Prescription Opioids: Risk Management and Strategies for Safe Use _ _________________________________ current history of substance abuse, 16% and 42% of physicians, respectively, would not prescribe opioids under any circumstance [13]. Possibly contributing to this knowledge deficit is the extent of educational exposure to concepts central in pain management. A 2018 systematic review evaluated pain medicine curricula in 383 medical schools in Australia, New Zealand, the United States, Canada, the United Kingdom, and Europe [14]. Pain medicine was pri- marily incorporated into anesthesia or pharmacol- ogy courses, rather than offered as a dedicated pain medicine module. Ninety-six percent of medical schools in the United Kingdom and the United States and nearly 80% of medical schools in Europe had no compulsory dedicated pain medicine educa- tion. The median number of hours of pain content in the entire medical school curriculum was 20 in Canada, 20 in Australia and New Zealand, 13 in the United Kingdom, 12 in Europe, and 11 in the United States [14]. developing from opioid analgesics and contributed to the undertreatment of pain [16]. The DSM-5 has eliminated the categories of substance dependence and substance abuse by combining them into the single diagnostic entity of substance use disorder. The disorder is measured on a continuum from mild to severe [16]. In 2011, the American Society of Addiction Medi- cine (ASAM) published their latest revision in defin- ing the disease of addiction. Since that time, the public understanding and acceptance of addiction as a chronic brain disease and the possibility of remission and recovery have increased. Additionally, there is growing acknowledgment of the roles of prevention and harm reduction along the spectrum of addiction and recovery. Consequently, ASAM updated its definition of addiction and adopted the following revised definition in 2019 [17]:
Addiction is a treatable, chronic medi- cal disease involving complex interactions among brain circuits, genetics, the environ- ment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compul- sive and often continue despite harmful consequences. Prevention efforts and treat- ment approaches for addiction are gener- ally as successful as those for other chronic diseases. According to the ASAM, the five characteristics of addiction are [18]: • Inability to consistently abstain • Impairment in behavioral control • Craving or increased “hunger” for drug or reward experiences • Diminished recognition of significant problems with one’s behaviors and interpersonal relationships • A dysfunctional emotional response This summary of addiction should not be used as diagnostic criteria for addiction because the core symptoms vary substantially among addicted persons, with some features more prominent than others [17].
The nomenclature related to addiction is often inconsistent, inaccurate, and confusing, partially reflecting the diverse perspectives of those working in the related fields of health care, law enforcement, regulatory agencies, and reimbursement/payer orga- nizations. Changes over time in the fundamental understanding of addiction have also contributed to the persistent misuse of obsolete terminology [15]. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychi- atric Association, is perhaps the most influential reference for the diagnosis of addiction and all other psychiatric disorders. Prior to the 2013 release of the DSM-5, previous versions eschewed the term “addiction” in favor of “substance dependence,” with a separate diagnostic entity of “substance abuse” representing a lower-grade, less severe version of substance dependence [16]. Also in earlier DSM versions, physiological dependence, manifesting as substance tolerance and withdrawal, was considered a diagnostic criterion of substance dependence. The result was the perpetuation of patient and healthcare professional confusion between physical and psy- chological dependence and the belief that tolerance and withdrawal meant addiction. This confusion enhanced provider and patient fears over addiction
6
MDMS1526
Powered by FlippingBook