Chapter 25 Substance Use Disorders and Detoxification Flashcards
opioids as second-line medications
for neuropathic pain treatment
opioid as first-line agents in certain circumstances
(i.e., acute neuropathic
pain, during titration periods with a first-line agent and
episodic exacerbations of neuropathic pain
What system is implicated in the development of psychological dependence?
Mesolimbic dopaminergic projections to the nucleus
accumbens
physical dependence
on opioids is probably due to
noradrenergic activity in the locus ceruleus.
The incidence of analgesic
tolerance is lower with more potent opioids such as fentanyl,
presumably because these agents are more receptor-specific and fewer receptors are needed to produce
an analgesic effect
risk for developing an
addiction to opioids
Strong predictors include personal history of illicit drug use and alcohol abuse. Selfreported craving
Comorbid psychiatric and chronic pain disorders
disorders were found to improve with benzodiazepines.
chronic pain conditions such as trigeminal
neuralgia, tension headache, and temporomandibular disorders
Clonazepam has been reported to provide long-term relief of
the episodic lancinating variety of phantom limb pain.
Benzodiazepines
have been used for
the detoxification of patients
with chronic pain from sedative/hypnotic medications
and were superior to barbiturates for minimizing symptoms of withdrawal
Benzodiazepines also cause
cognitive impairment as demonstrated by abnormalities on neuropsychological testing and EEG.
In patients with chronic pain use of benzodiazepines and not opioids was associated with
decreased activity levels, higher rates of healthcare visits, increased domestic
instability, depression, and more disability day
Benzodiazepines have been associated with exacerbation of
pain and interference with opioid analgesia, which is mediated by the
serotonergic system
Benzodiazepines also increase the rate of developing
tolerance to opioids.
Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association defines both substance abuse and dependence as
maladaptive (behavioral) patterns of substance use leading to clinically significant impairment or distress
Substance abuse must be accompanied by any of the following:
interpersonal
problems, legal problems, failure to fulfill major role obligations, and recurrent substance use in hazardous situations
In contrast to abuse, substance dependence is manifested by
tolerance, withdrawal, using the substance in larger amounts or over a longer period than was intended, persistent desire or unsuccessful efforts to decrease or control substance use, spending large amounts of time in activities necessary to obtain the substance, the giving up or reduction of important activities
because of substance use, and continued substance use despite knowledge of having physical or psychological problems caused or exacerbated by the substance
core criteria for a substance
use disorder in patients with chronic pain include
the loss of control in the use of the medication, excessive preoccupation with the medication despite adequate analgesia, and adverse consequences associated with the use of the medication
Items from the Prescription Drug Use Questionnaire that best predicted the presence of addiction in a sample of patients with problematic medication use were
(1) the patients believing they were addicted, (2) increasing analgesic dose/frequency, and (3) a preferred route of administration.
The diagnosis of addiction in the patient with chronic pain must demonstrate
certain drug taking behaviors that interfere with the successful fulfillment of life activities.
goals of treatment.
Increased function and opioid analgesia without side effects,
not the avoidance of high doses of opioids
evaluation of a patient suspected of misusing medications
should be thorough and include an assessment of
the pain syndrome as well as other medical disorders, patterns of medication use, social and family factors, patient and family history of substance abuse, and a psychiatric history
pseudoaddiction
Reliance on medications that provide pain relief can result in a number of stereotyped patient behaviors that are often mistaken for addiction. Persistent pain can lead to increased focus on opioid medications. Patients
may take extraordinary measures to ensure an adequate medication supply even in the absence of addiction. This may be manifested as frequent requests for higher medication
doses and larger quantities of medication or seeking
medication from additional sources.
Under optimal circumstances opioid contracts attempt to
improve compliance by distributing information and utilizing a mutually designed, agreed-upon treatment plan
that includes consequences for aberrant behaviors and incorporates the primary care physician to form a “trilateral”
agreement with patient and pain specialist.
aberrant behaviors consistent with addiction
selling medications, losing prescriptions, using oral medications intravenously, concurrent abuse of alcohol or illicit drugs, repeated noncompliance with the prescribed use of medications, and deterioration in the patient’s ability to function in family, social, or occupational
roles
Abuse
Harmful use of a specific psychoactive substance
Addiction
Continued use of a specific psychoactive substance
despite physical, psychological, or social harm
Misuse
Any use of a prescription drug that varies from accepted medical practice
Physical
dependence
Physiologic state of adaptation to a dependence-specific
psychoactive substance characterized by the emergence of a withdrawal syndrome during abstinence that may be relieved in total or in part by readministration of the substance
Psychological
dependence
Subjective sense of need for a specific-dependence
psychoactive substance, either for its positive effects or
to avoid negative effects associated with its abstinence
an active substance use disorder is a relative
contraindication
to chronic opioid therapy.
