Pain and Addiction Flashcards
What tools are used for opioid risk assessment?
- ORT (1-3 low; 4-7 moderate; 8 or greater high)
- SOAPP-R (Screener and Opioid Assessor for Patients with Pain; 7 or greater is high risk) - for detecting tisk of SUD (substance use disorder)
- COMM (Current opioid misuse measure - 9 or greater are high risk)
- DIRE - for patients already on opioids
What are five clinical features if patients with comorbid pain and addiction?
- increased psych disorders
- increased use of alcohol
- increased use of illicit substances
- increased medical comorbities
- increased use of prescription and non-prescription medication use
Define addiction
- chronic neurobiological disease with geneticm psychoscial and environmental factors
- characterized by
- craving
- compulsive use
- continued use despite harm
- control impaired
- +/- physical dependence and tolerance
- tendency to relapse
- cognitive distortions
Define physical dependence
- physical adaptation that is substance specific and results in withdrawal symptoms when substance is removed, tapered, etc.
Define tolerance
Physical adaptation where prolonged exposure to a substance results in a diminished effect
define pseudoaddiction
syndrome of abnormal behavoir in which patients become intesnely focused on obtaining analgesic medications (opioids) due to under-treatment of pain rather than true addiction
Once adequate analgesia is obtained, abnormal behaviors cease
Identify the brain region assoaciated with each behavioral aspect of addiction:
- inhibitory control
- withdrawal
- reward
- memory/learning
- motivation/drive
- PFC
- LC
- VTA (ventral tegmental area)
- Amygdala
- OFC (orbitofrontal cortex)
What are 10 components of universal precautions in opioid prescribing?
- Appropriate Dx with DDx
- Psych assessment with addiction screening
- informed consent for opioids
- Document written or verbal agreement
- Assess and document pain level and function before opioid trial
- Provide opioid trial +/- adjuvant
- Regularly assess pain scores and function
- Assess 5As
- OReview Dx and cormorbidies (including opioid misuse) often
- Document appropriately
What are the 5 As of pain treatment outcome?
Analgesia
Affect
Adverse events
Aberrant behaviors
Activity level
What are some therapuetic strategies for pain management in individuals with co-morbid psychiatric issues?
- Non-pharm
- CBT
- Mindfulness-based therapies
- Non-opioids
- TCAs, SNRIs, GPN
- Avoid short-acting Rx
- Physical therapies
- graded exercise programs
- OT/PT
- Massage, etc.
What personality disorder cluster has a higher susceptibilty to substance abuse?
Cluster B
(Borderline personality disorder - higher pain sensitivity)
What personality disorder has a higher susceptibilty to chronic pain development?
Cluster C
Avoidant, dependant, obsessive-compulsive
Name 5 serious aberrant drug-taking behaviors
- selling medications
- obtaining medications from non-medical sources
- injecting medications that are supposed to be PO
- resisting changing medication despite decreasing function
- presenting intoxicated
- drug binging
- recurrent lost prescription
- refusing UDS
- loss of control over other substance use
- use of illegal substances
- recurrent episodes of losing Rx, early refills, increasing dosing on own
Name 5 less serious aberrant drug realted behaviors
- drug hoarding
- requesting short acting opioids
- concern from family or friends
- requests for Rx for travel
- early refill request
- occasional dose increases
- non-adherenec to other treatments
- missed appointments
- multiple injuries or accidents
- non-prescribed opioids in UDS
What are the main treatment strategies for pain management in individuals with active or history of addiction?
- Psych
- CBT
- MBSR
- ACT
- Physical
- PT
- OT
- Massage, etc
- Pharm
- Non-opioids - TCAs, SNRI, GPN
- Methadone
- Suboxone
- Kadian
- avoid short-acting opioids
- Short dispensing intervals
- DWI of opioids
- frequent UDS
- assessment of relaspe
- frequently assess psych and medical comorbidities
- Treatment for OUD
- refer to outpatient SUD program
- refer to inpatient SUD program
- Treat active SUD with Rx
- refer to addiction specialist
- Refer to multidisciplinary pain program