Opioid Intoxication DSM-5 292.89 (F11.219)

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DSM-5 Category: Substance Abuse Disorders

Introduction

Opioid Intoxication is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who are under the influence of a psychoactive chemical substance which has been either derived from opium (e.g., morphine or heroin) or is a synthetic copy of opium (e.g., oxycodone) (Heller, Zieve, Black, Slon, & Wang., 2013). Opium is a psychoactive compound contained in the opium poppy (Papaver Somnoverum) (Stolbach, Hoffman, Traub, & Grayzel, 2014).Opioids have a variable onset of action and duration of action, depending on the type which has been administered. Opioids are used therapeutically for management of moderate to severe pain, control of diarrhea, and as a cough suppressant. Prescribed Opioids are also widely diverted for illicit use, and Heroin is an Opioid specifically produced for the illicit market, as it has no legitimate medical use. Opioids can be administered by a variety of routes, including intravenous, intranasal/insulfation, (Fareed, Stout, Casarella, Vayalapalli, Cox, & Drexler, 2011), oral, sub-lingual, inhalation, subcutaneous, buccal, or as a suppository The onset of action will be partly determined by the route of administration- e.g, an IV injection of an Opioid will be faster acting than an oral dose. Certain Opioids are also absorbed more efficiently and are more bioavailable than others. The tolerance of the user, and to a degree, the use setting and user expectations will all influence the subjective effects of the Opioid that has been administered. Opioids produce both an extremely uncomfortable withdrawal syndrome following cessation of use, and Opioid Intoxication has the potential to result in life threatening overdose, mainly due to respiratory depression. Opioids are extremely sought after by users, as they produce an initial full-body orgasmic sensation when given by the IV or IN route, followed by several hours of a peaceful, warm, somnolence, soothing sensation. This pleasurable experience is accompanied by cravings for more Opioids, and tolerance in a relatively short time- weeks in some individuals. The tolerance diminishes the initial pleasurable sensation and prolonged feeling of relaxation in Opioid Intoxication, resulting in the user increasing the dose or seeking more potent Opioids. This eventually progresses to the point where pleasure is minimal or absent, and the user administers opioids just to prevent the onset of withdrawal symptoms. Once physiological dependency is established, failure to administer a subsequent dose of Opioids approximately 24 hours after the last dose will result in severe withdrawal symptoms. The symptoms of Opioid withdrawal are: fever, diaphoresis, lacrimation, rhinitis, headache, muscle cramps, joint aches, nausea, vomiting and diarrhea. These symptoms can be acute for 72 hours to seven days, and in some users persist in a lesser form for two or three weeks. Withdrawal symptoms can be relieved almost immediately by the administration of another dose of Opioids, This combination of reinforcement and punishment produces powerful conditioning to continue using, despite multiple adverse consequences.

Symptoms of Opioid Intoxication

According to the DSM-5, there are four criterion for Opioid Intoxication, of which Criterion C has three sub-features:

A. The individual has recently used an Opioid.

B. Clinical level behavioral and psychological alterations become apparent during or shortly after use of an Opioid

C. Pupils will become constricted and will be accompanied by one of the following during or shortly after use of an Opioid:

1. Somnolence or loss of consciousness

2. Speech articulation will slurred.

3. There will be deficits in attention or memory.

D. The above criteria are not better accounted for by a medical condition, a mental disorder, or use of another substance.

The clinician can add a specifier if the individual is experiencing auditory, visual, or tactile hallucinations. This can occur with opioid use, albeit rarely and with retention of insight. (American Psychiatric Association, 2013).

Other diagnostic features of Opioid Intoxication

The clinician will be able to provide the best treatment in terms of acute management and follow up if the use of opioids is confirmed, and other medical conditions or substance use if ruled out. Other means of diagnosing Opioid Intoxication include:

1, Admission of use by the individual.

2. Presence of “ track marks”, ( linear bruises from rupturing a vein) from injection, typically in the antecubuital space, forearms, feet, in between fingers or toes, under the tongue, in the testicles or labia, or neck, but could be anywhere on the body.