TREATMENT OF SUBSTANCE
USE DISORDERS IN PATIENTS
WITH CHRONIC PAIN
A strict treatment structure with therapeutic goals, landmarks to document
progress, and contingencies for noncompliance should be made explicit and agreed upon by the patient and
all the providers of health care
Management of patients with substance use disorders in patients with chronic pain
The first step for the patient
is acknowledging that a problem with medication use
exists. The next step for the clinician is to stop the patient’s
behavior of misusing medications. Then, sustaining factors must be assessed and addressed
Interventions for patients with substance use disorders in patients with chronic pain
These interventions include
treating other medical diseases and psychiatric disorders, managing personality vulnerabilities, meeting situational challenges and life stressors, and providing support and understanding. Finally, the habit of taking the medication
inappropriately must be extinguished
Approach to patient who are being considered for chronic opioid treatment
A total approach to
the patient including a history of substance abuse, psychosocial comorbidities, and aberrant drug-related behaviors must be considered in an evaluation. Only if these potential risks can be minimized or treated should chronic opioid treatment be considered
Detoxification
the process of withdrawing a person from a specific psychoactive substance in a safe and effective manner
WHY IS DETOXIFICATION NECESSARY?
Because long-term treatment will have resulted in physiologic dependence, discontinuation or substantial dose reduction requires gradual tapering of the medication
When is physiologic opioid dependence demonstrated?
Although physiologic opioid dependence can be demonstrated experimentally within 7 days, most patients will not experience withdrawal symptoms unless they have continuously taken opioids for at least several weeks
once physiologic dependence is established
abrupt discontinuation of opioids will precipitate acute withdrawal
The essential element for successful opioid detoxification
the gradual tapering of the dose of medication
When is Opioid withdrawal dangerous?
Opioid withdrawal is generally not dangerous except
with patients at risk from increased sympathetic tone
(e.g., increased intracranial pressure or unstable angina)
Patients with pain are often particularly
miserable during opioid withdrawal because of
the phenomenon of rebound pain.
the goal of detoxification
ameliorate withdrawal as much as is clinically practical
What should be discussed with the patient prior to starting a detoxification program?
Explaining the treatment plan to patients before the detoxification begins is critical. In particular, patients should know to expect worsening of pain and should have a few concrete short-term goals to focus on, such as the
improvement in withdrawal symptoms, increasing functional abilities, or an alternative analgesic trial when withdrawal
has resolved
Indications for Detoxification
Intolerable side effects Inadequate response or benefit Aberrant drug-related behaviors - Noncompliance - Loss of control of medication use - Preoccupation with the medication - Continued use despite adverse consequences Refractory comorbid psychiatric illness Lack of functional improvement or impairment in role responsibilities
Indications for inpatient detoxification
failure of outpatient detoxification attempts,
medically unstable patients, comorbid psychiatric illness, unreliable or noncompliant patients, and complicated
pharmacologic regimens requiring taper of more than one medication or illicit drug
Subjective Opioid Withdrawal Scale (SOWS) and the Objective
Opioid Withdrawal Scale (OOWS)
allow for the objective rating of withdrawal and documentation of the patient’s condition over time
Short–Half-Life Opioid Taper
Determine the total daily dosage being used by the patient.
Adopt a fixed interval schedule with equal doses every 4–6 hr for 48 hr.
Increase the prescribed dose until the patient has no opioid
withdrawal symptoms for 48 hr.
Taper the amount of each dose without lengthening the interval
between doses.
Taper the total daily dose approximately 10% every 3–7 days
Short–Half-Life Opioid Taper
Slowing the taper may be accomplished by:
(1) increasing the number
of days at a given total dose; (2) decreasing a single dose amount while keeping the remaining doses the same;
(3) increasing the time
between doses only if the smallest individual dose has been reached
The preferable pharmacologic strategy for opioid detoxification
is to choose a long–half-life pure opioid agonist such as methadone, sustained-release morphine or oxycodone, and transdermal fentanyl patches
long–half-life pure opioid agonist primary advantage
This strategy has the
primary advantage of more consistent opioid serum levels
with less chance of intermittent withdrawal between doses
With a long–half-life agent, when is the onset of withdrawal symptoms
With a long–half-life agent, the onset of withdrawal symptoms
should be expected at 12 to 24 hr, although 24 to 48 hr is the usually reported time course. The severity will
usually peak at 36 to 96 hr but can occur up to 1 week later
Benefits of Switching from short– to long–half-life opioids
in anticipation of detoxification
may serendipitously prove an effective analgesic strategy. Side effects, intermittent
withdrawal, and rebound pain may all improve such that detoxification may not be needed.
detoxification strategy use of the partial agonist/
antagonist opioids.
