Pain and SUD

what are the 3 types of pain?

-nociceptive: actual or threatened damage to non-neural tissue and activation of nociceptors in the setting of normal nerve functioning

-neuropathic: lesion or disease of the somatosensory nervous system

-nociplastic: altered nociception despite no clear evidence of actual or threatened tissue damage; influenced by biopsychosocial factors

what are the 3 time-based classifications of pain?

-acute: <4 weeks

-subacute: 4-12 weeks

-chronic: >12 weeks

what are the 4 aspects of the biopsychosocial model of pain?

-biological

-psychological

-behavioral

-social

what are the 5 main CDC guidelines for prescribing opioids for chronic pain?

-short acting over long

-<50 MME and avoid >90 MME or justify

-no BZDs

-assess risk for dependency

-counsel on naloxone use

what were 3 unintended outcomes of the CDC guidelines for prescribing opioids for chronic pain?

-no guidance for safe use of opioids in acute pain and patients already on long term opioids

-arbitrary limits on MME superseding medical judgement

-many pain patients abruptly discontinued or dismissed from care without a follow up plan

what are 7 cases in which opioids are not recommended first line?

-low back pain

-neck pain

-musculoskeletal injuries

-minor surgery, mild post op pain

-dental pain

-kidney stone pain

-headache/migraine

what are 5 common non pharmacologic therapies for pain?

-lifestyle

-physical rehabilitation

-CBT

-complementary and alternative medicine

-device and procedure based methods

what are 3 aspects of monitoring opioid use?

-check PDMP when starting new opioids and with every new rx or every 3 months

-confirm adherence and identify use of illicit drugs or other meds that could interfere with treatment goals

-patient should understand and agree to treatment and monitoring plans

what are 4 indications for naloxone?

-hx of OD or behavior concerning for OUD

-recent detox/rehab or release from prison with OUD hx

-high doses of chronic opioids or concurrent benzos

-hx of obstructive sleep apnea

what are the 5 main symptoms of stimulant intoxication?

-euphoria

-alertness

-decreased appetite

-twitching

-psychosis/paranoia

what are the 3 main outcomes of stimulant intoxication and their treatments?

-standard: supportive care

-agitation/psychosis: antipsychotics or BZDs

-hyperautonomic state: BZDs or beta blockers (controversial due to cardiac risk)

what are the 3 main outcomes of stimulant withdrawals?

-intense cravings

-agitation

-fatigue/hypersomnolence

how long are stimulants detected in urine?

1-4 days after last use

what are 5 medications that have been used off label for stimulant use disorder?

-topiramate: 300 mg/d in 2 doses

-mirtazapine: 30 mg/d

-bupropion: 150 mg PO bid

-naltrexone: 380 mg IM qmonth

-agonist treatment

what are 3 agonist treatments for stimulant use disorder and a main consideration?

-ER amphetamine salts

-ER methylphenidate

-modafinil

-higher doses are more effective

what are 2 main complications from cannabis intoxication?

-cannabis induced psychosis

-cannabis induced hyperemesis syndrome

how long does cannabis withdrawal take and what are 4 common symptoms?

-1 week after cessation due to lipophilicity

-irritability, anger, aggression

-nervousness/anxiety

-sleep difficulty

-restlessness

what are 3 treatments for cannabis use disorder?

-gabapentin: 1200 mg/d in 2-3 divided doses

-n-acetylcysteine: 1200 mg PO bid, reduced cannabis craving in youth

-CBD: attenuates paranoia and anxiety associated with THC

what are 3 cannabinoids used for cannabis withdrawal?

-dronabinol: 90 mg/d

-nabilone: 6-8 mg

-nabixmols: reduces days of cannabis use and withdrawal symptoms

what are 5 symptoms associated with BZD intoxication?

-hypotension

-relaxation

-urinary retention

-anterograde amnesia

-ataxia

what is the treatment for BZD overdose and its considerations?

flumazenil; 0.2 mg IV over 30 sec, maxed out at 3 mg, boxed warning for seizures

what is the general rule for tapering BZD withdrawal?

reduce dose by 10-25% per week

what are 3 symptoms of empathogen overdose?

-risk of serotonin toxicity, especially with DDIs

-hyperthermia

-tachycardia

what are 5 negative effects of hallucinogen intoxication?

-anxiety, fear, panic

-difficulty regulating body temperature

-insomnia

-nausea

-unwanted and overwhelming feelings

what are 3 therapeutic uses for hallucinogens?

-treatment refractory depression

-anxiety disorders

-treatment of SUDs

what are 4 symptoms of dissociative intoxication?

-euphoria

-dissociation of mind from body

-loss of motor coordination

-hallucinations/delusions

what are 5 symptoms of dissociative overdose?

-irregular heartbeat

-muscle rigidity

-hyperthermia

-seizures

-coma

what are the dosing suggestions for use of ketamine and esketamine for treatment resistant depression and suicidality?

-ketamine: 0.5-1 mg/kg IV infusion over 40 min

-esketamine: 56-84 mg IN qweek/q2week