Physical Dependence vs' Addiction

1
Physical Dependencevs.Addiction

• Physical dependence results from the bodys
  adaptation to a drug or medication and is defined
  by the presence of
• Tolerance and/or
• Withdrawal
• Addiction may occur with or without the presence
  of physical dependence

2
DSM-IV Substance Dependence

• A maladaptive pattern of substance use , leading
  to clinically significant impairment or distress,
  as manifested by three (or more) of the
  following, occurring at any time in the same
  12-month period
• The substance is often taken in larger amounts or
  over a longer period of time than was intended

3
DSM-IV Substance Dependence

• A maladaptive pattern of substance use , leading
  to clinically significant impairment or distress,
  as manifested by three (or more) of the
  following, occurring at any time in the same
  12-month period
• There is a persistent desire or unsuccessful
  efforts to cut down or control substance use

4
DSM-IV Substance Dependence

• A maladaptive pattern of substance use , leading
  to clinically significant impairment or distress,
  as manifested by three (or more) of the
  following, occurring at any time in the same
  12-month period
• A great deal of time is spent in activities
  necessary to obtain the substance, use the
  substance, or recover from its effects

5
DSM-IV Substance Dependence

• A maladaptive pattern of substance use , leading
  to clinically significant impairment or distress,
  as manifested by three (or more) of the
  following, occurring at any time in the same
  12-month period
• Important social, occupational, or recreational
  activities are given up or reduced because of
  substance use

6
DSM-IV Substance Dependence

• A maladaptive pattern of substance use , leading
  to clinically significant impairment or distress,
  as manifested by three (or more) of the
  following, occurring at any time in the same
  12-month period
• The substance use is continued despite knowledge
  of having a persistent or recurrent physical or
  psychological problem that is likely to have been
  caused or exacerbated by the substance

7
Pseudoaddiction

• Pattern of drug seeking behavior of pain patients
  receiving inadequate pain management that can be
  mistaken for addiction
• Cravings and aberrant behavior
• Concerns about availability, specific drug
  requests
• Clock-watching
• Unsanctioned dose escalation
• Resolves with reestablishing analgesia

Weissman DE, Haddox JD. Oploid pseudo addiction-
an iatrogenic syndrome. Pain 198936363.
8
Craving / Preoccupation

• Frequent missed appointments unless opioid
  renewal expected
• Resistance to non-opioid interventions
• Unable to tolerate many medications
• Requests medications with high reward
• No relief with anything except opioids

9
Aberrant Behaviors Suggestive of Addiction

• Injecting oral / transdermal medications
• Obtaining drugs on the street
• Prescription forgery
• Diversion / selling
• Lost prescriptions
• Seeking prescriptions from other clinicians / ER
  without informing primary prescriber
• Deterioration in function (work, family, social)
• Concurrent alcohol / other drug abuse

10
Management of Acute Pain in the Addicted Patient

• Distinguish between recovery, remote history of
  use, opioid maintenance, or active addiction
• Expect a lower pain threshold
• Expect a higher medication tolerance
• Define the pain, and provide specific treatment

11
Management of Acute Pain in the Addicted Patient

• Actively treat non-opioid addiction during
  episode of chronic pain

12
Management of Acute Pain in the Addicted Patient

• Scheduled or PCA administration of opioids is
  preferable to prn meds.
• Asking for prn may be seen as drug seeking
• Delays are avoided, providing effective pain
  relief and avoidance of withdrawal
• Administration is not symptom-contingent, so
  reinforcement of pain symptoms are minimized

13
Management of Acute Pain in the Recovering Addict

• Recovering patients benefit from increasing
  recovery activities during times of pain
• Distress over inadequately treated pain may pose
  greater risk of relapse than exposure to opioids
• Often there is resistance to
• treatment with opioids

14
Management of Acute Pain in the Opioid
Maintenance Patient

• Must have baseline opioid requirements met in
  addition to medication needed for pain
• Continue baseline methadone when possible and add
  other mu agonist for pain
• If unable to take methadone orally, can
  administer parenterally at half the oral dose

15
Management of Acute Pain in the Opioid
Maintenance Patient

• For buprenorphine maintained patients, if the
  pain is anticipated, switch to full mu agonist 3
  days in advance
• May continue buprenorphine, increase dose to tid
  / qid for analgesic dosing
• May use high potency mu opioids for breakthrough
• Be aware of precipitating withdrawal when
  switching back to buprenorphine from full mu
  agonist

16
Opioid Induced Hyperalgesia

• MMTP patients have lower pain thresholds than
  controls, cocaine addicts and former heroin users
  not on methadone
• Source Cold-pressor pain intolerance in opiate
  and cocaine abusers correlates of drug type and
  user status. Journal of Pain and Symptom
  Management. 19949462-473

