PAIN MANAGEMENT CONCLUSIONS
Those suffering from addiction develop compulsions to repeatedly use substances or engage in behaviors despite harmful circumstances. 171 Addiction can have immediate and long-term consequences on the patient, their family, and society as a whole. Addiction can also be costly; addiction to illicit drugs, nicotine, and alcohol costs the United States over $740 billion annually due to healthcare costs, crime, and lost productivity. 172 Addiction is used as a term to describe the compulsion to seek drugs despite negative consequences but is not a diagnosis itself. 172 The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) characterizes drug use diagnoses as “substance use disorders”, which are subclassified into mild, moderate, or severe conditions. 173 Treatment of this complex condition can be difficult, and measures must be patient-specific and focus on several aspects of the patient’s health, including medical, psychological, and social problems in addition to the drug use itself. Much effort has gone into evaluating effective treatments in an effort to decrease morbidity and mortality. 174
Acute and chronic pain are common disease states seen by healthcare providers, and pain management can be complex and time-consuming. The pathophysiology of pain is as diverse as each patient’s characterization of their experience, and to further complicate matters, there is a myriad of treatment options available. It is important for providers to thoroughly assess a patient’s pain before developing an individualized, patient-specific treatment plan that often involves the use of multiple treatment modalities. Pain management treatment regimens require regular reassessment to ensure the benefits of treatment continue to outweigh the risks, and if this balance shifts, providers should ensure treatment regimens are changed, discontinued, or referred to a more appropriate provider as the patient’s condition evolves. Introduction to Addiction The American Society of Addiction Medicine defines addiction as a chronic medical disease that involves complex interactions among brain circuits, the environment, genetics, and a patient’s life experiences.
CAUSES OF ADDICTION
The etiology of addiction is not well understood, but research suggests it is a complex and chronic brain disorder. One widely accepted theory involves the activation of the mesolimbic dopaminergic system, known as the brain’s “reward system”. Addictive substances enhance the release of dopamine from neurons in the ventral tegmental area and signal reward or feelings of pleasure. Since dopamine also activates conditioning and memory mechanisms in the brain, the satisfying behaviors are reinforced and continued, and the brain becomes accustomed to this stimulation. The user may feel strong cravings for the substance, especially when surrounded by environmental factors associated with substance use. These may include stress, negative feelings, or other people who normally use with them. 175,176 Over time, individuals can become less able to control their drug use. The brain increases motivation toward desirable behaviors involving drugs and decreases motivation for non-drug rewards that once brought pleasure; the individual’s motivation to take the drug is driven by conditioned responses to signals and by negative emotional situations. This means the addict focuses on immediate reward and the high levels of dopamine released from drugs. The constant high levels of dopamine may cause the brain to downregulate dopamine receptors and decrease its usual release. Individuals no longer feel reward from behaviors that once brought gratification because those behaviors do not release a large amount of dopamine. 175,176
Although dopamine is a key player, it has also been suggested that glutamate, GABA, serotonin, norepinephrine, and acetylcholine are involved. Further study is needed in this area, both in biology and psychology, to find the sources of addiction. 175,176 Beyond the brain’s neurobiological mechanisms, researchers suggest a variety of risk factors may contribute to developing addiction, although they are not well understood. Genetic predisposition is one proposed risk factor for addiction or substance use disorder. Certain structural alterations in the brain, such as impairments in the reward circuitry, may increase an individual’s vulnerability for addiction. Additional causes may include stress, impulsivity, mood disorders such as depression and anxiety, and other comorbid psychological issues. Another factor is environmental influences. Individuals may be trying to offset trauma or abuse, they may be surrounded by substance use by family or friends, or they may have easy access to these substances. Age can be an important factor, with a majority of those with addiction having started drug use at an early age. Additionally, some research suggests that using one addictive substance can “prime” the brain and make it more prone to becoming addicted to another substance. Having one or more of these risk factors does not mean someone will become addicted, but it does increase the odds. The more risk factors present, the greater the chance an individual will develop the disease. 177
SUBSTANCE USE DISORDER
The many types of addiction defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and referred to as “substance use disorders”. Prolonged, repeated use of illicit or nonprescribed substances, such as opioids, at high doses or high
frequencies can lead to substance use disorder (SUD). The Diagnostic and Statistical Manual (DSM-5) uses a list of 11 equally weighted symptoms when diagnosing substance use disorders. Patients who display fewer than two symptoms on the list are not considered to
Book Code: CA23CME
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