Define the following concepts:
Tolerance
Tolerance, as defined by either of the following:
- (a) a need for markedly increased amounts of a substance. to achieve intoxication or a desired effect,
- (b) markedly diminished effect with continued use of the. the same amount of a substance.
Physical dependence
A condition in which a person takes a drug over time, and unpleasant physical symptoms occur if the drug is suddenly stopped or taken in smaller doses.
Substance use disorder
Substance use disorder (SUD) is the persistent use of drugs (including alcohol) despite substantial harm and adverse consequences
Describe the evolution of the terms:
Tolerance
No significant evolution of the term. The concept has been static for some time.
Physical dependence
Substance use disorder
Addiction
The term addiction has lead to prejudice, stigma and ignorance of the difficulties of substance use disorder. It encompasses medical, psychological, sociological, cultural, economic, religious, ethical and legal considerations
The use of terms like 'narcotic' particularly in lay speak and legal settings has also further stigmatised substance use.
The DSM 5 is moving away from the longstanding distinction between substance dependence and substance abuse. SUD is seen as a single continuum from mild, moderate to severe. This is instead of the terms substance dependence and substance abuse.
The abuse was seen as a milder form of dependence however in practice abuse can be very severe. This was therefore altered in DSM 5.
Reasons for change from substance dependence and substance abuse being separate into a combined continuum:
(1) the distinction provided little guidance for treatment
(2) the distinction created “diagnostic orphans” (individuals who endorsed two dependence symptoms and no abuse symptoms and therefore did not meet any diagnostic criteria)
(3) the hierarchical structure did not follow the anticipated relationship between abuse and dependence (that abuse was largely a less severe prodrome4 of dependence)
(4) the separation caused the abuse diagnosis to suffer from significant reliability problems
The legal problems criterion was dropped due to low endorsement, poor fit with other items, and the poor discrimination of this item (almost all people endorsing the legal criteria endorsed other criteria also)
3.4.3 - Discuss the current DSM-5 and ICD-11 criteria for diagnosis of substance use disorder
Differences:
- ICD-11 and DSM 5 categorise multiple sub-types of substances of dependence differently
- Polysubstance dependence has been removed from both
- Gambling and gaming disorders have been added to both
- DSM 5's SUD criteria is now very broad with over 2000 different possible ways to be diagnosed as a mix of different diag criteria
- Unclear if this will effect its usefulness for treatment
- Craving was added to DSM 5 to keep more in line with ICD11
3.4.4 - Discuss how inappropriate prescribing behaviour may contribute to problematic substance use
Increased prescribing of opioids leads to increased availability for patients, the community and illicit use
Prolonged prescription increases long term use
Restricted availability may lead to illicit use
Inappropriate use of opioids to treat non-opioid indicated, or responsive, pain
Non-tracking of opiate prescriptions and opioid use
Excessive scripts and larger pack sizes
3.4.5 - Describe the impact of the following substances on health and pain experience:
Caffeine
Pros:
Increased physical performance
Possibly helps lose weight
Increased focus and mental alertness
Overall reduction in mortality
Reduced cancer risk
Reduced stroke risk
Reduced Parkinsons disease risk
Reduced type 2 diabetes risk
Cons:
An overdose could kill (though ridiculous high amounts)
Increased insomnia and restlessness
Effects on pregnancy
Half-life of 5 hours
Can exacerbate anxiety components of pain experience
Nicotine
Pros:
Boosts concentration
Improve memory
Reduce bodyweight
?Small to medium anti analgesic effect but worsened after dose reduces
Cons:
High risk of physical addiction - as severe as cocaine or heroin
Increased metabolic syndrome risk
Increases cancer initiation