3. Positive urine enzyme-immunoassay panel for opioids

4. Respiratory depression. (This is inconclusive as other CNS ( Central Nervous System Depressants) will produce respiratory depression (Heller, Zieve, Black, Slon, & Wang., 2013)

Treatment for Opioid Intoxication

The DSM-5 does not specify treatment options for Opioid Intoxication (American Psychiatric Association, 2013). Pulse, blood oxygen levels, blood pressure, and body temperature should be monitored in the event of Opioid intoxication. If the individual is experiencing respiratory depression, supplemental oxygen may be administered to elevate blood oxygen levels. If the individual’s respiration is more severely depressed they may require intubation and manual ventilation, Naloxone may also be administered (Heller, Zieve, Black, Slon, & Wang., 2013) Naloxone is a mu-opiate antagonist, which will competitively antagonize my-opiate receptor sites, and produce prompt resolution of all symptoms of opioid intoxication, including respiratory depression. Naloxone may be given intravenously, or through a nebulizer (Baumann, Patterson, Parone, Jones, Glaspey, Thompson, Stauss, & Haroz, 2013).

Impact on Functioning

Opioid Intoxication can render an individual incapacitated, impaired, or able to function with almost no obvious impairment. The level of functioning following administration of Opioids will depend on several factors:

  • Tolerance
  • The dose of the opioid
  • The potency of the Opioids
  • The route of administration

One could argue semantics, stating that if level of functioning is minimally or not obviously impaired, then the individual is not intoxicated, but under the influence. A continuous rather than dichotomous model may be more useful here, as the difference between being under the influence and intoxicated can be seen as a matter of severity of impairment. Severity of impairment can be further defined by considering the context in which the individual is operating, If one's fine motor skills and high level cognitive processing are required for a task, the individual will be more noticeable y impaired, than if they are engaged in a more simple or sedentary task. The broader picture is that individuals intoxicated on opiates, regardless of how one chooses to define this, are at risk for repeated use of a chemical substance with a substantial addictive potential. Addiction to Opioids will eventually affect all areas of functioning, and make life unmanageable.

Differential Diagnosis

There are diagnostic rule-outs for the clinician to consider. In the DSM -5, Alcohol Intoxication and other sedative-hypnotics can produce symptoms similar to Opioid Intoxication (American Psychiatric Association, 2013). The illicit user may have used several different drugs, such as Alcohol and Opioids, which can complicate proper management, and produce a synergistic effect which increases risk of life –threatening overdose. Illicit use of Buprenorphine with benzodiazepines and Alcohol are noted as especially high risk (Häkkinen, Launiainen, & Ojanperä,, 2012). This is a popular combination for addicts, as the effects of an opioid are potentiated by benzodiazepines, and Alcohol is widely regarded as “ not a drug”, and may not be thought of as entailing risk when consumed with other drugs.

References:

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

Baumann, B.M. , Patterson, R.A., Parone, D.A. Jones, M.K., Glaspey, L.J., Thompson, N.M. Stauss,

M.P., Haroz, R. ( 2013). Use and efficacy of nebulized naloxone in patients with suspected opioid Intoxication. The American Journal of Emergency Medicine . (Abstract). (31). 3. 585–588. Retrieved March 10, 2014, from http://dx.doi.org/10.1016/j.ajem.2012.10.004

Fareed, A., Stout, S. Casarella, J., Vayalapalli, S., Cox, J., Drexler, K. (2011). Illicit Opioid Intoxication: Diagnosis and Treatment. Substance Abuse: Research and Treatment 2011:5 17–25. doi: 10.4137/SART.S7090

Häkkinen, M., Launiainen, E. V. and Ojanperä, I. (2012). Benzodiazepines and Alcohol are associated with cases of fatal buprenorphine poisoning. European Journal of Clinical Pharmacology (68). 3. 301-309 Retrieved March 10, 2014, from: http://link.springer.com/article/10.1007/s00228-011-1122-4

Heller, J.L. Zieve, D., Black, B., Slon, S., and Wang.S. (2013) Opioid Intoxication.Medline Plus. Retrieved March 12, 2014 from http://www.nlm.nih.gov/medlineplus/ency/article/000948.htm

Stolbach, A. Hoffman, R.S., Traub, S.J., Grayzel, J. ( 2014). Acute opioid intoxication in adults Retrieved March 10, 2014 from http://www.uptodate.com/contents/acute-opioid-intoxication-in-adults


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