PHYSICAL DEPENDENCE Case PAIN AND ADDICTION

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PHYSICAL DEPENDENCE Case PAIN AND ADDICTION

Boise State University, US has reference to this Academic Journal, PAIN AND ADDICTION Steven Rapaport, MD Attending Physician Comprehensive HIV Center Saint Vincent?s Catholic Medical Center A Local Performance Site of the NY/NJ AIDS Education in addition to Training Center New York City Medical Director West Midtown Medical Group New York City Case Alex is a 44 year old man having difficulty alongside pain medications He has AIDS CD4 nadir 75 several years ago Currently on Kaletra in addition to Combivir Recent CD4 325 Viral Load

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He is currently taking 8 percocets daily His primary provider has tried unsuccessfully so that discontinue the percocets He no longer has hip pain, but he complains of irritability, malaise, insomnia, generalized body pain, abdominal cramping, diarrhea, sweats in addition to chills when he doesn?t take them Both the patient in addition to his primary provider are concerned that he has developed an addiction so that pain medications What is your assessment? PHYSICAL DEPENDENCE A state of adaptation characterized by a class specific drug withdrawal syndrome that can be produced by the abrupt cessation, rapid dose reduction, decreasing blood level of the drug, or administration of an antagonist A predictable drug effect Consensus statement of the American Pain Society, American Academy of Pain Medicine, in addition to the American Society of Addiction Medicine (2001) ADDICTION A primary, chronic condition characterized by: Impaired control over drug use, compulsive use Craving, preoccupation alongside obtaining in addition to using the drug Continued use despite harm (physical, psychologic, social) Consensus statement of the American Pain Society, American Academy of Pain Medicine, in addition to the American Society of Addiction Medicine (2001)

DSM-IV CRITERIA NOT WELL SUITED FOR PAIN PATIENTS SUBSTANCE DEPENDENCE DISORDER (three or more) Larger amounts used in consideration of longer time than intended Persistent desire or unsuccessful attempts so that control use Great deal of time spent in activities related so that use Important social, occupational, or recreational activities given up or reduced due so that substance use Continued use despite problems caused or exacerbated by use Tolerance Withdrawal (physical dependence) KEY QUESTIONS: What percentage of patients treated alongside opioids in consideration of chronic pain will develop an addiction disorder? Are there risk factors in consideration of the development of addictions? How can you tell if the patient is developing an addiction disorder? ?MALIGNANT? VS. ?NON-MALIGNANT? Concerns about addiction are usually irrelevant in palliative care at the end of life Nonetheless, fear of addiction contributes so that unnecessary pain in addition to suffering, even at the end of life. Fear of regulatory scrutiny inhibits appropriate prescribing by physicians, even at the end of life. On the other hand, opioid analgesic therapy in consideration of chronic non-malignant pain should involve a careful assessment of benefits in addition to risks, including addiction.

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PAIN AND AIDS Late stage AIDS is often associated alongside pain Before the advent of HAART, AIDS was always a terminal disease, similar so that incurable cancer Chronic pain in the HIV/AIDS in the post-HAART era is more often similar so that other non-malignant pain conditions (chronic back pain, arthritis) in addition to the use of opioid analgesics should involve a careful risk-benefit analysis PAIN AND ADDICTION What percentage of patients treated alongside opioids in consideration of chronic pain will develop addiction? Pain specialist have reported that addiction is a rare occurrence among chronic pain patients Published rates of addiction in chronic pain populations 3% so that 18% PAIN AND ADDICTION On the other hand? Rates of addiction problems in the general US population: Alcoholism: 10% Drug abuse: 5% Many patients alongside opiate addiction (up so that 25% in some surveys), report that their addiction resulted from prescribed opioid analgesics.

PAIN AND ADDICTION In retrospective analyses, nearly all chronic pain patients who developed problems alongside opioid use had a prior history of addiction. However, prospective longitudinal studies, in well-characterized patient populations, are lacking RISK FACTORS FOR ADDICTION (not evidence-based) Prior history of addiction Family history of addiction Co-occurring psychiatric disorders Use of short-acting opioids which are more ?reinforcing? than long-acting opioids CASE: Used drugs extensively in the 1980?s in addition to 1990?s, especially cocaine, crystal methamphetamine, alcohol, in addition to Marijuana, while working in the fashion industry, where drug use was very common. He injected heroin several times in college, but ?didn?t really like it? He lost several jobs due so that inability so that control his drug use. Attended detox in addition to rehab in 1996 after a suicide attempt. He continues so that drink alcohol on weekends, up so that 4 so that 5 drinks per night, despite having been told that he should stop because of his hepatitis C infection. Denies other drugs since leaving the rehab.