Direct effects on lungs through CNS effects (and also clearly smoking it)
Peptic ulcer disease
Immune suppression
Macular degeneration in mice
Alcohol
Pros:
Acute analgesic benefits lastin 8-10 days however withdrawal can cause hyperalgesia
Relaxation acutely
Cons:
Associated with acute pain conditions such as pancreatitis
Increased risk of injury
Dysregulation of opioids
Can stimulate TLR-4 and cause hyperalgesia
Ethylgluconiride damage
Thiamine deficiency leading to motor damage
Cannabinoids
Pros:
Acute anxiolytic component
Possibly utility in chronic neuropathic pain - however evidence of benefit does not outweight harm
NNT 24 (30%) - NNH 6 (Stockings et al 2018 - 104 studies, 10,000 patients)
Cons:
POINT study -
Associated with greater pain intensity
Lower self-efficacy
Greater pain interference
Greater levels of anxiety
Methamphetamine and other stimulants
Pros:
Used for ADHD specifically
Cons:
3.4.6 - Discuss the contribution of benzodiazepines to problematic substance use in pain medicine
Benzodiazepines and opioids are among the most frequently abused psychoactive substances in the world
Co use of benzodiazepines and opioids is common - particularly in abuse
E.g. 75% of patients admitted to a heroin treatment program had used BZDs in the past 12 months. 25% of those used them regularly
Nonmedical use of BZDs in chronic pain approaches 40-60% of patients in some cohort studies
Benzodiazepines add little therapeutic benefit for chronic pain patients. They may enhance the euphoric effects of opioids.
The use of both substances has a significantly increased risk for drug overdose. Respiratory depression is the most common mechanism.
Opioids cause a medullary respiratory centre reduction in response to circulating CO2. Inhibitory GABA receptors are also highly concentrated in these areas and the drugs likely work synergistically. The effect of both together is higher than each separately.
Benzodiazepines are the most sold drugs on the internet
Chronic pain is associated with a state of hyperarousal - which may explain why benzos are sought after
3.4.7 - Recognise the spectrum of problematic substance use that may be co-morbid with the experience of pain
Between 3 and 50% of patients with chronic non-cancer pain have a current substance use disorder
Rates are higher than in the general population
94% of SUD patients will experience symptoms BEFORE the onset of their chronic pain
Interestingly patients with chronic pain are NO MORE likely than any other patient in a primary care setting to have a current SUD - suggesting chronic pain is NOT associated with a unique risk for substance abuse
Reference:
3.4.8 - Recognise aberrant drug-taking behaviours
Red flags include:
Benefitting
Selling their prescription
Prescription forgery
Reporting lost/stolen medications
Abnormal pain behaviours
Disproportionate pain
Negative interactions with pain providers
Anxiety or desperation over recurrent symptoms
Maladaptive coping with pain
Drinking more alcohol when in pain
Raising the dose of opioids on their own
Seeking
Doctor shopping
Borrowing or stealing opioids
Hoarding medication
Performing sex for drugs
Opioids from more than one source
3.4.9 - Identify intoxication and withdrawal syndromes associated with:
Opioids / Methdone / Herioin / Morphine
Intoxication
Constriction of pupils
Itching/scratching
Sedation
Lowered BP
Slowed pulse
Hypoventilation
Withdrawal
(Short acting - onset 8-24 hrs after use, duration 4-10 days)
(Long acting - onset 12-48 hrs, duration 10-20 days)
Nausea and vomiting
Anxiety
Insomnia
Hot and cold flushes
Perspiration
Muscle cramps
Watery discharge from eyes and nose
Diarrhoea
Managing Opioid withdrawal
2-3 L of water drank
Vitamin B and C supplementation
Can use clonidine, or buprenorphine/methadone or short acting
Consider benzodiazepines
Clonidine - Helps with sweating, diarrhoea, vomiting, abdo cramps, chills, anxiety, insomnia and tremor. It can cause drowsiness, dizziness and low blood pressure. Cease clonidine if BP drops below 90/5o mmHg or HR <50. Check BP 30 mins after giving first dose of clonidine.
Dose - Day 1 - 150 mcg TDS, increase to 150-300mcg TDS, then reduce at day 4-5.
