● Keep current with relevant federal, state, and institutional policies and laws. ● Establish goals of care for cannabis use. ● Screen for signs of misuse, CUD, and diversion. ● Counsel patients on harms and risks on the basis of symptoms, condition, and comorbidities. ● Advise on routes of administration using current evidence base. ● Continually monitor similarly to opioids (informed consent, written agreement, regular follow-up, functional status, considering periodic urine testing, symptom severity, and use of other medications or substances). ● Monitor for other harms, including car accidents and falls. ● Advise on discontinuation or referral to CUD treatment if pain relief and function goals are not being met without harm. 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). 149 ● The 8-item Cannabis Use Disorders Identification Test-Revised (CUDIT-R). 151 ● Comprehensive Marijuana Motives Measure. 152
although other research notes similar exposure as smoking to carbon monoxide and other respiratory toxins. 150 Other delivery options including edibles and extracts. Patients may develop cannabis-use disorder (CUD) and be unable to stop use on their own even though it is interfering with their health and function. Signs of CUD include: 149 ● Using a larger quantity or over a longer duration than intended. ● Unsuccessful attempts to limit or quit. ● Significant amounts of time spent obtaining cannabis. ● Cravings. ● School or occupational impairment. ● Social or interpersonal impairment. ● Reduction of social, occupational, or recreational activities. ● Recurrent use in physically harmful situations. ● Continued use despite recurrent physical or psychological harms. ● Tolerance. ● Withdrawal. Because some patients who are taking opioids will elect to use cannabis, HCPs should be aware of certain clinical recommendations: 150
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 (Box 2). 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; 92,145 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. Box 2: 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 need for markedly increased amounts of opioids to achieve intoxication or desired effect. ○ 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.
Book Code: MDCO1025
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