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Pain Medicine > Pain and Addiction > Flashcards

Pain and Addiction Flashcards

1
Q

What tools are used for opioid risk assessment?

A
    • 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
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2
Q

What are five clinical features if patients with comorbid pain and addiction?

A
  1. increased psych disorders
  2. increased use of alcohol
  3. increased use of illicit substances
  4. increased medical comorbities
  5. increased use of prescription and non-prescription medication use
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3
Q

Define addiction

A
  • 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
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4
Q

Define physical dependence

A
  • physical adaptation that is substance specific and results in withdrawal symptoms when substance is removed, tapered, etc.
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5
Q

Define tolerance

A

Physical adaptation where prolonged exposure to a substance results in a diminished effect

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6
Q

define pseudoaddiction

A

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

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7
Q

Identify the brain region assoaciated with each behavioral aspect of addiction:

  1. inhibitory control
  2. withdrawal
  3. reward
  4. memory/learning
  5. motivation/drive
A
  1. PFC
  2. LC
  3. VTA (ventral tegmental area)
  4. Amygdala
  5. OFC (orbitofrontal cortex)
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8
Q

What are 10 components of universal precautions in opioid prescribing?

A
  1. Appropriate Dx with DDx
  2. Psych assessment with addiction screening
  3. informed consent for opioids
  4. Document written or verbal agreement
  5. Assess and document pain level and function before opioid trial
  6. Provide opioid trial +/- adjuvant
  7. Regularly assess pain scores and function
  8. Assess 5As
  9. OReview Dx and cormorbidies (including opioid misuse) often
  10. Document appropriately
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9
Q

What are the 5 As of pain treatment outcome?

A

Analgesia

Affect

Adverse events

Aberrant behaviors

Activity level

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10
Q

What are some therapuetic strategies for pain management in individuals with co-morbid psychiatric issues?

A
  • Non-pharm
    • CBT
    • Mindfulness-based therapies
  • Non-opioids
    • TCAs, SNRIs, GPN
  • Avoid short-acting Rx
  • Physical therapies
    • graded exercise programs
    • OT/PT
    • Massage, etc.
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11
Q

What personality disorder cluster has a higher susceptibilty to substance abuse?

A

Cluster B

(Borderline personality disorder - higher pain sensitivity)

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12
Q

What personality disorder has a higher susceptibilty to chronic pain development?

A

Cluster C

Avoidant, dependant, obsessive-compulsive

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13
Q

Name 5 serious aberrant drug-taking behaviors

A
  1. selling medications
  2. obtaining medications from non-medical sources
  3. injecting medications that are supposed to be PO
  4. resisting changing medication despite decreasing function
  5. presenting intoxicated
  6. drug binging
  7. recurrent lost prescription
  8. refusing UDS
  9. loss of control over other substance use
  10. use of illegal substances
  11. recurrent episodes of losing Rx, early refills, increasing dosing on own
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14
Q

Name 5 less serious aberrant drug realted behaviors

A
  1. drug hoarding
  2. requesting short acting opioids
  3. concern from family or friends
  4. requests for Rx for travel
  5. early refill request
  6. occasional dose increases
  7. non-adherenec to other treatments
  8. missed appointments
  9. multiple injuries or accidents
  10. non-prescribed opioids in UDS
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15
Q

What are the main treatment strategies for pain management in individuals with active or history of addiction?

A
  • 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
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16
Q

What can opioid prescribers do to reduce opioid diversion?

A
  • UDS
  • checking pharmanet (prescription monitoring program software)
  • screening for substance use disorders
  • random pill counts
  • writing short prescriptions
  • reassess patient care plans
17
Q

What is the approaching to benzodiazepine (BZD) tapering?

A
  • May taper with a long-acting BZD (clonazepam or diazepam) or use agent patient is taking
  • Taper by no more than 5 diazepam equivalents (DEQ) per week
    • slow pace of taper once 20mg of DEQ is reached (1-2mg/wk)
  • dispense BZD daily, twice weekly or weekly depending on patient

​Alternative approach:

  • taper by 10% of dose q1-2weeks until dose is ar 20% of original
  • then taper by 5% q2-4 weeks
18
Q

What are 4 clinical scenarios that you should screen for (or be cautious of) when considering an opioid taper?

A
  • pregnancy
  • unstable medical or psychiatric conditions that can be worsened by anxiety
  • Opioids are easily obtained from the street or other providers
  • Concurrent sedative-hypnotic medication use
19
Q

What is the approach to opioid tapering?

A
  • Type of opioid and dispensing
    • switch to controlled release morphine if possible
      • when switching decrease dose by 50%
    • prescribe scheduled doses (not PRN)
    • frequent dispensing intervals (days, or weekly)
  • Rate of taper
    • 10% daily to 10% q1-2 weeks
    • longer taper for anxious patients, psychologically dependant, cardio-respiratory illness, or patient preference
    • hold if necessary
  • Monitoring
    • frequent follow-ups (weekly)
    • UDS
  • Should be complete between 2-3 weeks and 3-4 months
20
Q

What are DSM5 diagnostic criteria for Substance Use Disorder?

CCLT SOAPHaz TD

A
  • Impaired Control (CCLT)
    • Unsuccessful attempts to cut down
    • Using larger amounts or for longer periods of time than intended
    • Excessive time spent using, obtaining or recovering from use
    • Craving
  • Social Impairment (SOA)
    • Failure to fulfill major role obligations given up due to recurrent substance use
    • Activities reduced or given up due to substance use
    • Persistent and recurrent social or interpersonal problems exacerbated by use of continued use despite these problems
  • Risky use (PHaz)
    • Continued use despite psychological and physical problems
    • Use in physically hazardous situations
  • Pharmacological Properties (TD)
    • Tolerance
    • Dependence

Pain Medicine (14 decks)

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