Occurrence and management of iatrogenic analgesia addiction

Question 1

Define iatrogenesis?

Answer 1

Causation of an adverse/undesired effect/condition resulting from medical/surgical treatment

Question 2

Describe how iatrogenic addiction generally arises in clinical practice?

Answer 2

Patient becomes addicted to a drug that was originally prescribed for a medical condition

Question 3

What kind of drug can cause iatrogenic analgesia addiction?

Answer 3

A drug that targets reward circuit in brain and targets compulsive drug-seeking and taking

Question 4

What are the 3 processes of taking analgesia that can ultimately result in iatrogenic analgesia addiction?

Answer 4

Tolerance

Dependence

Addiction

Question 5

What is meant by drug tolerance?

Answer 5

Increased drug doses are needed to achieve same effect due to repeated or prolonged exposure to the drug

Question 6

How many analgesia doses are typically taken by a patient before tolerance develops?

Answer 6

After repeated use or from single usage

Question 7

How does analgesia tolerance develop into analgesia dependence?

Answer 7

Body has adapted to having that analgesic regularly that you need that particular analgesic to function normally

Question 8

What are the 2 forms of dependence?

Answer 8

Physical

Psychological

Question 9

What is meant by physical dependence and psychological dependence?

Answer 9

Physical dependence: Withdrawal symptoms present when drug is stopped abruptly/taken in smaller doses

Psychological dependence: Craving for the drug which can last for months to years

Question 10

Define drug addiction?

Answer 10

Chronic, relapsing disorder characterised by compulsive drug seeking and use despite resulting adverse consequences

Question 11

What is the relationship between drug addiction and Substance Use Disorder (SUD)?

Answer 11

Addiction is the most severe form of substance use disorder

Question 12

Which 3 brain regions cause drug dependence to develop into drug addiction, and what behaviour develops in the patient from this?

Answer 12

Effects on basal ganglia, extended amygdala and prefrontal cortex of brain by analgesics causes compulsive seeking behaviour which leads to addiction

Question 13

What brain circuit does the basal ganglia play a role in, and what neurotransmitter mediates this circuit?

Answer 13

Basal ganglia plays role in reward circuit, which is mediated by dopamine

Question 14

What 2 aspects of the patient’s lifestyle are controlled by the reward circuit of the brain?

Answer 14

Production of positive motivation, such as pleasant effects from natural activities like food

Formation of habits and routines

Question 15

How does analgesia affect the basal ganglia and reward circuit so that the patient develops compulsive drug seeking behaviour?

Answer 15

Analgesia over-activate reward circuit by increasing dopamine release from neurons by unnaturally large amount which provides euphoria

Circuit eventually adapts to analgesia presence and it desensitised to anything else that previously activated reward circuit, as they no longer meet the increased dopamine threshold

Compulsive seeking of analgesia is now the only way to provide the euphoric high, creates craving for analgesia

Question 16

How does analgesia affect the basal ganglia and reward circuit so that the patient develops compulsive drug taking behaviour, which leads to habitual drug taking?

Answer 16

Analgesia has been integrated into normal habits and routines, forms habitual substance taking

Question 17

What feelings are produced by the circuit of the extended amygdala, and how does this correlate to substance use?

Answer 17

Circuit produces feelings such as irritability, anxiety, unease

This circuit is triggered by substance withdrawal

Question 18

How does prolonged analgesic drug use affect circuit of the extended amygdala and lead to compulsive drug-seeking behaviour of addiction?

Answer 18

Prolonged substance use causes circuit to become increasingly sensitive, so that drugs are needed to provide temporary relief from increasingly intense withdrawal

Question 19

What 3 aspects of the patient’s lifestyle are controlled by the prefrontal cortex?

Answer 19

Mediates circuit of impulse self-control, thinking, making decisions

Question 20

How does prolonged analgesic drug use affect circuit of the prefrontal cortex and lead to compulsive drug-seeking behaviour and use of addiction?

Answer 20

Function of prefrontal cortex is decreased by prolonged drug use, so that there is less balance between this circuit and reward and withdrawal circuits, resulting in loss of impulse control over drug-seeking and drug-taking behaviours.

Question 21

Give 8 examples of risk groups of analgesia addiction?

Answer 21

Poverty

Employment and history of legal problems

Personal/family history of substance misuse

Lack of access to medical care

History of severe depression/anxiety/mental health disorders

Thrill-seeking or risk-taking behaviour

Heavy tobacco use

Chronic pain

Question 22

Give 3 common ways in which iatrogenic analgesia addiction is managed?

Answer 22

Life history review

Assertive training

Methadone maintenance with psychotherapy

Question 23

Why is life history review an effective way of managing iatrogenic analgesia addiction?

Answer 23

Patient usually feel need to make up for lost time in neglecting themselves and family, which makes them feel overwhelmed and inadequate

Meeting with therapist for review on what they want to make up for can provide patients with reinforcement and support on solving each problem in orderly way

Question 24

Why is assertive training an effective way of managing iatrogenic analgesia addiction?

Answer 24

Patients tend to have passive, non-assertive behaviour and can have assertion deficiency diagnosis so training allows patients to deal with conflict situations without seeking substance use after

Question 25

What is assertive deficiency diagnosis?

Answer 25

Patient is passive and accepting of unreasonable circumstances

Or

Reports anxiety and psychosomatic symptoms in response to situations which require assertive behaviour

Question 26

Why is methadone maintenance and psychotherapy an effective way of managing iatrogenic analgesia addiction?

Answer 26

Methadone is a long-acting opiate so can be given under programme control only and avoids take-home medication.

Psychotherapy allows development of coping mechanisms