What is the treatment for opioid dependence with intoxication indicated by ICD (International Classification of Diseases) code F11.21?

Treatment of Opioid Dependence with Intoxication (ICD-10 F11.21)

For patients with opioid dependence in remission (F11.21) who present with acute intoxication or respiratory depression, immediately provide ventilation support with bag-mask, administer naloxone starting at 0.04-0.4 mg with dose escalation up to 2 mg as needed, and arrange evidence-based medication-assisted treatment with buprenorphine or methadone combined with behavioral therapies for long-term management. 1

Acute Management of Opioid Intoxication

Immediate Interventions

• Assist ventilation with bag-mask device for any patient with known or suspected opioid overdose presenting with respiratory depression who is not in cardiac arrest 1
• Administer naloxone beginning with low doses (0.04-0.4 mg) to avoid precipitating severe withdrawal in opioid-dependent individuals, with repeat dosing or escalation to 2 mg if initial response is inadequate 1
• Activate emergency medical services if the patient is unresponsive and not breathing normally, while providing high-quality CPR if needed 1

Naloxone Administration Considerations

• The duration of naloxone action is approximately 45-70 minutes, but respiratory depression from long-acting opioids (e.g., methadone) may persist longer, requiring repeat doses 1
• Monitor for resedation after naloxone administration, with brief observation appropriate for short-acting opioids (morphine, heroin) but extended observation required for long-acting or sustained-release opioids 1
• Naloxone can produce fulminate withdrawal symptoms including agitation, hypertension, and violent behavior in opioid-dependent individuals, justifying the low initial dosing strategy 1

Long-Term Medication-Assisted Treatment

First-Line Treatment Options

Offer medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies as the foundation of opioid use disorder treatment 1, 2

• Methadone maintenance therapy has the strongest evidence for effectiveness, with demonstrated benefits in retention in treatment, reduction in illicit opioid use, decreased craving, and improved social function 3, 4
• Buprenorphine (a partial opioid agonist) is equally effective and can be prescribed in office-based settings, showing similar outcomes to methadone for retention and reduction in illicit opioid use 3, 4
• Both medications suppress opioid withdrawal symptoms and attenuate the effects of other opioids, allowing restoration of social connections when used long-term 4

Naltrexone as Alternative Treatment

• Naltrexone (50 mg daily) may be considered for highly motivated patients, particularly those who cannot or do not wish to take continuous opioid agonist therapy 1, 5
• Ensure opioid-free interval of minimum 7-10 days for short-acting opioids before initiating naltrexone to avoid precipitated withdrawal 5
• Patients transitioning from buprenorphine or methadone may be vulnerable to precipitated withdrawal for up to 2 weeks 5
• Oral naltrexone has shown limited success compared to methadone and buprenorphine, though extended-release injectable formulations show more promise 3, 4

Naloxone Challenge Test Protocol

Before initiating naltrexone, perform naloxone challenge if occult opioid dependence is suspected 5:

Intravenous route:

• Inject 0.2 mg naloxone, observe 30 seconds for withdrawal signs
• If no withdrawal, inject 0.6 mg naloxone, observe additional 20 minutes 5

Subcutaneous route:

• Administer 0.8 mg naloxone, observe 20 minutes for withdrawal signs 5

Do not perform the challenge test in patients showing clinical signs of opioid withdrawal or whose urine contains opioids 5

Treatment Algorithm for F11.21

Step 1: Stabilize Acute Intoxication

• Provide respiratory support and naloxone as described above 1
• Monitor for resedation and repeat naloxone dosing as needed 1

Step 2: Assess for Opioid Use Disorder

• The F11.21 code indicates "opioid dependence, in remission," but acute intoxication suggests active use 6
• Screen for DSM-5 opioid use disorder criteria (problematic pattern leading to clinically significant impairment with ≥2 criteria within a year) 1
• Prevalence of opioid dependence in primary care settings ranges from 3-26% among patients on chronic opioid therapy 1

Step 3: Initiate Medication-Assisted Treatment

Prioritize buprenorphine or methadone over naltrexone based on superior evidence for retention and outcomes 1, 2, 3, 4:

• Start buprenorphine when patient is in mild-moderate withdrawal (typically 12-24 hours after last short-acting opioid use)
• Methadone can be initiated in specialized opioid treatment programs without waiting for withdrawal
• Consider naltrexone only for patients who refuse agonist therapy and can maintain 7-10 day opioid-free period 5

Step 4: Combine with Behavioral Therapies

• Provide concurrent behavioral therapies (e.g., cognitive behavioral therapy) with medication-assisted treatment to reduce opioid misuse and increase retention 1
• Longer duration of treatment allows restoration of social connections and is associated with better outcomes 4

Risk Mitigation Strategies

Concurrent Medication Concerns

• Avoid prescribing benzodiazepines concurrently with opioids whenever possible due to increased risk of fatal respiratory depression 1
• If both medications are necessary, taper opioids first as benzodiazepine withdrawal carries greater risks (seizures, delirium tremens) 1
• Check prescription drug monitoring program (PDMP) data to identify dangerous combinations 1

Overdose Prevention

• Offer naloxone for take-home use when risk factors are present, including history of overdose, substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use 1
• Overdose risk is dose-dependent, with hazard ratios increasing from 1.44 at 20-49 MME/day to 8.87 at ≥100 MME/day 1

Monitoring Requirements

• Review PDMP data when starting and periodically during treatment (every prescription to every 3 months) 1
• Consider urine drug testing at least annually to assess for prescribed medications and illicit drugs 1
• For naltrexone, monitor liver function tests at baseline and every 3-6 months due to risk of hepatic injury at supratherapeutic doses 1

Common Pitfalls to Avoid

• Do not use naloxone in cardiac arrest from opioid overdose; follow standard BLS/ACLS algorithms instead 1
• Do not initiate naltrexone without adequate opioid-free period or positive naloxone challenge, as this precipitates severe withdrawal 5
• Do not rely on behavioral interventions alone, as they have extremely poor outcomes with >80% returning to drug use 3
• Do not discontinue medication-assisted treatment prematurely, as this increases risk of relapse and overdose 4