Physical Dependence

Definition

Potential for abstinence on abrupt discontinuation or dose reduction, or administration of an antagonist

Physical Dependence

Key Points

(3)

Not a Problem if abstinence is avoided

Theoretical connection to the genesis of addication/relapse, but neither necessary nor sufficient

SHOULD NEVER BE LABELED "ADDICTION"

Tolerance

Definition

(2)

Declining effect with drug exposure

Tolerance to side effects is desirable; tolerance to analgesia may be a problem

Abbarent Drug-Related Behavior

Definition

Key Points (2)

Problematice behavior or "red flags" for clinicians

Culture-bound, but defined by conventional practice, and by laws and regulations

Should be viewed as "data," which must be interpreted in a differential diagnosis of addiction

Abuse

Definition

Drug use outside of socially accepted norms => includes any use of an illicit drug and some degree of abarrent use of prescription drugs

Addiction

Definition

Chronic disease with genetic, psychosocial, and environmental/situational influences, which can be induced in vulnerable people exposed to potentially abusable drug

Pseudoaddiction

Definition

Abarrant drug-related behavior in patients reacting to undertreatment of pain

Diagnostic challenge:  May co-exist with addiction or other psychiatric disorders

Diagnosis of Addiction

(3)

1.  Suggested by the occurrenc of aberrant drug-related behavior

2.  Distinguish from other phenomena in the DDx

3.  Diagnoses are NOT mutually exclusive 

Opioid Therapy:  Standard of Care

Treatment of Moderate to Severe Pain

(2)

Populations with advanced illness:  Cancer, HIV/AIDS, Others

Populations with acute illness, injury, or surgery

Opioids for Chronic Pain:

Unresolved Issues

(2)

Role of opiod therapy for chronic nonmalignant pain

Treatment of pain in patients with chemical dependence

Risk of Abuse and Addiction

(3)

Acute Pain:  very unlikely

Cancer pain and pain at EOL:  very unlikely

Chronic Nonmalignant Pain:  surveys and studies show rare addiction potential to mixed results

Opioids for Chronic Pain:  The Need for Balance

Essential Drugs

Abusable

Patients with pain, including those with addiction, must have access to treatment

Regulators and law enforcement must stem diversion and abuse

Opioid Therapy Assessment

(3)

Characterize the pain

Define etiology, syndrome, and pathophysiology

Clarify impact and prior therapies

Opioid Therapy Multimodality Approach

(6)

1.  Pharmacotherapy

2.  Rehabilitative approaches

3.  Psychological approaches

4.  Interventional approaches

5.  Complementary and alternative approaches

6.  Lifestyle changes  

Analgesic Pharmacotherapy

(3)

Opioids

Nonopioid analgesics

Adjuvant analgesics

Opioid Therapy:  Judging Initial Risk

(3)

Prior histroy of substance abuse

Family history of substance abuse

Major psychiatric pathology

Initial "Structuring" of Therapy to Reduce Risk

(4)

1.  Based on Assessment, Categorize Patient into low or high perceived risk

2.  Structure the therapy to match the perceived risk

3.  Multiple ways to initiate therapy (i.e. small prescription #)

4.  Written "contract" or treatment agreement

Role of Urine Drug Screen

Advantages (2)

Disadvantages (3)

Can confirm that prescribed drug is taken and that others are not

Makes a strong statment potentially useful in monitoring

Cannot confirm that the proper dose is taken

Can be misinterpreted

Can be stigmatizing

Opioid Therapy:  Principles of Prescribing

(6)

Selection of the drug

Selection of the route

Optimal Dosing

Side Effect Management

Monitoring Outcomes

Managining the poorly responsive patients

Opioid Therapy:  Monitoring Outcomes

4 A's

Analgesia (pain relief)

Activities of daily living (physical and phsychological functioning)

Adverse Effects (side effects)

Aberrant drug-related behavior

DDx of Aberrant Drug-Related Behavior

(4)

Addiction

Pseudoaddiction

Other Psychiatric Disorders:  Personality disorders, Encephalopathy, Family disturbances

Criminal Intent