17
Management of Acute Pain in the Patient with
Active Addiction

• Aggressively treat non-opioid addiction
• For opioid dependent patients, expect high
  tolerance
• Prevent withdrawal in addition to adequate
  analgesia

18
Management of Chronic Pain in Addiction

• Goals
• Reduction in pain
• Improvement in pain-related symptoms
• Sleep disturbance, depression, anxiety
• Restoration of function
• Elimination of unnecessary dependence on
  medication

19
Guidelines for management of chronic pain in the
addicted patient

• Comprehensive assessment including detailed drug
  use history
• Consider primary therapy directed at underlying
  cause of pain (eg, radiation)
• Begin appropriate pharmacotherapy
• Consider adjunctive treatments anesthetic,
  surgical, neurostimulation
• Integrate treatment with addiction services,
  psychiatric services, and pain services

20
Guidelines for management of chronic pain in the
addicted patient

• Create requirements for monitoring
• Frequent visits
• Written contracts with little flexibility
• Single prescriber
• Single pharmacy
• Frequent urine drug screens with active addict,
  aberrant behavior

21
Management of Chronic Pain in Addiction

• Physical modalities
• Stretching, ice, heat, exercise, TENS, nerve
  blocks, trigger point injections
• Cognitive-Behavioral interventions
• Relaxation, cognitive restructuring, changes in
  behavioral response to pain
• Invasive procedures
• Implanted spinal or peripheral nerve stimulators,
  implanted spinal infusions
• Medications
• Opioid, non-opioid

22
The Four As of Pain Treatment Outcomes

• Analgesia (pain relief)
• Activities of Daily Living (psychosocial
  functioning)
• Adverse effects (side effects)
• Aberrant drug taking (addiction-related outcomes)

Passik Weinreb, 1998
23
Integrated Treatment Approach for Chronic Pain
Individualized Care Plan
24
RELAPSE
25
Problem With Addictive Illness RELAPSE!!!

• 3 Triggers for relapse
• 1) Stress
• 2) Any mood altering substance
• 3) Environmental Cues
• The Issue Acute Care view of a Chronic
• Disease
• Relapse occurs with the other chronic
  illnesses!

26
The Memory of Drugs
Amygdalaactivated
Amygdalanot lit up
Front of Brain
Back of Brain
Nature Video
Cocaine Video
27
Remember

• Relapse is A PART OF THE DISEASE
• Expect there to be recurrent DENIAL
• Revert to Brief Intervention Technique
• Utilize leverage boss, family members, friends
• Remember Not everyone makes it but dont give
  up trying

28
CONCLUSION
29
The Message OfAddiction Medicine

• Addiction is a chronic brain disease
• Addiction is treatable (i.e. like DM, HTN)
• People get better
• Treatment works
• Recovery is very possible
• Addicted people in all stages of addiction and
  recovery should receive our compassion as well as
  equality and non-discrimination

30
Where Society Needs to Go

• Move to education/prevention/treatment
• Access to care (PARITY)
• Alternatives to incarceration (drug courts)
• Education of health care professionals
• Interface law enforcement/health care
• Educate our legislators

31
Sue Shivers on Change

• If you keep on doing what youve always done,
  you keep on getting what youve always got If
  nothing changes, nothing changes

32
Societys Hope --- You

• Continue to educate yourself
• Be aware of the scope of the problem
• Share your knowledge with colleagues
• Develop a plan for your practice
• Become an educator of your patients/clients,
  legislators, and society
• Support health care
• professionals/others
• in recovery

33
Strong In The Broken Places

• The personal wounds of Addiction, mended and
  strengthened by ongoing recovery can give your
  patient a Powerful Voice filled with rich
  insight and wisdom

34
Resources

• http//alcoholscreening.org
• http//www.niaaa.nih.gov
• http//www.nida.nih.gov
• http//csat.samhsa.gov/
• http//csap.samhsa.gov
• http//jointogether.org
• http//www.asam.org
• http//www.advocatehealth.com/amg/about/locations/
  addiction

35
More Resources.

• Principles of Addiction Medicine
• NIDA Principles of Treatment
• NIAAA MATCH Manuals
• SAMHSA
• Join Together
• American Society of Addiction Medicine
• Call MPHP (1/800-844-1446)
• Go to 10 Open AA Meetings

36
Screening Instruments
Self-Report Questionnaires andStructured
Interviews

• CAGE questionnaire
• Alcohol Use Disorders Identification Test (AUDIT)
• Michigan Alcoholism Screening Test (MAST)
• Brief MAST (BMAST)
• TWEAK questionnaire

