Chapter 25 Substance Use Disorders and Detoxification Flashcards Preview

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Flashcards in Chapter 25 Substance Use Disorders and Detoxification Deck (71):
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opioids as second-line medications

for neuropathic pain treatment

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opioid as first-line agents in certain circumstances

(i.e., acute neuropathic
pain, during titration periods with a first-line agent and
episodic exacerbations of neuropathic pain

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What system is implicated in the development of psychological dependence?

Mesolimbic dopaminergic projections to the nucleus
accumbens

4

physical dependence
on opioids is probably due to

noradrenergic activity in the locus ceruleus.

5

The incidence of analgesic
tolerance is lower with more potent opioids such as fentanyl,

presumably because these agents are more receptor-specific and fewer receptors are needed to produce
an analgesic effect

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risk for developing an
addiction to opioids

Strong predictors include personal history of illicit drug use and alcohol abuse. Selfreported craving
Comorbid psychiatric and chronic pain disorders

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disorders were found to improve with benzodiazepines.

chronic pain conditions such as trigeminal
neuralgia, tension headache, and temporomandibular disorders

8

Clonazepam has been reported to provide long-term relief of

the episodic lancinating variety of phantom limb pain.

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Benzodiazepines
have been used for

the detoxification of patients
with chronic pain from sedative/hypnotic medications
and were superior to barbiturates for minimizing symptoms of withdrawal

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Benzodiazepines also cause

cognitive impairment as demonstrated by abnormalities on neuropsychological testing and EEG.

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In patients with chronic pain use of benzodiazepines and not opioids was associated with

decreased activity levels, higher rates of healthcare visits, increased domestic
instability, depression, and more disability day

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Benzodiazepines have been associated with exacerbation of

pain and interference with opioid analgesia, which is mediated by the
serotonergic system

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Benzodiazepines also increase the rate of developing

tolerance to opioids.

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Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association defines both substance abuse and dependence as

maladaptive (behavioral) patterns of substance use leading to clinically significant impairment or distress

15

Substance abuse must be accompanied by any of the following:

interpersonal
problems, legal problems, failure to fulfill major role obligations, and recurrent substance use in hazardous situations

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In contrast to abuse, substance dependence is manifested by

tolerance, withdrawal, using the substance in larger amounts or over a longer period than was intended, persistent desire or unsuccessful efforts to decrease or control substance use, spending large amounts of time in activities necessary to obtain the substance, the giving up or reduction of important activities
because of substance use, and continued substance use despite knowledge of having physical or psychological problems caused or exacerbated by the substance

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core criteria for a substance
use disorder in patients with chronic pain include

the loss of control in the use of the medication, excessive preoccupation with the medication despite adequate analgesia, and adverse consequences associated with the use of the medication

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Items from the Prescription Drug Use Questionnaire that best predicted the presence of addiction in a sample of patients with problematic medication use were

(1) the patients believing they were addicted, (2) increasing analgesic dose/frequency, and (3) a preferred route of administration.

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The diagnosis of addiction in the patient with chronic pain must demonstrate

certain drug taking behaviors that interfere with the successful fulfillment of life activities.

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goals of treatment.

Increased function and opioid analgesia without side effects,
not the avoidance of high doses of opioids

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evaluation of a patient suspected of misusing medications

should be thorough and include an assessment of
the pain syndrome as well as other medical disorders, patterns of medication use, social and family factors, patient and family history of substance abuse, and a psychiatric history

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pseudoaddiction

Reliance on medications that provide pain relief can result in a number of stereotyped patient behaviors that are often mistaken for addiction. Persistent pain can lead to increased focus on opioid medications. Patients
may take extraordinary measures to ensure an adequate medication supply even in the absence of addiction. This may be manifested as frequent requests for higher medication
doses and larger quantities of medication or seeking
medication from additional sources.

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Under optimal circumstances opioid contracts attempt to

improve compliance by distributing information and utilizing a mutually designed, agreed-upon treatment plan
that includes consequences for aberrant behaviors and incorporates the primary care physician to form a “trilateral”
agreement with patient and pain specialist.

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aberrant behaviors consistent with addiction

selling medications, losing prescriptions, using oral medications intravenously, concurrent abuse of alcohol or illicit drugs, repeated noncompliance with the prescribed use of medications, and deterioration in the patient’s ability to function in family, social, or occupational
roles

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Abuse

Harmful use of a specific psychoactive substance

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Addiction

Continued use of a specific psychoactive substance
despite physical, psychological, or social harm

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Misuse

Any use of a prescription drug that varies from accepted medical practice

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Physical
dependence

Physiologic state of adaptation to a dependence-specific
psychoactive substance characterized by the emergence of a withdrawal syndrome during abstinence that may be relieved in total or in part by readministration of the substance

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Psychological
dependence

Subjective sense of need for a specific-dependence
psychoactive substance, either for its positive effects or
to avoid negative effects associated with its abstinence

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an active substance use disorder is a relative
contraindication

to chronic opioid therapy.

