Opioid Use Disorders 1 5 the reinforcing property of alcohol seems to be attenuated for some drinkers, naltrexone is helpful as an adjunct to treatment of alcohol dependence. No studies have reported the use of naltrexone beyond 12 weeks. Nalmefene, an experimental oral opioid antagonist, appears as effective as nal- trexone and possibly has less risk of liver toxicity. Acamprosate, an analog of homocysteic acid, has produced higher continuous abstinence rates and fewer drinking days. It seems to affect excitatory amino acid neurotransmitters and possibly the GABA system. It is not yet available in the US. Gamma hydroxybutyrate has been used to treat alcohol and opiate withdrawal outside the U.S., but it is an abusable drug. BIBLIOGRAPHY I . Brewer C: Combining pharmacological antagonists and behavioral psychotherapy in treating addictions. Br 2. Fuller RF, Branchey L, Brightwell DR, et al: Disulfiram treatment of alcoholism: A Veterans Administration 3. Garbutt JC, West SL, Carey TS, et al: Pharmacological treatment of alcohol dependence: A review of the evi- 4 Johnston SC Pelletier L L Jr: Enhanced hepatoxicity of acetorninophen in the alcoholic patient. Medicine 5 . O’Con nor PG, Schottenfeld R: Patients with alcohol problems. New Engl J Med 338:592400 , 1998. 6. O’Malley SS: Opioid antagonists in the treatment of alcohol dependence: Clinical efficacy and prevention of 7. Sass H, Soyka M, Mann K, Zieglgansberger W : Relapse prevention by acamprosate. Arch Gen Psychiat 8. Stibler H: Carbohydrate-deficient transferrin in serum: A new marker of potentially harmful alcohol con- Psychiatry 157:3440, 1990. cooperative study. JAMA 256:1449-1455, 1986. dence. JAMA 281:1318-1325, 1999. (Baltimore) 76:185-191, 1997. relapse. Alcohol Alcohol 31(Suppl 1):77-81, 1996. 53~673-680, 1996. sumption reviewed. Clin Chem 37:2029-2037, 199 1. 2 1. OPIOID USE DISORDERS Jane A Kennedy D.O. 1. What are opioids? Opioids include naturally occurring substances such as opium and morphine, semisynthetic drugs such as heroin and hydromorphone, and totally synthetic drugs such as methodone or meperi- dine. These substances act at specific opioid receptors in the brain and the body, as do the endoge- nous opioids (endorphins, enkephalins, and dynorphins). 2. Who abuses opioids? Opioid abusers sometimes are divided into heroin addicts and prescription opioid abusers (“medical addicts”). In the United States, approximately one-half million people are dependent on heroin, but only about 140,000 are in methadone maintenance treatment. In 1995, there were 141,000 new users, and most were under age 26; in 1997,2.1 of high school seniors reported using heroin at least once. Although most users are still injecting heroin, there is an increase in intranasal use and smoking, due to increased purity and fear of HIV transmission with needles. Prescription drug abusers frequently are patients with real or fabricated pain, or health professionals with access to medications by prescription or diversion. 3 Describe the signs and symptoms of opioi d intoxi cation. Soon after injecting heroin, the person may vomit because of activation of the chemoreceptor trigger zone in the medulla; for the heroin user, this reaction often indicates “good” heroin. Feeling sedation, warmth, and euphoria (“flush and rush”), the user “nods,” with the head dropping toward
