Complications
Physical dependence to opioids results in withdrawal symptoms if the dose of opioids is decreased abruptly. Withdrawal may occur as early as a few hours after the last time the drug is taken.
Symptoms of withdrawal include agitation, restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps, and restless legs.
Medical detoxification and/or opioid maintenance therapy are potential treatments of opioid withdrawal.
Intravenous drug abuse increases the risk of transmitting hepatitis A.
The Centers for Disease Control and Prevention recommends hepatitis A vaccination for injection and noninjection drug users (i.e., all those who use illicit drugs).[182]
Education and counseling that promote safe sexual activities and deter unsafe injecting drug use can minimize transmission.
Chronic intravenous drug abuse will lead to skin changes that can be a hallmark of heroin addicts.
These skin changes may develop into infections such as cellulitis and abscesses that require medical care with antibiotics and possibly surgery.[Figure caption and citation for the preceding image starts]: Needle marks and bruising at injection sites in a patient with opioid use disorderFrom the personal collection of Ashwin A. Patkar; used with permission [Citation ends].
Chronic intravenous drug abuse will lead to scarred and/or collapsed veins.
This manifestation can lead to difficult peripheral intravenous access.
Intravenous drug abuse and high-risk sexual activities increase the risk of transmitting HIV. Promoting use of clean needles (not sharing needles) and use of condoms can minimize transmission.
The Centers for Disease Control and Prevention recommends pre-exposure prophylaxis (PrEP) for HIV for adults and adolescents who inject drugs and report injection practices that place them at substantial ongoing risk of HIV exposure and acquisition (e.g., sharing needles).[181]
Treatment with methadone or buprenorphine can enhance patient recruitment on to antiretroviral therapy, adherence to antiretroviral therapy, and HIV viral suppression.[22]
Intravenous drug abuse and high-risk sexual activities increase the risk of transmitting hepatitis B, especially if patient does not have active immunity from the hepatitis B vaccine.
The Centers for Disease Control and Prevention recommends universal hepatitis B vaccination in all adults ages 19 to 59 years.[182] In people 60 years of age or older, hepatitis B vaccination is recommended in the presence of additional risk factors, including current or recent injection drug use.[182]
Education and counseling that promote safe sexual activities and deter unsafe injecting drug use can minimize transmission.
Intravenous drug abuse and high-risk sexual activities increase the risk of transmitting hepatitis C.
Promoting use of clean needles (not sharing needles) and use of condoms can minimize transmission.
Co-treatment of opioid use disorder and hepatitis C infection can help to improve outcomes for both conditions.[22]
Intravenous drug abuse, and environmental factors such as being in close quarters and with people at high risk for exposure to tuberculosis (e.g., prisons and shelters), increase risk of tuberculosis.
The American Society of Addiction Medicine recommends testing for tuberculosis with a purified protein derivative (PPD) skin test in all patients with opioid use disorder.[46]
Intravenous drug abuse increases the risk of infection of the heart lining and valves.
Bacteria and other pathogens can enter the bloodstream and travel to the heart valves and lining, leading to infection.
If patient develops endocarditis, patient will need expert consultation from infectious disease specialist and possibly cardiothoracic surgery for management.
Intravenous drug abuse increases the risk of infection of the bone or bone marrow. Bacteria and other pathogens can enter the bloodstream and travel to bones, leading to infection.
If patient develops osteomyelitis, patient will need expert consultation from infectious disease specialist and surgery for management.
Comorbid psychiatric disorders such as bipolar disorder, ADHD, major depression, anxiety disorders, personality disorders, PTSD, and psychosis are associated with increased risk of substance abuse, including opioid use.[17][18][19][20][21] People with mental health disorders are also more likely to receive prescription opioids than those without mental health disorders, and to initiate injection drug use.[30][31]
Psychiatric disorders and substance use disorders are both strongly associated with increased suicide risk.[46]
Assessment for the presence of psychiatric disorders should occur prior to treatment initiation.[46] Hospitalization may be appropriate for patients with severe or unstable psychiatric symptoms that may compromise the safety of self or others.[46]
Exposure to additives and contaminants found in illicit intravenous drugs can lead to immune reactions resulting in arthritis and other rheumatologic illness.
Patient should be referred to a rheumatologist for management.
Following emergency stabilization, consider hospitalization of patients with complications of opioid overdose.