Alcohol
Intoxication
Relaxation
Disinhibition
Impaired coordination
Impaired judgement
Decreased concentration
Slurred Speech
Ataxia
Vomiting
Withdrawal
Anxiety
Perspiration
Tremors
Dehydration
Increased HR and BP
Insomnia
Nausea and vomiting
Diarrhoea
SEVERE - Seizures, hallucinations, delirium, agitation
Management - Diazepam can be used 10mg QID and then weaned by 10mg /day
Benzodiazepines
Intoxication
Disinhibition
Sedation
Drooling
Incoordination
Slurred speech
Lowered blood pressure
Dizziness
Withdrawal
(Short acting - 1-2 days after last dose and continues for 2-4 weeks)
(Long acting - 2-7 days after last dose and continues for 2-8 weeks)
Anxiety
Insomnia
Restlessness
Agitation and irritability
Poor concentration and memory
Muscle tension/aches
Management - Usually use steadily reducing benzo amounts.
Convert benzo to diazepam - max 40 mg daily
Then slowly reduce depending on symptoms.
Amphetamines / Cocaine
Intoxication
Hyperactivity
Restlessness
Agitation
Anxiety/nervousness
Dilation of pupils
Elevated BP
Increased PR
Sweating
Elevated temperature
Tremor
Withdrawal
Symptoms within 24 hrs of last use and last for 3-5 days
Psychotic symptoms can occur such as paranoia, hallucinations, disordered thoughts
Agitation and irritability
Depression
Increased sleeping and appetite
Muscle aches
Management
Should drink 2-3 L of water per day
Multivitamin with B and C is recommended
Rarely Diazepam 10-20 mg every 30 mins can be given
Withdrawal phase may last 1-2 months duration with lethargy, anxiety unstable emotions, erratic sleep patterns and craving
Cannabinoids
Intoxication
Relaxation
Decreased concentration
Decreased psychomotor performance
Impaired balance
Conjunctival injection
Withdrawal
Anxiety and feeling of fear and dissociation
Restlessness
Irritability
Poor appetite
Disturbed sleep and vivid dreams
GI upset
Night sweats
Tremor
Management
Supportive, calm and symptomatic
Primarily psychosocial care is required
Ketamine
Intoxication
Reduced awareness of environment
Sedation
Decreased focus
Disorientation
Hallucinations
Tachycardia
Elevated BP
Excessive saliva
Increased urination
Forgetfulness
Withdrawal
Memory loss
Impaired judgement and disorientation
Clumsiness
Aches and pains
Anxiety
Gabapentinoids
Intoxication
Dizziness
Tremors
Slurred speech
Ataxia
Double vision
Tachycardia
High or low BP
Diarrhoea
Withdrawal
Atypical anti-psychotics and hypnotics
NB: Increasingly olanzapine may have a role in chronic pain wiht associatefd psyciatric comorbidity. May have a role in fibromyalgia and headache/migraine
Intoxication
Lethargy
Sedation
Miosis, tachycarda and orthostatic hypotension (from alpha adrenergic component)
Anticholinergic symptoms
Withdrawal
Nausea
Vomiting
Insomnia
Dizziness
Excessive sweating
Increased heart rate
References:
3.4.10 - Identify people with or at risk of substance use disorders
Biomedical
Family history of substance abuse
Personal history of substance abuse
Psychological
History of depression/anxiety
Previous treatment programs including AA
Social
History of criminal/legal problems
Regular contact with high-risk people
Past problems with employers, family members, friends
Risk-taking behaviours
Heavy tobacco use
ORT
SOAPP
SCREEN-RS
3.4.11 - Identify fellow healthcare professionals with substance use problems, or at risk of
Younger age
Cigarette use
Moderate alcohol use
Sense of immunity to becoming addicted
Health professional burnout
Being in situations where offered alcohol or drugs
Socialising with substance users
Early use of tobacco/alcohol
Genetics
Coexisting psychiatric illness
Family history of SUD
Easy access to drugs
Yellow flags - Warning signs (lifestyle and stress factors)
Red Flags - Practitioner needs to stop working (Severe depression, anxiety, substance use)
Reference:
3.4.12 - Outline factors in determining suitability for opioid pharmacotherapy
Predicting
Screener and Opioid Assessment for Patients with Pain (SOAPP-R)
