Addiction

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Addiction Pain
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What is addiction?

• Compulsive use despite harm

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Addiction

• 1 chronic neurobiological disease
• Development manifestations influenced by
• Genetic
• Drug disposition
• Stress responsivity
• Environmental
• Drug-induced neurochemical changes
• Psychosocial
• Psychopathology
• Personality traits

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Anatomic Pathways

• Mesocorticolimbic pleasure, reward, motivation
• Prefrontal cortex
• Memory, emotnal processing, impulse control,
  decisn making
• Ventral pallidum
• Craving, seeking, relapse
• Basolateral amygdala
• Associative learning, emotional memory
• Ventral tegmental area
• Reinforcement, reward priming circuit
• Nucleus accumbens
• PFC NAc VP motor memory circuit

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Neurotransmitters

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

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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

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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?

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The Spectrum

• Recreational users
• Chemical copers
• Substance abusers
• Addicted

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Wanting More

• Tolerance
• O.I.H.
• Pseudoaddiction
• Disease progression
• Withdrawal
• Aberrant behaviour
• Diversion

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Opioid Withdrawal

• the cost of opioid dependence
• Anxiety, insomnia, irritability, restlessness
• Nausea vomiting, abdominal cramping
• Myalgias, arthralgias, bone pain
• Tremor, myoclonic jerks

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Pseudoaddiction

• Drug-seeking 2 to inadequate analgesia
• Reassess
• Diagnosis
• Drug
• Dogma

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Recognising the Drug Seeker

• Time
• Patience
• Awareness
• Monitoring
• Sense of humour

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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

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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

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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 hx psychiatric disorder
• Level 3 specialist care
• Current substance abuse
• Psychopathology