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
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 Conclusions All HCPs who treat pain with the use of opioids need up-to-date competencies to manage potential opioid-related harms. This includes a familiarity with the full complement of nonpharmacologic and pharmacologic options to create an individualized treatment plan, reserving opioids for when other strategies are not effective.
An optimal multimodal approach to pain management consists of using treatments from one or more clinical disciplines incorporated into comprehensive plan. 1 For select patients who benefit from opioids long term, HCPs should reduce risk and optimize benefits by patient education, screening of high- risk patients for OUD, continuous monitoring, combining treatments with non-opioid options when indicated, referral and co-management of comorbid conditions, and an exit strategy to ensure careful tapering when indicated. It is important for patient outcomes and for regulatory and legal requirements to document every aspect of opioid therapy within the medical record and to follow all federal, state, and local regulations regarding opioid therapy. HCPs should know the signs and symptoms of OUD and be prepare to treat or refer for treatment with the understanding that medications for OUD are essential to save lives.
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
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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