The agent most commonly used in this category is buprenorphine or the buprenorphine-naloxone combination called suboxone. The naloxone component prevents abuse of the
medication
The use of partial agonist/antagonists is designed to
reduce the severity of withdrawal and cause less reinforcing drug effects, less risk of respiratory depression,
When using partial agonist/antagonists such as buprenorphine, it is important to give a small test dose under
supervision because
of the rare precipitation of withdrawal symptoms secondary to the partial antagonist effect
Buprenorphine Taper
- Test for the precipitation of acute withdrawal symptoms by giving an initial dose of 0.1 mg SQ/IM or 1.0 mg SL.
- Determine the total daily dose of the prescribed agent being taken by the patient.
- Estimate the equivalent total daily dose of buprenorphine (0.2 mg SQ/IM – morphine 10 mg PO).
- Adopt a fixed interval schedule with equal doses every 8–12 hr.
- Titrate the dosage until the patient has no withdrawal symptoms for 24–72 hr.
Taper the dose and interval to 0.1 mg SQ/IM or 1.0 mg PO QD. - Discontinue the medication when the patient experiences no or tolerable withdrawal symptoms
Clonidine,
an alpha-2-adrenergic agonist that decreases adrenergic
activity. Clonidine can help relieve many of the autonomic symptoms of opioid withdrawal, such as nausea, cramps, sweating, tachycardia,
and hypertension, which result from the loss of opioid
suppression of the locus ceruleus during the withdrawal
syndrome
Other factors that
tend to increase the difficulty and length of a taper
the longer a patient has been taking opioids, the more difficulty, medical comorbidity and complexity, older age, female gender, and detoxification from multiple agents simultaneously
Progress in detoxification can be demonstrated by
simple compliance with taper instructions, not using other
illicit substances, improvement in side effects of opioids,
and maintenance of function
Patients can have lingering
subacute withdrawal symptoms for weeks.
Insomnia and rebound
pain are the most common symptoms.
Criteria for BENZODIAZEPINE DETOXIFICATION
been using benzodiazepines continuously for more than
2 weeks should be tapered to avoid the unpleasant experience
of mild withdrawal and the risk of unexpected major
withdrawal symptoms.
The general features of benzodiazepine withdrawal
hyperarousal
and hypersympathetic states.
benzodiazepine withdrawal is much more dangerous than
opioid withdrawal
potential for seizures,
hallucinations, hyperthermia, and delirium tremens
The two main techniques for Benzodiazepine detoxification
taper of the agent a patient has been taking and the substitution of an equivalent dose of a long–half-life agent such as diazepam or clonazepam. Another strategy for benzodiazepine
detoxification utilizes phenobarbital substitution,
especially in cases of complex detoxification from multiple
agents such as opioids, sedative-hypnotics, and alcohol
“second-generation” benzodiazepines
(clonazepam, alprazolam, oxazepam, triazolam) are not fully crosstolerant with each other or with the more traditional agents. A patient may require higher doses than expected to avoid significant withdrawal symptoms when taking
these medications.
Signs and Symptoms of Sedative-Hypnotic
Withdrawal - Hyperarousal
Agitation Anxiety Hyperactivity Insomnia Fever
Signs and Symptoms of Sedative-Hypnotic
Withdrawal- Neurological
Ataxia Fasciculation/myoclonic jerks Formication Headache Myalgia Paresthesias/dysesthesias Pruritus Tinnitus Tremor Seizures Delirium
Signs and Symptoms of Sedative-Hypnotic
Withdrawal - Genitourinary
Incontinence
Loss of libido
Urinary urgency, frequency
Signs and Symptoms of Sedative-Hypnotic
Withdrawal - Psychiatric
Depersonalization Depression Hyperventilation Malaise Paranoid delusions Visual hallucinations
Signs and Symptoms of Sedative-Hypnotic
Withdrawal - Gastrointestinal
Abdominal pain Constipation Diarrhea Nausea Vomiting Anorexia
Signs and Symptoms of Sedative-Hypnotic
Withdrawal - Cardiovascular
Chest pain Flushing Palpitations Hypertension Orthostatic hypotension Tachycardia Diaphoresis