FAMILY HISTORY: His father was an alcoholic, died of cirrhosis. His brother was addicted so that heroin, now in a methadone program. MENTAL HEALTH: He has a history of depression in past, which was associated alongside periods of drug use. He is not currently depressed in addition to is on effexor. CASE Alex is concerned that he is having difficulty getting off the pain medications, but he: Denies craving in consideration of the pain medications Has a half-full bottle of percocet at home in addition to left-over MS Contin from an old prescription. Never takes them in consideration of a euphoric effect or in consideration of any other effects other than so that eliminate the withdrawal symptoms. What is your assessment? SIGNS OF ADDICTION IN PAIN PATIENTS: ?ABERRANT BEHAVIORS? Lost or stolen Rx Escalating doses, early renewals Obtaining medication form other sources Use of pain medications in consideration of psychic effects, e.g. so that relieve anxiety, increase energy, or in consideration of euphoria Unwillingness so that try non-opioid mediations Deterioration in function

ADDICTION IN PAIN PATIENTS: Impaired control, compulsive use Craving, preoccupation Continued use despite harm, which leads so that deterioration in function PSEUDOADDICTION Behaviors that resemble addiction that occur when pain is under-treated. ?Watching the clock? in consideration of pain medications in hospital ?Drug seeking? in addition to ?doctor shopping? Asking in consideration of specific medications by name Hoarding of medications Unsanctioned escalation in dose These behaviors resolve when the pain is adequately treated. CASE: In order so that treat opioid withdrawal, Alex received a long acting opioid which slowly tapered off over the course of several weeks. He completed the taper without any complications in addition to did not display any aberrant behaviors. Despite being advised so that abstain completely from alcohol in addition to cigarettes, he continues so that drink in addition to smoke as before.

CASE: version #2 The surgery was unsuccessful in addition to he continues so that have severe pain How should his pain be managed? PAIN AND ADDICTION Chronic pain is very common among patients alongside addictions disorders trauma medical illness Chronic opioid use, e.g. methadone maintenance, may lead so that increased sensitivity so that pain (hyperalgesia) PAIN AND ADDICTION Should you prescribe opioid analgesics in consideration of patients alongside addiction disorders? Regulatory issues (will you get in trouble alongside the DEA?) Clinical issues (is it good medicine?)

PAIN AND ADDICTION REGULATORY ISSUES The use of opioids so that treat opioid addiction is limited so that federally approved Opioid Treatment Programs (Narcotic Drug Treatment Act of 1974) in addition to is monitored by the DEA in addition to State authorities Office-based treatment of opioid addiction alongside buprenorphine is allowed under the Drug Addiction Treatment Act of 2000 Physicians may prescribe opioids so that addicts in consideration of pain, as long as the chart clearly documents that the opioids are being used so that treat pain in addition to not addiction DIVERSION The diversion of prescribed controlled substances in consideration of other than legitimate medical uses poses a threat so that the individual in addition to society. Prescribers have a responsibility so that minimize the potential in consideration of the abuse in addition to diversion of controlled substances, but efforts so that stop diversion should not interfere alongside the legitimate use of opioids in consideration of pain management. from Model Policy on Controlled Substances in consideration of Treatment of Pain: Federation of State Medical Boards (2004) PATIENT EVALUATION Complete history in addition to physical Detailed pain history, physical exam, prior treatment history, indications in consideration of opioid analgesic (under accepted medical standard of care) History of substance abuse Psychiatric history Communicate alongside prior clinicians, obtain prior records

INFORMED CONSENT Discussion of risks in addition to benefits Consider use of a written agreement INFORMED CONSENT WRITTEN AGREEMENT One prescriber One pharmacy Patient agrees so that safeguard medication No replacement of lost or stolen medication No illegal substances No diversion (selling, sharing) Urine toxicology testing PERIODIC REVIEW Analgesic response Aberrant behaviors, signs of addiction or diversion Functional status: patients on effective analgesia should have improved function; patients alongside addiction disorders will get worse Do the benefits of opioid analgesics continue so that outweigh any risks?

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Shaw, Bob Host

Shaw, Bob is from United States and they belong to Host and work for KWRK-FM in the AZ state United States got related to this Particular Article.

Journal Ratings by Boise State University

This Particular Journal got reviewed and rated by PAIN AND ADDICTION REGULATORY ISSUES The use of opioids so that treat opioid addiction is limited so that federally approved Opioid Treatment Programs (Narcotic Drug Treatment Act of 1974) in addition to is monitored by the DEA in addition to State authorities Office-based treatment of opioid addiction alongside buprenorphine is allowed under the Drug Addiction Treatment Act of 2000 Physicians may prescribe opioids so that addicts in consideration of pain, as long as the chart clearly documents that the opioids are being used so that treat pain in addition to not addiction DIVERSION The diversion of prescribed controlled substances in consideration of other than legitimate medical uses poses a threat so that the individual in addition to society. Prescribers have a responsibility so that minimize the potential in consideration of the abuse in addition to diversion of controlled substances, but efforts so that stop diversion should not interfere alongside the legitimate use of opioids in consideration of pain management. from Model Policy on Controlled Substances in consideration of Treatment of Pain: Federation of State Medical Boards (2004) PATIENT EVALUATION Complete history in addition to physical Detailed pain history, physical exam, prior treatment history, indications in consideration of opioid analgesic (under accepted medical standard of care) History of substance abuse Psychiatric history Communicate alongside prior clinicians, obtain prior records and short form of this particular Institution is US and gave this Journal an Excellent Rating.