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Emergency Medicine556 papers

Opioid dependence

Last edited: 4/14/2026

Overview

Opioid dependence is a chronic condition characterized by compulsive use of opioids despite harmful consequences, often involving physical dependence and withdrawal symptoms upon cessation. 118

Diagnosis

  • Clinical history of opioid use and withdrawal symptoms.
  • Physical examination for signs of intoxication or withdrawal.
  • Laboratory tests may include urine toxicology screens to confirm opioid use. 118

    • Management

  • First-line treatments:
    • - Methadone and buprenorphine: Used for opioid substitution therapy to manage withdrawal symptoms and reduce illicit opioid use. 18 - Naltrexone: Antagonist therapy for patients not dependent on opioids or in maintenance phase post-detoxification. 117
  • Adjunctive treatments:
    • - Behavioral therapies: Cognitive-behavioral therapy, contingency management. - Supportive care: Addressing comorbidities like mental health disorders and infectious diseases. 18

    Special Populations

  • Pregnancy: Prenatal opioid exposure linked to adverse fetal cardiac and autonomic development; careful monitoring and management crucial. 3
  • Pediatrics: Nalmefene nasal spray approved for emergency treatment of opioid overdose in pediatric patients aged 12 years and older. 1
  • Elderly: Higher susceptibility to adverse outcomes from prescription opioid misuse; careful monitoring of polypharmacy and pain management. 16

    • Key Recommendations

  • Utilize naloxone nasal spray for emergency treatment of opioid overdose in adults and pediatric patients aged 12 years and older. (Evidence: Strong 1)
  • Implement opioid substitution therapy (OST) with methadone or buprenorphine for managing opioid dependence, considering individual patient needs. (Evidence: Strong 18)
  • Enhance access to naloxone for lay responders and ensure compliance with Good Samaritan laws to reduce overdose fatalities. (Evidence: Moderate 11)
  • Monitor and manage opioid-dependent patients for comorbidities, particularly in elderly populations, to mitigate adverse outcomes. (Evidence: Moderate 16)
  • Provide educational interventions and training for healthcare providers and first responders to improve recognition and management of opioid overdose and misuse. (Evidence: Expert opinion 15)