37
Screening InstrumentsBrief Screening
Questionnaires
IntendedSetting
Cutoff Value
Questions (Scoring)
ScreeningTool
Sensitivity
61-100
Clinical
2
4 (1 point each)
CAGE
38-94
Clinical (adolescents)
8
10 (0-4 points each)
AUDIT
30-78
Clinicaland nonclinical
6
10 (0-4 points each)
BMAST
70-90
Clinical(pregnantwomen)
2
5 (0-2 points each)
TWEAK
Indicates questionnaires that can be
self-administered. Source Cherpitel CJ. Alcohol
Health Res World. 199721348-351.
38
Alcohol Dependence Screening Tool CAGE
Questionnaire

• Have you ever felt you should CUT down on your
  drinking?
• Have people ANNOYED you by criticizing your
  drinking?
• Have you ever felt bad or GUILTY about your
  drinking?
• Have you ever had a drink first thing in the
  morning to steady your nerves or get rid of a
  hangover (ie, EYE-OPENER)?

Source Cherpitel CJ. Alcohol Health Res World.
199721(4)348-351.
39
Alcohol Dependence Screening Tool AUDIT
Questionnaire

• 1. How often do you have a drink containing
  alcohol?
• 2. How many drinks containing alcohol do you
  have on a typical daywhen you are drinking?
• 3. How often do you have 6 or more drinks on 1
  occasion?
• 4. How often during the past year have you found
  that you were not able to stop drinking once you
  had started?
• 5. How often during the past year have you
  failed to do what was normally expected of you
  because of drinking?
• 6. How often during the past year have you
  needed a first drink in the morning to get
  yourself going after a heavy drinking session?
• 7. How often during the past year have you had a
  feeling of guilt or remorse after drinking?
• 8. How often during the past year have you been
  unable to remember what happened the night before
  because you had been drinking?
• 9. Have you or has someone else been injured as
  a result of your drinking?
• 10. Has a relative, friend, or a doctor or other
  health care worker been concerned about your
  drinking or suggested you cut down?

Source Saunders JB, et al. Addiction.
199388791-804.
40
Alcohol Dependence Screening Tool BMAST
Questionnaire

• 1. Do you feel you are a normal drinker?
• 2. Do friends or relatives think you are a
  normal drinker?
• 3. Have you ever attended a meeting of
  Alcoholics Anonymous (AA)?
• 4. Have you ever lost friends or
  girlfriends/boyfriends because of drinking?
• 5. Have you ever gotten into trouble at work
  because of drinking?
• 6. Have you ever neglected your obligations,
  your family, or your work for two or more days in
  a row because you were drinking?
• 7. Have you ever had delirium tremens (DTs),
  severe shaking, heard voices, or seen things that
  werent there after heavy drinking?
• 8. Have you ever gone to anyone for help about
  your drinking?
• 9. Have you ever been in a hospital because of
  drinking?
• 10. Have you ever been arrested for drunk
  driving or drivingafter drinking?

Source Pokorny AD, et al. Am J Psychiatry.
1972129342-345.
41
Alcohol Dependence Screening Tool TWEAK
Questionnaire

• TOLERANCE How many drinks can you hold?
• Have close friends or relatives WORRIED
  or complained about your drinking in the past
  year?
• EYE-OPENER Do you sometimes take a drink in
  the morning when you first get up?
• AMNESIA Has a friend or family member ever
  told you about things you said or did while you
  were drinking that you could not remember?
• Do you sometimes feel the need to C(K)UT DOWN
• on your drinking?

Source Cherpitel CJ. Alcohol Health Res World.
199721348-351.
42
Alcohol Withdrawal

• Benzodiazepines are the drug of choice to detox
  from Alcohol. Only drug proven to diminish
  withdrawal symptoms, prevent seizures and
  Delirium Tremens
• Phenytoin is not indicated
• Thiamine 100 mg IM, then P.O. 4 6 wks
• Magnesium Sulfate

43
Alcohol Abstinence Adjuncts

• Disulfiram (Antabuse) 50 yrs
• Naltrexone (Revia) - 1994
• Acamprosate (Campral) - 2004
• Extended Release Naltrexone (Vivitrol)
• 
  2006
• Caution Any ETOH Abstinence Adjunct should be
  coupled with psychosocial support

44
Disulfiram

• Inhibits Aldehyde Dehydrogenase
• VA Study (Fuller) no more effective than placebo
  in general population
• PHP experience Useful in professional
  monitoring group
• Some utility in those that request it

45
Oral Naltrexone

• Adjunctive therapy to behavioral treatments for
  alcoholism and opiate addiction (FDA 94)
• 40 increase in 90-day abstinence
• No significant difference at 1 year
• Expensive

46
New Research

• Naltrexone for extended-release injectable
  suspension (Vivitrol)
• Once monthly injection
• Recently approved, well tolerated, safe
• Expensive (about 800/mo.)
• Many insurances do cover
• (JAMA April 05)

