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