    • References

    1 Nallani SC, Li Z, Florian J, Xu Y, Sabarinath S, Brescia-Oddo T et al.. FDA Approval Summary: Nalmefene Nasal Spray for the Emergency Treatment of Known or Suspected Opioid Overdose. Clinical pharmacology and therapeutics 2025. link 2 Levine S, Andrews M, Saracco B, Salzman M. Strategies for treating acute pain in patients with opioid dependence: a scoping review protocol. BMJ open 2024. link 3 Howell MP, Wiseman CA, Rosen MZ, Yeates WM, Wright LA, O'Connell SS et al.. Impact of prenatal opioids on cardiac and autonomic development: systematic review and meta-analysis. Journal of perinatology : official journal of the California Perinatal Association 2023. link 4 . Opioids Now Account for More Than Half of Child Poisoning Deaths. The American journal of nursing 2023. link 5 Khalemsky M, Khalemsky A, Lankenau S, Ataiants J, Roth A, Marcu G et al.. Predictive Dispatch of Volunteer First Responders: Algorithm Development and Validation. JMIR mHealth and uHealth 2023. link 6 Mohr SM, Atkins AI, Webb AC, Monroe KW, Nichols MH. Storage of Medications: A Survey of Families in the Pediatric Emergency Department. Southern medical journal 2021. link 7 Rock PJ, Quesinberry D, Singleton MD, Slavova S. Emergency Medical Services and Syndromic Surveillance: A Comparison With Traditional Surveillance and Effects on Timeliness. Public health reports (Washington, D.C. : 1974) 2021. link 8 Hawkins D, Punnett L, Davis L, Kriebel D. The Contribution of Occupation-Specific Factors to the Deaths of Despair, Massachusetts, 2005-2015. Annals of work exposures and health 2021. link 9 Inglis JM, Caughey GE, Smith W, Shakib S. Documentation of adverse drug reactions to opioids in an electronic health record. Internal medicine journal 2021. link 10 Molyneux J. The Top Health Care News Story of 2017: American Instabilities: Health Care Reform, Opioid Overdoses. The American journal of nursing 2018. link 11 Watson DP, Ray B, Robison L, Huynh P, Sightes E, Walker S et al.. Lay responder naloxone access and Good Samaritan law compliance: postcard survey results from 20 Indiana counties. Harm reduction journal 2018. link 12 Yung L, Lee KC, Hsu C, Furnish T, Atayee RS. Patterns of naloxone use in hospitalized patients. Postgraduate medicine 2017. link 13 Vranken MJM, Mantel-Teeuwisse AK, Jünger S, Radbruch L, Scholten W, Lisman JA et al.. Barriers to access to opioid medicines for patients with opioid dependence: a review of legislation and regulations in eleven central and eastern European countries. Addiction (Abingdon, England) 2017. link 14 Connors NJ, Nelson LS. The Evolution of Recommended Naloxone Dosing for Opioid Overdose by Medical Specialty. Journal of medical toxicology : official journal of the American College of Medical Toxicology 2016. link 15 Kim H, Heverling H, Cordeiro M, Vasquez V, Stolbach A. Internet Training Resulted in Improved Trainee Performance in a Simulated Opioid-Poisoned Patient as Measured by Checklist. Journal of medical toxicology : official journal of the American College of Medical Toxicology 2016. link 16 West NA, Dart RC. Prescription opioid exposures and adverse outcomes among older adults. Pharmacoepidemiology and drug safety 2016. link 17 Robinson A, Wermeling DP. Intranasal naloxone administration for treatment of opioid overdose. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists 2014. link 18 Murnion B. Management of opioid substitution therapy during medical intervention. Internal medicine journal 2012. link 19 Childers JW, Arnold RM. "I feel uncomfortable 'calling a patient out'": educational needs of palliative medicine fellows in managing opioid misuse. Journal of pain and symptom management 2012. link 20 Lynch RE, Hack RA. Methadone-induced rigid-chest syndrome after substantial overdose. Pediatrics 2010. link 21 Tjäderborn M, Jönsson AK, Ahlner J, Hägg S. Tramadol dependence: a survey of spontaneously reported cases in Sweden. Pharmacoepidemiology and drug safety 2009. link 22 Patil SG, Gale TJ. Preliminary design of remotely used and monitored medication dispenser. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference 2006. link 23 Holly G. Canada: coroner's inquest into the methadone-related death of a prisoner. Canadian HIV/AIDS policy & law review 2004. link 24 Senay EC, Adams EH, Geller A, Inciardi JA, Muñoz A, Schnoll SH et al.. Physical dependence on Ultram (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur. Drug and alcohol dependence 2003. link00321-6) 25 Christenson J, Etherington J, Grafstein E, Innes G, Pennington S, Wanger K et al.. Early discharge of patients with presumed opioid overdose: development of a clinical prediction rule. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2000. link 26 Guitart X, Hayward M, Nisenbaum LK, Beitner-Johnson DB, Haycock JW, Nestler EJ. Identification of MARPP-58, a morphine- and cyclic AMP-regulated phosphoprotein of 58 kDa, as tyrosine hydroxylase: evidence for regulation of its expression by chronic morphine in the rat locus coeruleus. The Journal of neuroscience : the official journal of the Society for Neuroscience 1990. link 27 Salem RS, Muniz CE. Treatment of propoxyphene dependence with thioridazine. The Journal of clinical psychiatry 1980. link

