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Addiction & Pain

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  1. Addiction & Pain

  2. What is addiction? • Compulsive use despite harm

  3. Addiction • 1° chronic neurobiological disease • Development & manifestations influenced by: • Genetic • Drug disposition • Stress responsivity • Environmental • Drug-induced neurochemical changes • Psychosocial • Psychopathology • Personality traits

  4. 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

  5. Neurotransmitters • NAd • 5OH-T • ACh • Glutamate • GABA • Enkephalins • Cannabinoids

  6. 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

  7. 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?

  8. The Spectrum • Recreational users • Chemical copers • Substance abusers • Addicted

  9. ‘Wanting More’ • Tolerance • O.I.H. • Pseudoaddiction • Disease progression • Withdrawal • Aberrant behaviour • Diversion

  10. Opioid Withdrawal • = the cost of opioid dependence • Anxiety, insomnia, irritability, restlessness • Nausea & vomiting, abdominal cramping • Myalgias, arthralgias, bone pain • Tremor, myoclonic jerks

  11. Pseudoaddiction • ‘Drug-seeking’ 2° to inadequate analgesia • Reassess • Diagnosis • Drug • Dogma

  12. Recognising the Drug Seeker • Time • Patience • Awareness • Monitoring • Sense of humour

  13. 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

  14. 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

  15. 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