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TREATMENT OF SUBSTANCE
USE DISORDERS IN PATIENTS
WITH CHRONIC PAIN

A strict treatment structure with therapeutic goals, landmarks to document
progress, and contingencies for noncompliance should be made explicit and agreed upon by the patient and
all the providers of health care

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Management of patients with substance use disorders in patients with chronic pain

The first step for the patient
is acknowledging that a problem with medication use
exists. The next step for the clinician is to stop the patient’s
behavior of misusing medications. Then, sustaining factors must be assessed and addressed

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Interventions for patients with substance use disorders in patients with chronic pain

These interventions include
treating other medical diseases and psychiatric disorders, managing personality vulnerabilities, meeting situational challenges and life stressors, and providing support and understanding. Finally, the habit of taking the medication
inappropriately must be extinguished

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Approach to patient who are being considered for chronic opioid treatment

A total approach to
the patient including a history of substance abuse, psychosocial comorbidities, and aberrant drug-related behaviors must be considered in an evaluation. Only if these potential risks can be minimized or treated should chronic opioid treatment be considered

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Detoxification

the process of withdrawing a person from a specific psychoactive substance in a safe and effective manner

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WHY IS DETOXIFICATION NECESSARY?

Because long-term treatment will have resulted in physiologic dependence, discontinuation or substantial dose reduction requires gradual tapering of the medication

37

When is physiologic opioid dependence demonstrated?

Although physiologic opioid dependence can be demonstrated experimentally within 7 days, most patients will not experience withdrawal symptoms unless they have continuously taken opioids for at least several weeks

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once physiologic dependence is established

abrupt discontinuation of opioids will precipitate acute withdrawal

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The essential element for successful opioid detoxification

the gradual tapering of the dose of medication

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When is Opioid withdrawal dangerous?

Opioid withdrawal is generally not dangerous except
with patients at risk from increased sympathetic tone
(e.g., increased intracranial pressure or unstable angina)

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Patients with pain are often particularly
miserable during opioid withdrawal because of

the phenomenon of rebound pain.

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the goal of detoxification

ameliorate withdrawal as much as is clinically practical

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What should be discussed with the patient prior to starting a detoxification program?

Explaining the treatment plan to patients before the detoxification begins is critical. In particular, patients should know to expect worsening of pain and should have a few concrete short-term goals to focus on, such as the
improvement in withdrawal symptoms, increasing functional abilities, or an alternative analgesic trial when withdrawal
has resolved

44

Indications for Detoxification

Intolerable side effects
Inadequate response or benefit
Aberrant drug-related behaviors
- Noncompliance
- Loss of control of medication use
- Preoccupation with the medication
- Continued use despite adverse consequences
Refractory comorbid psychiatric illness
Lack of functional improvement or impairment in role responsibilities

45

Indications for inpatient detoxification

failure of outpatient detoxification attempts,
medically unstable patients, comorbid psychiatric illness, unreliable or noncompliant patients, and complicated
pharmacologic regimens requiring taper of more than one medication or illicit drug

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Subjective Opioid Withdrawal Scale (SOWS) and the Objective
Opioid Withdrawal Scale (OOWS)

allow for the objective rating of withdrawal and documentation of the patient’s condition over time

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Short–Half-Life Opioid Taper

Determine the total daily dosage being used by the patient.
Adopt a fixed interval schedule with equal doses every 4–6 hr for 48 hr.
Increase the prescribed dose until the patient has no opioid
withdrawal symptoms for 48 hr.
Taper the amount of each dose without lengthening the interval
between doses.
Taper the total daily dose approximately 10% every 3–7 days

48

Short–Half-Life Opioid Taper
Slowing the taper may be accomplished by:

(1) increasing the number
of days at a given total dose; (2) decreasing a single dose amount while keeping the remaining doses the same;
(3) increasing the time
between doses only if the smallest individual dose has been reached

49

The preferable pharmacologic strategy for opioid detoxification

is to choose a long–half-life pure opioid agonist such as methadone, sustained-release morphine or oxycodone, and transdermal fentanyl patches

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long–half-life pure opioid agonist primary advantage

This strategy has the
primary advantage of more consistent opioid serum levels
with less chance of intermittent withdrawal between doses

51

With a long–half-life agent, when is the onset of withdrawal symptoms

With a long–half-life agent, the onset of withdrawal symptoms
should be expected at 12 to 24 hr, although 24 to 48 hr is the usually reported time course. The severity will
usually peak at 36 to 96 hr but can occur up to 1 week later

52

Benefits of Switching from short– to long–half-life opioids
in anticipation of detoxification

may serendipitously prove an effective analgesic strategy. Side effects, intermittent
withdrawal, and rebound pain may all improve such that detoxification may not be needed.

