Remote Primary Health Care Manuals

Opioids

  • Opioid withdrawal is usually not life threatening — opioid toxicity and overdose is life threatening
  • Use of opioids is increasing — typically prescribed or non-prescribed pharmaceutical opioids, eg paracetamol+codeine, oxycodone, morphine, tramadol
  • Chronic use will result in dependence
  • In remote areas opioids usually taken orally but may be smoked or injected
  • Regular use of opioids in pregnancy may cause serious harm to foetus — withdrawal, potential effects on neural development of long term exposure
  • Use in the mother during labour can result in suppression of babies respiration at birth
Red Flags — Urgent Medical Consult
  • Opioid intoxication
  • If person asks for opioid medicines prescribed elsewhere
  • If person seeking opioid medicines with possible dependence issues 
  • Withdrawal in pregnant woman

Effects of opioids

  • Pain relief
  • Calm, decreased anxiety, some euphoria
  • Strong respiratory system depressant
  • Slows bowel and causes constipation

Table 5.7  

Opioid intoxication (overdose)

Opioid withdrawal

  • Drowsy
  • Slow RR, low BP, pinpoint pupils
  • Unconscious, respiratory arrest
  • Restless, agitated, irritable
  • Pupils dilated, high BP, fast pulse
  • Runny nose, sneeze, goose bumps
  • Muscle ache, stomach ache, diarrhoea

Do first

  • If unconscious — DRS ABC AND give naloxone IM — adult 0.4mg, single dose 
  • If naloxone given — monitor in clinic for 4 hours
    • May need repeated naloxone doses until more awake and breathing adequately
    • Giving naloxone may cause rapid reversal of overdose and trigger aggressive behaviour — have 2 staff members with person
    • Naloxone only works in the body for 30 to 90 minutes — after initial recovery, loss of consciousness may return and further treatment with naloxone is needed

Ask — person, family or friends

  • What has person taken and how — tablets, injection, smoking
  • When did they last have it — day/date and time
  • How often and how much used
  • Other drugs used — prescribed, legal, illegal
  • Existing physical and mental illness — thoughts of self-harm or suicide
  • Who is their usual prescriber

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • U/A — positive blood may mean muscle break down
  • Urine drug screen if drug use unclear — label opioid use
    • Results make take weeks. Still important for long-term management
  • ECG and Coma scale score 
  • Head-to-toe exam — with attention to pupil size

Do

  • Be calm, supportive, reassuring — explain what is happening to them and what you are doing
  • Medical consult

Give medicines as needed

  • Opioid medication is not necessary to manage acute withdrawal. Treat symptomatically for 3–5 days
  • Adult doses
    • Paracetamol oral — 1g, up to 4 times a day (qid)
    • Antiemetic for nausea or vomiting — see Nausea and vomiting
    • Loperamide oral — adult 4mg, single dose for diarrhoea THEN loperamide oral — 2mg after each bowel action, up to 16mg/day
    • Muscle ache — ibuprofen (if no contraindications) oral — 200mg, 3 times a day (tds) 
    • Abdominal cramps — hyoscine butylbromide oral —10mg, 3 times a day (tds) 

Follow-up

  • Refer to drug and alcohol service, mental health service if needed
  • Notify usual opioid prescriber of any opioid overdose episodes
  • Make management plan Provide Brief interventions

If person asks for opioid medicines prescribed elsewhere — you must

  • Follow your organisation's policy about supply
  • Medical consult — doctor to check Prescription Shopping Alert Service
  • Contact current prescriber to obtain medical history, reason for using opioids, current dose and usual collection site

If person seeking opioid medicines with concerns raised of dependence issues

  • Medical consult or get advice from Drug and Alcohol Clinical Advisory Service