Chapter 25 Substance Use Disorders and Detoxification

Question 1

opioids as second-line medications

Answer 1

for neuropathic pain treatment

Question 2

opioid as first-line agents in certain circumstances

Answer 2

(i.e., acute neuropathic
pain, during titration periods with a first-line agent and
episodic exacerbations of neuropathic pain

Question 3

What system is implicated in the development of psychological dependence?

Answer 3

Mesolimbic dopaminergic projections to the nucleus

accumbens

Question 4

physical dependence

on opioids is probably due to

Answer 4

noradrenergic activity in the locus ceruleus.

Question 5

The incidence of analgesic

tolerance is lower with more potent opioids such as fentanyl,

Answer 5

presumably because these agents are more receptor-specific and fewer receptors are needed to produce
an analgesic effect

Question 6

risk for developing an

addiction to opioids

Answer 6

Strong predictors include personal history of illicit drug use and alcohol abuse. Selfreported craving
Comorbid psychiatric and chronic pain disorders

Question 7

disorders were found to improve with benzodiazepines.

Answer 7

chronic pain conditions such as trigeminal

neuralgia, tension headache, and temporomandibular disorders

Question 8

Clonazepam has been reported to provide long-term relief of

Answer 8

the episodic lancinating variety of phantom limb pain.

Question 9

Benzodiazepines

have been used for

Answer 9

the detoxification of patients
with chronic pain from sedative/hypnotic medications
and were superior to barbiturates for minimizing symptoms of withdrawal

Question 10

Benzodiazepines also cause

Answer 10

cognitive impairment as demonstrated by abnormalities on neuropsychological testing and EEG.

Question 11

In patients with chronic pain use of benzodiazepines and not opioids was associated with

Answer 11

decreased activity levels, higher rates of healthcare visits, increased domestic
instability, depression, and more disability day

Question 12

Benzodiazepines have been associated with exacerbation of

Answer 12

pain and interference with opioid analgesia, which is mediated by the
serotonergic system

Question 13

Benzodiazepines also increase the rate of developing

Answer 13

tolerance to opioids.

Question 14

Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association defines both substance abuse and dependence as

Answer 14

maladaptive (behavioral) patterns of substance use leading to clinically significant impairment or distress

Question 15

Substance abuse must be accompanied by any of the following:

Answer 15

interpersonal

problems, legal problems, failure to fulfill major role obligations, and recurrent substance use in hazardous situations

Question 16

In contrast to abuse, substance dependence is manifested by

Answer 16

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

Question 17

core criteria for a substance

use disorder in patients with chronic pain include

Answer 17

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

Question 18

Items from the Prescription Drug Use Questionnaire that best predicted the presence of addiction in a sample of patients with problematic medication use were

Answer 18

(1) the patients believing they were addicted, (2) increasing analgesic dose/frequency, and (3) a preferred route of administration.

Question 19

The diagnosis of addiction in the patient with chronic pain must demonstrate

Answer 19

certain drug taking behaviors that interfere with the successful fulfillment of life activities.

Question 20

goals of treatment.

Answer 20

Increased function and opioid analgesia without side effects,
not the avoidance of high doses of opioids

Question 21

evaluation of a patient suspected of misusing medications

Answer 21

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

Question 22

pseudoaddiction

Answer 22

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.

Question 23

Under optimal circumstances opioid contracts attempt to

Answer 23

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.

Question 24

aberrant behaviors consistent with addiction

Answer 24

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

Question 25

Abuse

Answer 25

Harmful use of a specific psychoactive substance

Question 26

Addiction

Answer 26

Continued use of a specific psychoactive substance | despite physical, psychological, or social harm

Question 27

Misuse

Answer 27

Any use of a prescription drug that varies from accepted medical practice

Question 28

Physical | dependence

Answer 28

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

Question 29

Psychological | dependence

Answer 29

Subjective sense of need for a specific-dependence psychoactive substance, either for its positive effects or to avoid negative effects associated with its abstinence

Question 30

an active substance use disorder is a relative | contraindication

Answer 30

to chronic opioid therapy.

Question 31

TREATMENT OF SUBSTANCE USE DISORDERS IN PATIENTS WITH CHRONIC PAIN

Answer 31

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

Question 32

Management of patients with substance use disorders in patients with chronic pain

Answer 32

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

Question 33

Interventions for patients with substance use disorders in patients with chronic pain

Answer 33

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

Question 34

Approach to patient who are being considered for chronic opioid treatment

Answer 34

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

Question 35

Detoxification

Answer 35

the process of withdrawing a person from a specific psychoactive substance in a safe and effective manner

Question 36

WHY IS DETOXIFICATION NECESSARY?

Answer 36

Because long-term treatment will have resulted in physiologic dependence, discontinuation or substantial dose reduction requires gradual tapering of the medication

Question 37

When is physiologic opioid dependence demonstrated?

