Addiction & Pain
What is addiction?
• Compulsive use despite harm
Addiction
• 1° chronic neurobiological disease
• Development & manifestations influenced by:
– Genetic
• Drug disposition
• Stress responsivity
– Environmental
• Drug-induced neurochemical changes
– Psychosocial
• Psychopathology
• Personality traits
Anatomic Pathways
• Mesocorticolimbic : pleasure, reward, motivation
– Prefrontal cortex
• Memory, emotnal processing, impulse control, decisn making
– Ventral pallidum
• Craving, seeking, relapse
– Basolateral amygdala
• Associative learning, emotional memory
– Ventral tegmental area
• Reinforcement, reward = priming circuit
– Nucleus accumbens
• PFC
NAc
VP = motor memory circuit
Neurotransmitters
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NAd
5OH-T
ACh
Glutamate
GABA
Enkephalins
Cannabinoids
Principles of Opioid Management
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Have a clear diagnosis
Identify/manage pyschiatric illness
Identify/manage psychological distress
Long acting opioids only
Limited supply
Frequent visits
Regular monitoring (blood, urine)
Emphasis on wellness & behavioural change
U.D.T.
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Purpose – check compliance, other meds
Use prophylactically, nonpunitively, randomly
Philosophical opposition = problem
Basic panel
Drug not there – testing issue or diversion
Is sample own, fresh, human?
The Spectrum
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Recreational users
Chemical copers
Substance abusers
Addicted
‘Wanting More’
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Tolerance
O.I.H.
Pseudoaddiction
Disease progression
Withdrawal
Aberrant behaviour
Diversion
Opioid Withdrawal
• = the cost of opioid dependence
– Anxiety, insomnia, irritability, restlessness
– Nausea & vomiting, abdominal cramping
– Myalgias, arthralgias, bone pain
– Tremor, myoclonic jerks
Pseudoaddiction
• ‘Drug-seeking’ 2° to inadequate analgesia
• Reassess
– Diagnosis
– Drug
– Dogma
Recognising the Drug Seeker
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Time
Patience
Awareness
Monitoring
Sense of humour
Recognising the Drug Seeker
• History
– Forging/altering/losing/hoarding prescriptions
– Doctor shopping
– Stealing/borrowing
– Unsanctioned escalation
– Injecting oral preparations
– Using polysubstances
– Preoccupation with opioids
– Insistence on certain forms/routes
Recognising the Drug Seeker
• Examination
– Intoxicated/withdrawing
– Poor habitus/hygiene (bumble bee teeth)
– Track marks
– Cellulitis/abscess
– Injuries from falls
– Abnormal illness behaviour
– Pupils
– LOC
Triaging Management
• Level 1 = 1° care
– No past / current hx of concern
– Environment safe
• Level 2 = shared care
– Past hx substance abuse
– Environment potentially unsafe
– Past / current hx psychiatric disorder
• Level 3 – specialist care
– Current substance abuse
– Psychopathology
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