A bag-valve-mask should be used, with attention paid to depth and rate of ventilation. Physician should be prepared to initiate endotracheal intubation if respiratory depression continues despite naloxone treatment to reverse opioid effects.[174][175]
Opioid toxicity and/or naloxone treatment may lead to acute pulmonary edema, which requires supportive care.[176]
Propoxyphene has type IA antidysrhythmic properties that can cause prolongation of the QRS interval, which is responsive to sodium bicarbonate administration.[177]
Methadone overdose can lead to QTc prolongation and torsades de pointes. If QTc is 500 milliseconds or longer, patient should be placed on a cardiac monitor for a 24-hour period with correction of hypomagnesemia, hypocalcemia, and hypokalemia if present.
Be aware of opioid intoxication in combination with central nervous system depressants, such as benzodiazepines and alcohol.[178]
Patients suspected to have pneumonia, pulmonary edema, endocarditis, persistent respiratory depression, or altered mental status require further observation and/or hospitalization.
Consider psychiatry consult for further evaluation.
The US Surgeon General provided an advisory on naloxone and opioid overdose. It states that naloxone can be prescribed or dispensed to individuals who are at elevated risk for opioid overdose and to their friends and family.[179]
Risk for nonfatal opioid overdose is greatest during periods of benzodiazepine use, in the 4 weeks after release from prison, in the 2 weeks after being discharged from hospital, on the day of admission to prison, and after discontinuation of antipsychotics.[180] Improvements in continuity of care when transitioning between services and ensuring safe prescribing and medication monitoring processes can reduce risk.[180]
Chronic intravenous drug abuse can lead to serious skin infections.
These skin changes may develop into infections such as cellulitis and abscesses that require medical care with antibiotics and possibly surgery.
Opioid intoxication and overdose increase risk of aspiration pneumonia due to sedation and inability to protect the airway.
Aspiration precautions should be maintained at all times.
Has been reported with ultra-rapid opioid detoxification.
Pregnant women with opioid use disorder experience increased obstetric complications, such as perinatal mortality, low birth weight, nonreassuring fetal status, malpresentation, third-trimester bleeding, and preeclampsia.[122]
Patients will need to be closely monitored, and require perinatal counseling and follow-up.
Neonatal complications of mothers with opioid use disorder include potential neonatal abstinence syndrome (NAS), neurobehavioral deficits, prematurity, postnatal growth deficiency, microcephaly, and sudden infant death syndrome.
With positive identification of opioids in either maternal or neonatal specimen, NAS can be diagnosed based on clinical features related to neurologic excitability, gastrointestinal dysfunction, and autonomic signs.[183] An abstinence scoring method, such as the Finnegan scoring system, can assess the severity of NAS and response to treatment.[184]
Initial treatment of NAS is supportive (e.g., providing nutrition for increased metabolism, decreasing sensory stimulation, assessing need for pharmacologic therapy).
Medication is indicated for neonates who have poor feeding with weight loss or failure to gain adequate weight, significant diarrhea and/or vomiting with hypovolemia, seizures, fever unrelated to another source, or inability to sleep.
If pharmacologic treatment is indicated, opioids are the drug of choice for reducing symptoms of withdrawal.[185][186] A Cochrane review concluded that addition of an opioid compared with standard care alone may increase duration of hospitalization and treatment, but may reduce days to regain birth weight and the duration of supportive care each day.[187] Buprenorphine has proved to be efficacious and apparently safe and may become a new treatment for NAS.[188][189]
Endocrine effects of opioid use include inhibition of the gonadal axis in the hypothalamus and increased conversion of testosterone to dihydrotestosterone.[190] Hypogonadism is present in up to 63% of male individuals on chronic opioids.[190] Gonadotroph deficiency is highest after exposure to fentanyl.[190] Male and female patients with hypogonadism may experience sexual dysfunction and decreased libido.[190] Male patients can present with erectile dysfunction, impotence, and gynecomastia, while female patients can have menstrual irregularities.[190]
Naloxone in the setting of opioid overdose has been associated with acute lung injury and/or pulmonary edema.[176]
Treatment is primarily supportive.
Pulmonary edema has also been reported with ultra-rapid opioid detoxification.
Endocrine effects of opioid use include aberrant modulation of the corticotropic axis via effects on opioid receptors located in the hypothalamus and pituitary gland.[190]
Hypocortisolism affects between 15% and 24% of males and females on chronic opioids.[190]
Hypocortisolism can present with a wide range of symptoms including fatigue, malaise, abdominal discomfort, anorexia, and orthostatic hypotension.[190]
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