Answer 37

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

Question 38

once physiologic dependence is established

Answer 38

abrupt discontinuation of opioids will precipitate acute withdrawal

Question 39

The essential element for successful opioid detoxification

Answer 39

the gradual tapering of the dose of medication

Question 40

When is Opioid withdrawal dangerous?

Answer 40

Opioid withdrawal is generally not dangerous except with patients at risk from increased sympathetic tone (e.g., increased intracranial pressure or unstable angina)

Question 41

Patients with pain are often particularly | miserable during opioid withdrawal because of

Answer 41

the phenomenon of rebound pain.

Question 42

the goal of detoxification

Answer 42

ameliorate withdrawal as much as is clinically practical

Question 43

What should be discussed with the patient prior to starting a detoxification program?

Answer 43

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

Question 44

Indications for Detoxification

Answer 44

``` 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 ```

Question 45

Indications for inpatient detoxification

Answer 45

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

Question 46

Subjective Opioid Withdrawal Scale (SOWS) and the Objective | Opioid Withdrawal Scale (OOWS)

Answer 46

allow for the objective rating of withdrawal and documentation of the patient’s condition over time

Question 47

Short–Half-Life Opioid Taper

Answer 47

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

Question 48

Short–Half-Life Opioid Taper | Slowing the taper may be accomplished by:

Answer 48

(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

Question 49

The preferable pharmacologic strategy for opioid detoxification

Answer 49

is to choose a long–half-life pure opioid agonist such as methadone, sustained-release morphine or oxycodone, and transdermal fentanyl patches

Question 50

long–half-life pure opioid agonist primary advantage

Answer 50

This strategy has the primary advantage of more consistent opioid serum levels with less chance of intermittent withdrawal between doses

Question 51

With a long–half-life agent, when is the onset of withdrawal symptoms

Answer 51

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

Question 52

Benefits of Switching from short– to long–half-life opioids | in anticipation of detoxification

Answer 52

may serendipitously prove an effective analgesic strategy. Side effects, intermittent withdrawal, and rebound pain may all improve such that detoxification may not be needed.

Question 53

detoxification strategy use of the partial agonist/ | antagonist opioids.

Answer 53

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

Question 54

The use of partial agonist/antagonists is designed to

Answer 54

reduce the severity of withdrawal and cause less reinforcing drug effects, less risk of respiratory depression,

Question 55

When using partial agonist/antagonists such as buprenorphine, it is important to give a small test dose under supervision because

Answer 55

of the rare precipitation of withdrawal symptoms secondary to the partial antagonist effect

Question 56

Buprenorphine Taper

Answer 56

- 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

Question 57

Clonidine,

Answer 57

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

Question 58

Other factors that | tend to increase the difficulty and length of a taper

Answer 58

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

Question 59

Progress in detoxification can be demonstrated by

Answer 59

simple compliance with taper instructions, not using other illicit substances, improvement in side effects of opioids, and maintenance of function

Question 60

Patients can have lingering | subacute withdrawal symptoms for weeks.

Answer 60

Insomnia and rebound | pain are the most common symptoms.

Question 61

Criteria for BENZODIAZEPINE DETOXIFICATION

Answer 61

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.

Question 62

The general features of benzodiazepine withdrawal

Answer 62

hyperarousal | and hypersympathetic states.

Question 63

benzodiazepine withdrawal is much more dangerous than | opioid withdrawal

Answer 63

potential for seizures, | hallucinations, hyperthermia, and delirium tremens

Question 64

The two main techniques for Benzodiazepine detoxification

Answer 64

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

Question 65

“second-generation” benzodiazepines

Answer 65

(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.

Question 66

Signs and Symptoms of Sedative-Hypnotic | Withdrawal - Hyperarousal

Answer 66

``` Agitation Anxiety Hyperactivity Insomnia Fever ```

Question 67

Signs and Symptoms of Sedative-Hypnotic | Withdrawal- Neurological

Answer 67

``` Ataxia Fasciculation/myoclonic jerks Formication Headache Myalgia Paresthesias/dysesthesias Pruritus Tinnitus Tremor Seizures Delirium ```

Question 68

Signs and Symptoms of Sedative-Hypnotic | Withdrawal - Genitourinary

Answer 68

Incontinence Loss of libido Urinary urgency, frequency

Question 69

Signs and Symptoms of Sedative-Hypnotic | Withdrawal - Psychiatric

Answer 69

``` Depersonalization Depression Hyperventilation Malaise Paranoid delusions Visual hallucinations ```

Question 70

Signs and Symptoms of Sedative-Hypnotic | Withdrawal - Gastrointestinal

Answer 70

``` Abdominal pain Constipation Diarrhea Nausea Vomiting Anorexia ```

Question 71

Signs and Symptoms of Sedative-Hypnotic | Withdrawal - Cardiovascular

Answer 71

``` Chest pain Flushing Palpitations Hypertension Orthostatic hypotension Tachycardia Diaphoresis ```