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Similaire à Wsam Presentation For Opiate Guidelines
Similaire à Wsam Presentation For Opiate Guidelines (20)
Wsam Presentation For Opiate Guidelines
- 1. Chronic Non-Cancerous Pain & Problematic Opiate Use Diagnostic and Therapeutic Principles with some Guidelines James K. Rotchford MD MPH Olympic Pain & Addiction Services (OPAS) Port Townsend, WA
- 2. Disclosure: OPAS is a private medical practice. New patients are seen primarily because of consultation request. Medicare Provider Labor & Industry Provider Kitsap Physician Service Provider
- 14. Copyright ©2001 CMA Media Inc. or its licensors Tomkins, D. M. et al. CMAJ 2001;164:817-821 Fig. 1: Schematic diagram of the human brain that highlights some of the main brain areas and neurotransmitter pathways implicated in reward processes
- 16. Dopamine is the “currency” which determines the response of Nucleus Accumbens: dopamine spikes within the NA occur as below to “cues” and promotes behavior accordingly
- 21. Hypothesis regarding pseudoaddiction: Our ideas about pseudoaddiction in pain management stem from “neurotic” patterns particularly prominent in American culture: “ In 1919 , a Federal ruling held that treatment of addiction was “outside the realm of legitimate medical interest”. This created the conundrum that allowed physicians to treat pain but not addiction that sometimes occurs in the context of medical use. (Principles of Addiction Medicine, 2009 p. 1329, Chapter on Opioid Therapy of Pain by Savage SR et al.)
- 24. Difference Between a Chronic Pain Patient & an Addict Adapted from: Schnoll SH, Finch J. J Law Med Ethics . 1994;22:252-6. Addiction is a disease; medication compliance is not addiction Yes No Denial about any problems Yes No Use continues in spite of problem No Yes Medications improve quality of life Yes No Out of control with medications Addiction Physical dependence
- 31. Problematic Analgesic Opioid Use - a disorder with a clinical continuum? Less than effective Use/Prescribing? Poor Pain Management/education Chemical Coping/Self Medicating Occasional Abuse Regular Abuse 5 C’s of Addiction Complications alone define problematic analgesic opioid use
Notes de l'éditeur
- Many medical students are taught that if opioids are prescribed in high doses or for a prolonged time, the patient will invariably become an addict. Therefore, the common wisdom is to prescribe the lowest possible dose at the longest possible dosing interval. As a result, opioids are frequently prescribed in doses that are inadequate and at time intervals beyond the duration of action of the drug, resulting in poor analgesia. 1 The term pseudoaddiction was first introduced by Weissman and Haddox in 1989 to describe the iatrogenic syndrome of abnormal behavior developing in direct consequence of inadequate pain management. 2 They described the natural history of pseudoaddiction as a progression through 3 characteristic phases including: (1) inadequate prescription of analgesics to meet the primary pain stimulus; (2) escalation of analgesic demands by the patient associated with behavioral changes to convince others of the pain's severity; and (3) a crisis of mistrust between the patient and the health care team. Treatment strategies include establishing trust between the patient and the health care team and providing appropriate and timely analgesics to control the patient's level of pain. 2,3 1. Schnoll SH, Finch J. Medical education for pain and addiction: making progress toward answering a need. J Law Med Ethics. 1994;22:252-6. 2. Weissman DE, Haddox JD. Opioid pseudoaddiction—an iatrogenic syndrome. Pain . 1989;36:363-6. 3. A consensus document from the American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions Related to the Use of Opioids for the Treatment of Pain . 2001.
- There is a distinction between the patient who is physically dependent, but not out of control with medication, and the addict who is. The physically dependent person’s quality of life is improved through use of the medication, whereas the addict’s quality of life is severely impaired. Use of medication continues or increases despite adverse consequences to the addict; however, the physically dependent patients will complain or seek to deal with negative consequences, such as side effects, by trying to cut down on the medication. The addict is unaware or in denial about the problems caused by the medication; the physically dependent patient is concerned about these problems. 1 1. Schnoll SH, Finch J. Medical education for pain and addiction: making progress toward answering a need. J Law Med Ethics . 1994;22:252-6.