53

detoxification strategy use of the partial agonist/
antagonist opioids.

The agent most commonly used in this category is buprenorphine or the buprenorphine-naloxone combination called suboxone. The naloxone component prevents abuse of the
medication

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The use of partial agonist/antagonists is designed to

reduce the severity of withdrawal and cause less reinforcing drug effects, less risk of respiratory depression,

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When using partial agonist/antagonists such as buprenorphine, it is important to give a small test dose under
supervision because

of the rare precipitation of withdrawal symptoms secondary to the partial antagonist effect

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Buprenorphine Taper

- Test for the precipitation of acute withdrawal symptoms by giving an initial dose of 0.1 mg SQ/IM or 1.0 mg SL.
- Determine the total daily dose of the prescribed agent being taken by the patient.
- Estimate the equivalent total daily dose of buprenorphine (0.2 mg SQ/IM -- morphine 10 mg PO).
- Adopt a fixed interval schedule with equal doses every 8–12 hr.
- Titrate the dosage until the patient has no withdrawal symptoms for 24–72 hr.
Taper the dose and interval to 0.1 mg SQ/IM or 1.0 mg PO QD.
- Discontinue the medication when the patient experiences no or tolerable withdrawal symptoms

57

Clonidine,

an alpha-2-adrenergic agonist that decreases adrenergic
activity. Clonidine can help relieve many of the autonomic symptoms of opioid withdrawal, such as nausea, cramps, sweating, tachycardia,
and hypertension, which result from the loss of opioid
suppression of the locus ceruleus during the withdrawal
syndrome

58

Other factors that
tend to increase the difficulty and length of a taper

the longer a patient has been taking opioids, the more difficulty, medical comorbidity and complexity, older age, female gender, and detoxification from multiple agents simultaneously

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Progress in detoxification can be demonstrated by

simple compliance with taper instructions, not using other
illicit substances, improvement in side effects of opioids,
and maintenance of function

60

Patients can have lingering
subacute withdrawal symptoms for weeks.

Insomnia and rebound
pain are the most common symptoms.

61

Criteria for BENZODIAZEPINE DETOXIFICATION

been using benzodiazepines continuously for more than
2 weeks should be tapered to avoid the unpleasant experience
of mild withdrawal and the risk of unexpected major
withdrawal symptoms.

62

The general features of benzodiazepine withdrawal

hyperarousal
and hypersympathetic states.

63

benzodiazepine withdrawal is much more dangerous than
opioid withdrawal

potential for seizures,
hallucinations, hyperthermia, and delirium tremens

64

The two main techniques for Benzodiazepine detoxification

taper of the agent a patient has been taking and the substitution of an equivalent dose of a long–half-life agent such as diazepam or clonazepam. Another strategy for benzodiazepine
detoxification utilizes phenobarbital substitution,
especially in cases of complex detoxification from multiple
agents such as opioids, sedative-hypnotics, and alcohol

65

“second-generation” benzodiazepines

(clonazepam, alprazolam, oxazepam, triazolam) are not fully crosstolerant with each other or with the more traditional agents. A patient may require higher doses than expected to avoid significant withdrawal symptoms when taking
these medications.

66

Signs and Symptoms of Sedative-Hypnotic
Withdrawal - Hyperarousal

Agitation
Anxiety
Hyperactivity
Insomnia
Fever

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Signs and Symptoms of Sedative-Hypnotic
Withdrawal- Neurological

Ataxia
Fasciculation/myoclonic jerks
Formication
Headache
Myalgia
Paresthesias/dysesthesias
Pruritus
Tinnitus
Tremor
Seizures
Delirium

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Signs and Symptoms of Sedative-Hypnotic
Withdrawal - Genitourinary

Incontinence
Loss of libido
Urinary urgency, frequency

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Signs and Symptoms of Sedative-Hypnotic
Withdrawal - Psychiatric

Depersonalization
Depression
Hyperventilation
Malaise
Paranoid delusions
Visual hallucinations

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Signs and Symptoms of Sedative-Hypnotic
Withdrawal - Gastrointestinal

Abdominal pain
Constipation
Diarrhea
Nausea
Vomiting
Anorexia

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Signs and Symptoms of Sedative-Hypnotic
Withdrawal - Cardiovascular

Chest pain
Flushing
Palpitations
Hypertension
Orthostatic hypotension
Tachycardia
Diaphoresis

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