Opioid risk tool (Though recently less sensitivity)
Assessing in current use
Current Opioid Misuse Measure (COMM)
3.4.13 - Statement on Medicinal Cannabis
THC recently rescheduled from S9 to S8
Political and community demands have created this imperative
FPM is concerned about adverse effects including:
Impaired respiratory function
Psychotic symptoms
Cognitive impairment
Cannabis is the third most used substance after alcohol and tobacco worldwide
Unauthorised use of cannabis in Australia is widespread
90% of people stated that hydroponic cannabis was easy or very easy to acquire
Cannabinoids are:
Delta9-tetrahydrocannabinoil (THC)
Cannabidol
Cannabinol
Sativex - Licence in Aus for MS spasticity
Transpulmonary
18% bioavailability
Inaccurate dosing
Rapid onset and offset (falls in 2h)
Oral and transmucosal
Poor absorpbtion
<10% bioavailability
Difficult to titrate
Cannabinoid evidence
Stockings et al, 2018
10,000 participants, 50 RCTs, and 50 observational studies
CNCP cannabinoids were more likely than placebo to reduce pain 30%. NNTB = 24
No evidence it reduced pain by 50% compared to placebo
Reduction in pain intensity but unlikely clinically significant
Patients who had cannabinoids had twice the chance of withdrawing from the trial due to adverse events.
NNTH = 6
Discuss the uses and limitations of drug testing in pain medicine practice
Can be used to assess compliance (particularly in opioid substitution programs) and also detect other drugs of abuse
Consent must be sought first
Usually an immunoassay screen of drugs of dependence or abuse
If positive, can do a chromatography-mass spectrometry - (less false positives)
Saliva tests are less intrusive but also less accurate
Compile a comprehensive medication record
Reconciliation of quantity, identification of discord,
Consultation with community prescribers and dispensing points
Identification of pharmacodynamic interactions
Discuss strategies to minimise problematic substance use
Strategies to improve appropriateness of opioid use
Standardised definitions and laws across states and territories
Effective national surveillance and scripting program
Up-scheduling of codeine
Improved analysis of PBS prescriptions
State and territory systems to support continual and coordinated care for complex patients
Improved use of opioid stewardship in acute settings
Support for the 'medical home' concept
Adequate education and support for general practice
Improved collaboration with pharmacists
Education of health professionals of non-pharmaceutical EBM treatments
Reference: RACGP Guidelines S8 drugs book
Explain the regulations for prescription, restrictions and monitoring in relevant jurisdictions
Real-Time Prescription Monitoring (RTPM) - Counter system alerting prescribes to patient medication history before they prescribe
If the concerned patient is a doctor-shopper - they can call Medicare Australia's Prescription Shopping Information Service
NB: No evidence that these programs decrease or increased overdoses
Explain the operation of:
Prescription shopping information service
PSP criteria include:
PBS item prescribed by 6 or more prescribers
Total of 25 or more PBS target items
Total of 50 or more target or non-target items
Can call DDU QLD - S8 scripts, QOTP, drug dependent, regulatory requirements, approval
Real-time online monitoring of controlled drugs
Script is not yet active in QLD
Explain controlled opioid substitution therapy programs in your jurisdiction
AOD services
Voluntary service
Often there is a wait list
OST is at no cost - however, community pharmacy often adds dispensing fees
2 in 3 opioid pharmacotherapy long-term patients are male
1 in 10 are aboriginal
Daily dosing at a community pharmacy is standard
Most are now Suboxone
Outline the principles of collaborative management of patients with substance use disorders
Be collaborative...
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