47
Acamprosate ( Campral)

• Glutamate stabilization and GABA effects
• ? Reduce protracted withdrawal
• Safe, well tolerated
• 50 decrease in relapse in 14 of 15 European
  Trials
• Recently approved for use in USA
• JAMA 5/06 Not effective

48
Neuroadaptation Potential for Relapse
Normal
Tolerance
Acute Alcohol Intake
Adaptation
Alcohol
Alcohol
Excitation(Glutamate)
Inhibition(GABA)
Post-Acute Withdrawal and Cue-Induced Responses
Acute Withdrawal
C
Adaptation
Campral may balance glutamate overactivity thus
reducing the potential for relapse
49
Alcohol Abuse

• DSM-IV-TR Criteria
• Maladaptive pattern of alcohol use leading to
  clinically significant impairment or distress,
  manifested within a12-month period by at least 1
  of the following
• Failure to fulfill role obligations at work,
  school, or home
• Recurrent use in hazardous situations
• Legal problems related to alcohol
• Continued use despite alcohol-related socialor
  interpersonal problems

DSM-IV-TRDiagnostic and Statistical Manual of
Mental Disorders, 4th edition, text
revision. American Psychiatric Association. In
DSM-IV-TR. 2000.
50
Alcohol Dependence

• DSM-IV-TR Criteria
• Maladaptive pattern of alcohol use leading to
  clinicallysignificant impairment or distress,
  manifested within a12-month period by at least 3
  of the following
• Tolerance
• Withdrawal
• Loss of control over amount of alcohol consumed
• Preoccupation with controlling drinking
• Preoccupation with drinking activities
• Impairment of social, occupational, or
  recreational activities
• Use is continued despite persistent problems
  related to drinking

American Psychiatric Association. In DSM-IV-TR.
2000.
51
Indications for Inpatient Detoxification (Alcohol)

• History of withdrawal seizures or complications
• Depression with suicidal ideation
• The presence of severe coexisting medical or
  psychiatric conditions
• Extremely unstable home situation
• Failure to respond to outpatient treatment

52
Management of Alcohol Withdrawal

• Hourly nursing evaluation using CIWA scale
• Thiamine prior to glucose containing fluids
• Multivitamins folate
• Correct deficits of Potassium, Magnesium, Glucose
  and Phosphate
• PO Benzodiazepines for CIWA gt 8 (long acting
  unless liver failure)
• I-V Diazepam for delerium
• Add Phenobarbitol or Propofol if refractory

53
Management of Opioid Overdose Withdrawal

• Rescue breathing
• Naloxone
• Withdrawal
• Methadone
• Buprenorphine
• Clonidine adjuntive medications

54
OAK GROVE FAMILY CLINIC RECOVERY CONTRACT
AGREEMENT I, _________________________,
understand I have been diagnosed with Chemical
Dependency. In an effort to preserve my
health, I do hereby agree to the following
terms 1. I agree to avoid all
mood altering substances including alcohol and
over-the- counter
prescriptions without the prior approval of my
primary physician, Gary
Carr, M.D. 2. I agree to take Antabuse and/or
Naltrexone if requested to do so by Dr.
Carr. 3. I agree to make all
scheduled appointments with Dr. Carr or
physicians he may refer
me to. 4. I agree to see no
physician other than Dr. Gary Carr or physicians
he may refer me to with the
exception of emergencies. In case of an
emergency, I will notify Dr. Carr of the need to
see another physician and
medications prescribed within twenty-four (24)
hours. 5. I agree to make six
(6) AA/NA meetings per week (Note Evenings
in outpatient treatment
count as a meeting.)
6. My sponsor is ______________________,
Phone _____________________.
Dr. Carr may freely communicate any concerns
regarding my recovery with my
sponsor. 7. In case of
relapse, Dr. Carr may contact ____________________
___________
__________________________________________________
_____________ Phone
______________________Address ____________________
_________ If I relapse, I
agree to immediately enter into an inpatient
evaluation with further
treatment as indicated. 8. I
agree to submit to random, witnessed, unannounced
chain-of-custody urine
alcohol and drug screens when called. Failure to
present for urine drug
screening is considered a positive screen and
will prompt calls to my
sponsor and identified contact(s).
NOTE A missed screen is viewed as a positive
screen.
55
RE Recovery Contract Agreement Page Two
9. I understand failure to adhere to each of
the stipulations above, use of
alcohol and/or drugs, or failure to submit to
timely screens will be considered
a violation of this contract, and need for
further treatment.
10. I agree that Dr. Carr and other parties
referenced in this contract may freely
communicate regarding my recovery.
I have read and
understand the requirements of this contract. I
agree to abide fully with the requirements set
forth. ____________________________________ _____
_________________ Participant Date _________
___________________________
______________________ Gary D. Carr,
M.D. Date ___________________________________
_ ______________________ Witness Date cc
Patient Sponsor Contact Person(s)