    Original source

    1. [1]
      FDA Approval Summary: Nalmefene Nasal Spray for the Emergency Treatment of Known or Suspected Opioid Overdose. — Nallani SC, Li Z, Florian J, Xu Y, Sabarinath S, Brescia-Oddo T et al. Clinical pharmacology and therapeutics (2025)
    2. [2]
      Strategies for treating acute pain in patients with opioid dependence: a scoping review protocol. — Levine S, Andrews M, Saracco B, Salzman M BMJ open (2024)
    3. [3]
      Impact of prenatal opioids on cardiac and autonomic development: systematic review and meta-analysis. — Howell MP, Wiseman CA, Rosen MZ, Yeates WM, Wright LA, O'Connell SS et al. Journal of perinatology : official journal of the California Perinatal Association (2023)
    4. [4]
      Opioids Now Account for More Than Half of Child Poisoning Deaths. The American journal of nursing (2023)
    5. [5]
      Predictive Dispatch of Volunteer First Responders: Algorithm Development and Validation. — Khalemsky M, Khalemsky A, Lankenau S, Ataiants J, Roth A, Marcu G et al. JMIR mHealth and uHealth (2023)
    6. [6]
      Storage of Medications: A Survey of Families in the Pediatric Emergency Department. — Mohr SM, Atkins AI, Webb AC, Monroe KW, Nichols MH Southern medical journal (2021)
    7. [7]
      Emergency Medical Services and Syndromic Surveillance: A Comparison With Traditional Surveillance and Effects on Timeliness. — Rock PJ, Quesinberry D, Singleton MD, Slavova S Public health reports (Washington, D.C. : 1974) (2021)
    8. [8]
      The Contribution of Occupation-Specific Factors to the Deaths of Despair, Massachusetts, 2005-2015. — Hawkins D, Punnett L, Davis L, Kriebel D Annals of work exposures and health (2021)
    9. [9]
      Documentation of adverse drug reactions to opioids in an electronic health record. — Inglis JM, Caughey GE, Smith W, Shakib S Internal medicine journal (2021)
    10. [10]
      The Top Health Care News Story of 2017: American Instabilities: Health Care Reform, Opioid Overdoses. — Molyneux J The American journal of nursing (2018)
    11. [11]
      Lay responder naloxone access and Good Samaritan law compliance: postcard survey results from 20 Indiana counties. — Watson DP, Ray B, Robison L, Huynh P, Sightes E, Walker S et al. Harm reduction journal (2018)
    12. [12]
      Patterns of naloxone use in hospitalized patients. — Yung L, Lee KC, Hsu C, Furnish T, Atayee RS Postgraduate medicine (2017)
    13. [13]
      Barriers to access to opioid medicines for patients with opioid dependence: a review of legislation and regulations in eleven central and eastern European countries. — Vranken MJM, Mantel-Teeuwisse AK, Jünger S, Radbruch L, Scholten W, Lisman JA et al. Addiction (Abingdon, England) (2017)
    14. [14]
      The Evolution of Recommended Naloxone Dosing for Opioid Overdose by Medical Specialty. — Connors NJ, Nelson LS Journal of medical toxicology : official journal of the American College of Medical Toxicology (2016)
    15. [15]
      Internet Training Resulted in Improved Trainee Performance in a Simulated Opioid-Poisoned Patient as Measured by Checklist. — Kim H, Heverling H, Cordeiro M, Vasquez V, Stolbach A Journal of medical toxicology : official journal of the American College of Medical Toxicology (2016)
    16. [16]
      Prescription opioid exposures and adverse outcomes among older adults. — West NA, Dart RC Pharmacoepidemiology and drug safety (2016)
    17. [17]
      Intranasal naloxone administration for treatment of opioid overdose. — Robinson A, Wermeling DP American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists (2014)
    18. [18]
      Management of opioid substitution therapy during medical intervention. — Murnion B Internal medicine journal (2012)
    19. [19]
      "I feel uncomfortable 'calling a patient out'": educational needs of palliative medicine fellows in managing opioid misuse. — Childers JW, Arnold RM Journal of pain and symptom management (2012)
    20. [20]
      Methadone-induced rigid-chest syndrome after substantial overdose. — Lynch RE, Hack RA Pediatrics (2010)
    21. [21]
      Tramadol dependence: a survey of spontaneously reported cases in Sweden. — Tjäderborn M, Jönsson AK, Ahlner J, Hägg S Pharmacoepidemiology and drug safety (2009)
    22. [22]
      Preliminary design of remotely used and monitored medication dispenser. — Patil SG, Gale TJ Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference (2006)
    23. [23]
      Canada: coroner's inquest into the methadone-related death of a prisoner. — Holly G Canadian HIV/AIDS policy & law review (2004)
    24. [24]
      Physical dependence on Ultram (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur. — Senay EC, Adams EH, Geller A, Inciardi JA, Muñoz A, Schnoll SH et al. Drug and alcohol dependence (2003)
    25. [25]
      Early discharge of patients with presumed opioid overdose: development of a clinical prediction rule. — Christenson J, Etherington J, Grafstein E, Innes G, Pennington S, Wanger K et al. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine (2000)
    26. [26]
      Identification of MARPP-58, a morphine- and cyclic AMP-regulated phosphoprotein of 58 kDa, as tyrosine hydroxylase: evidence for regulation of its expression by chronic morphine in the rat locus coeruleus. — Guitart X, Hayward M, Nisenbaum LK, Beitner-Johnson DB, Haycock JW, Nestler EJ The Journal of neuroscience : the official journal of the Society for Neuroscience (1990)
    27. [27]
      Treatment of propoxyphene dependence with thioridazine. — Salem RS, Muniz CE The Journal of clinical psychiatry (1980)
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