioral Therapy (CBT) and addiction counseling.
3. Harm Reduction Strategies – Naloxone for overdose prevention, needle exchange programs.
4. Long-Term Rehabilitation – Support groups, lifestyle modifications, and relapse prevention.

With treatment, Sarah gradually reduced opioid use and started rebuilding her life through therapy and social support.

Definition

• Opioid dependence is a chronic, relapsing condition characterised by compulsive opioid use despite harmful consequences, tolerance, withdrawal symptoms, and cravings.
• Can involve prescription opioids (morphine, oxycodone, fentanyl), heroin, or synthetic opioids (tramadol, methadone).

High risk of overdose, respiratory depression, and death if untreated.

Causes & Risk Factors

Pathophysiology

• Opioids Bind to µ-Opioid Receptors in the Brain → Pain Relief, Euphoria, Sedation.
• Chronic Use Causes Neuroadaptation → Tolerance (Higher Doses Needed) & Dependence (Withdrawal on Cessation).

Dysregulation of the Dopaminergic Reward System → Compulsive Drug-Seeking Behaviour.

Risk Factors for Opioid Dependence

🔹 Prescription opioid misuse is a leading cause of opioid dependence in high-income countries.

Clinical Features

Symptoms of Opioid Dependence (DSM-5 Criteria)

• Diagnosis Requires ≥2 Symptoms Within a 12-Month Period.

Signs of Opioid Intoxication & Withdrawal

Mnemonic for Opioid Intoxication & Withdrawal: “PRAGMA”

Each letter represents key signs of opioid intoxication (overdose) and withdrawal (abstinence syndrome).

Intoxication (Overdose) – “PRAGMA” (Think: “Too much opioids make you PRAGMA-tic!”)

• P → Pinpoint Pupils (Miosis)
• R → Respiratory Depression (Hypoxia, slow breathing)
• A → Altered CNS (Sedation, euphoria, slurred speech)
• G → GI Slows Down (Constipation, nausea, vomiting)
• M → Muscle Relaxation (Weakness, limp body)
• A → Autonomic Depression (Hypotension, bradycardia)

Withdrawal (Abstinence) – “MY HATE” (Think: “My Hate for Withdrawal Symptoms!”)

• M → Mydriasis (Dilated Pupils)
• Y → Yawning & Hyperventilation
• H → Hypertension & Tachycardia (Sweating, autonomic activation)
• A → Anxiety & Agitation (Restlessness, irritability)
• T → Tummy Issues (Diarrhea, abdominal cramps)
• E → Extremity Pain (Muscle aches, joint pain)

Quick Recall Phrase:

• PRAGMA → Opioid Intoxication (Sedation, Slow, Small Pupils)
• MY HATE → Opioid Withdrawal (Hyper, Painful, Dilated Pupils)

This mnemonic makes it easy to differentiate overdose vs withdrawal symptoms! 🚑

🔹 Opioid withdrawal is rarely life-threatening but is extremely distressing, leading to continued drug use.

Referral Criteria (NICE Guidelines)

Urgent Referral (Medical Emergency – Requires Immediate Intervention)

• Opioid Overdose (Respiratory Depression, Unresponsiveness).
• Severe Withdrawal Leading to Dehydration or Electrolyte Imbalance.
• Acute Mental Health Crisis (Suicidal Ideation, Psychosis).
• Pregnant Women With Opioid Dependence (Risk to Foetus).

Routine Referral (If Symptoms Persist or Affect Functioning)

• Chronic Opioid Dependence Requiring Substitution Therapy.
• Frequent Relapses Despite Previous Treatment.
• Comorbid Mental Health Disorders (Dual Diagnosis).
• High-Risk Individuals (Homeless, Injecting Drug Users).

🔹 Opioid dependence requires urgent referral in overdose cases and structured long-term treatment for recovery.

Diagnosis & Screening Tools

Clinical Diagnosis (DSM-5 Criteria for Opioid Use Disorder)

Screening Tools

Differential Diagnosis

🔹 Opioid withdrawal is distinct from alcohol and benzodiazepine withdrawal due to prominent GI symptoms.

Management (NICE Guidelines)

Acute Management (Withdrawal & Overdose Treatment)

🔹 Naloxone rapidly reverses opioid overdose but may precipitate withdrawal symptoms.

Long-Term Treatment & Relapse Prevention

Psychological & Social Interventions

• Cognitive Behavioural Therapy (CBT) for Addiction.
• Motivational Interviewing (Enhancing Readiness to Change).
• Harm Reduction Strategies (Needle Exchange, Safe Injection Sites).
• 12-Step Programmes (Narcotics Anonymous).

🔹 Medication-assisted treatment (MAT) combined with therapy improves long-term recovery.

Prognosis & Complications

Prognosis

Complications of Opioid Dependence

🔹 Early treatment reduces relapse risk and long-term harm.

UKMLA Key Points

• Best first-line treatment for opioid overdose: Naloxone.
• Best treatment for opioid withdrawal: Buprenorphine or Methadone.
• When to refer urgently: Overdose, severe withdrawal, pregnancy with opioid use.
• Best long-term management strategy: Opioid Substitution Therapy + Psychological Support.