Although not specific to pain therapy, useful measures to screen for CUD include: • Single question: How often in the past year did you use marijuana (never, less than monthly, monthly, weekly, daily or almost daily) 155 • The 8-item Cannabis Use Disorders Identification Test-Revised (CUDIT-R) 157 • Comprehensive Marijuana Motives Measure 158 The Basics of Addiction Medicine Definitions and terms used to discuss addiction have evolved over time. Certain phrasing that is potentially stigmatizing has fallen out of usage, and more accurate terminology has been introduced. For example, patients with SUD, including OUD, should not be referred to as “addicts.” The disease of OUD is diagnosed using DSM-5 criteria (Table 10). 92 A minimum of two-to-three criteria are required for a mild SUD diagnosis, while four-to-five is moderate, and six or more is severe; 92,151 OUD is specified if opioids are the substance of use. Addiction, while not a DSM-5 diagnosis, is a frequently used term and typically describes severe SUD. The presence of tolerance and physical dependence does not necessarily mean that an OUD has developed, particularly if the medication is taken as prescribed. The rewarding effects of drugs occur through dopamine stimulation in the mesolimbic system of the brain. 159 When a drug stimulates the brain’s mu opioid receptors, cells in the ventral tegmental area release dopamine into the nucleus accumbens, causing pleasurable feelings. 159 The pharmacokinetics and lipophilicity of the drug and its route of administration influence the speed and amount of dopamine released and thus the degree of reward experienced by the individual. Intravenous and inhalational use speeds onset more than oral ingestion. However, ER/LA opioids
can be altered by the individual to produce a rapid onset of action by crushing, chewing, or dissolving in liquids, for example. 68 Repeated ingestion stimulates the brain’s reward system. At the same time, the brain creates conditioned associations and lasting memories that associate reward with environmental cues of drug use. Normally, inhibitory feedback from the prefrontal cortex helps most individuals overcome drives to obtain pleasure through unsafe actions. 159 However, prefrontal cortex inhibitory cues are compromised in people with addictions, and drug use behaviors are driven by a complex combination of both positive and negative reinforcements. Positive reinforcements include the individual’s pleasure from using the substance and negative reinforcements include the desire to prevent withdrawal. As tolerance and dependence develop, more drug is necessary to obtain the same reward and prevent withdrawal. The locus coeruleus area of the brain plays an important role in the production or suppression of withdrawal symptoms. When an OUD is present, the compulsion to use opioids repeatedly goes beyond the reward drive. As changes in the brain develop, the person’s experience of pleasure diminishes and they engage in the compulsive drug use despite adverse consequences that characterizes OUD. 159 Updates to Florida Controlled Substances Regulation House Bill 831 Electronic Prescribing This bill was signed into law by Governor DeSantis with an effective date of January 1, 2020. The bill provides important new requirements for prescribers to generate and transmit all prescriptions electronically upon licensure renewal or by July 1, 2021, whichever is earlier.
The law requires prescribers to generate and transmit all prescription electronically, unless: • The practitioner and the dispenser are the same entity; • The prescription cannot be transmitted electronically under the most recently implemented version of the National Council for Prescription Drug Programs SCRIPT Standard; • The practitioner has been issued a waiver by the department, not to exceed 1 year, due to demonstrated economic hardship, technology limitations that are not reasonably within the control of the practitioner, or another exceptional circumstance demonstrated by the practitioners; • The practitioner reasonably determines that it would be impractical for the patient in question to obtain a medicinal drug prescribed by electronic prescription in a timely manner and such delay would adversely impact the patient’s medical condition; • The practitioner is prescribing a drug under a research protocol; • The prescription is for a drug for which the federal Food and Drug Administration requires the prescription to contain elements that may not be included in electronic prescribing; • The prescription is issued to an individual receiving hospice care or who is a resident of a nursing home facility; or • The practitioner determines that it is in the best interest of the patient, or the patient determines that it is in his or her own best interest to compare prescription drug prices among area pharmacies. The practitioner must document such determination in the patient’s medical record.
Table 10. Criteria for Opioid-Use Disorders from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 92 A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: • Opioids are often taken in larger amounts or over a longer period of time than was intended • There is a persistent desire or unsuccessful efforts to cut down or control opioid use • A great deal of time is spent in activities to obtain the opioid, use the opioid, or recover from its effects • Craving, or a strong desire or urge to use opioids • Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home • Continued opioid use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of opioids • Important social, occupational, or recreational activities are given up or reduced because of opioid use • Recurrent opioid use in situations in which it is physically hazardous • Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that’s likely to have been caused or exacerbated by the substance • Tolerance,* as defined by either of the following: a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect b. A markedly diminished effect with continued use of the same amount of an opioid • Withdrawal,* as manifested by either of the following: a. The characteristic opioid withdrawal syndrome b. The same—or a closely related—substance is taken to relieve or avoid withdrawal symptoms *This criterion is not met for individuals taking opioids solely under appropriate medical supervision. Severity: mild = 2–3 symptoms; moderate = 4–5 symptoms; severe = 6 or more symptoms.
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