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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

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Presentation Transcript

What is addiction
What is addiction?

  • Compulsive use despite harm


Addiction
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
Anatomic Pathways

  • Mesocorticolimbic : pleasure, reward, motivation

    • Prefrontal cortex

      • Memory, emotnal processing, impulse control, decisn making

    • Ventral pallidum

      • Craving, seeking, relapse

    • Basolateralamygdala

      • Associative learning, emotional memory

    • Ventral tegmental area

      • Reinforcement, reward = priming circuit

    • Nucleus accumbens

      • PFC NAc VP = motor memory circuit


Neurotransmitters
Neurotransmitters

  • NAd

  • 5OH-T

  • ACh

  • Glutamate

  • GABA

  • Enkephalins

  • Cannabinoids


Principles of opioid management
Principles of Opioid Management

  • 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
U.D.T.

  • 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
The Spectrum

  • Recreational users

  • Chemical copers

  • Substance abusers

  • Addicted


Wanting more
‘Wanting More’

  • Tolerance

  • O.I.H.

  • Pseudoaddiction

  • Disease progression

  • Withdrawal

  • Aberrant behaviour

  • Diversion


Opioid withdrawal
Opioid Withdrawal

  • = the cost of opioid dependence

    • Anxiety, insomnia, irritability, restlessness

    • Nausea & vomiting, abdominal cramping

    • Myalgias, arthralgias, bone pain

    • Tremor, myoclonic jerks


Pseudoaddiction
Pseudoaddiction

  • ‘Drug-seeking’ 2° to inadequate analgesia

  • Reassess

    • Diagnosis

    • Drug

    • Dogma


Recognising the drug seeker
Recognising the Drug Seeker

  • Time

  • Patience

  • Awareness

  • Monitoring

  • Sense of humour


Recognising the drug seeker1
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 seeker2
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
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 hxpsychiatric disorder

  • Level 3 – specialist care

    • Current substance abuse

    • Psychopathology


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