the patient with an...
TRANSCRIPT
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The Patient with an Addiction
Stephan A Schug
Anaesthesiology
University of Western Australia &
Pain Medicine
Royal Perth Hospital
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Disclosure
The Anaesthesiology Unit of the University of
Western Australia, but not Professor Schug
personally, has received research and travel
funding and speaking and consulting honoraria
from Eli Lilly, bioCSL/Seqirus, Grunenthal, Indivior,
Janssen, Mundipharma, Pfizer, Phosphagenics and
iXBiopharma within the last 5 years.
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Terminology
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Issues in Acute Pain Management
psychological, social and behavioural characteristics
associated with an addiction;
presence of the drug (or drugs) of abuse;
medications used to assist with drug withdrawal, relapse
prevention and/or rehabilitation;
complications of drug abuse including organ impairment,
infectious diseases and increased risk of traumatic injury;
the presence of tolerance, physical dependence and
withdrawal.
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General Principles of Management
• patient engagement
– empathic and open communication
– pragmatic treatment goals
• provision of effective analgesia
• use of strategies to attenuate tolerance and prevent
withdrawal
• secure drug administration procedures and discharge
planning
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Addiction to Drugs Other Than Opioids
Alcohol and benzodiazepines
– no effect on pain relief
– withdrawal may require substitution ➢ sedation
Cannabinoids
– possibly increased opioid requirements
– higher pain scores
– lower satisfaction
Amphetamines, cocaine
– no good data on pain and analgesic requirements
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Opioids in Patients on Opioids
increased requirements
reduced efficacy
reduced nausea/vomiting
paradoxically increased sensitivity with
increased sedation and possibly respiratory
depression, in particular with dose increase
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Always Consider Other Reasons for
Increased Opioid Requirements!
Acute neuropathic pain
Pain due to other causes
– surgical complication
– compartment syndrome
Major psychological distress
Aberrant drug seeking behaviour
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Scientific Evidence:
Multimodal Analgesia
There is Level I evidence for the effectiveness of the
following components of multimodal analgesia:
– Paracetamol
– NSAIDs/Coxibs
– Alpha-2-Delta Ligands (pregabalin, gabapentin)
– Systemic Local Anaesthetics (lignocaine/lidocaine)
– Ketamine
– Alpha-2 Agonists (clonidine/dexmedetomidine)
– Corticosteroids (dexamethasone)
– Regional anaesthesia (peripheral and epidural)
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Whenever Possible Use a Regional
Analgesia Technique!
Catheter techniques are better than single-
shot blocks:
– epidural analgesia
– peripheral nerve catheters
Regional techniques do NOT prevent
withdrawal!
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Antihyperalgesic Medications
Provide Effective Analgesia and
Attenuate Opioid Tolerance and OIH:
Ketamine
Gabapentin/Pregabalin
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Ketamine Provides Better Analgesia
Ketamine Placebo
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Ketamine Reduces PCA Reqirements
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Gabapentinoids Counteract
Central Sensitisation / Hyperexcitability
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Pregabalin As An Anxiolytic
Kavoussi Eur Neuropsychopharmacol 2006;16:S128
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Alpha-2-Delta Modulators and
OIH/Tolerance
In methadone-maintained patients, gabapentin
increased cold-pressor pain threshold and pain
tolerance.
Pregabalin in maintenance program patients reduced
methadone requirements and withdrawal symptoms.
OIH associated with remifentanil is attenuated by
preoperative pregabalin.
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Prevention of Withdrawal
Maintenance of normal preadmission opioid regimes
– including on the day of surgery
– check preadmission opioid doses with GP/pharmacist
Substitute with parenteral equivalent if patient NBM
Manage withdrawal symptoms should they occur
– clonidine
– pregabalin/gabapentin
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Alpha-2-Delta Modulators and
Withdrawal
Pregabalin attenuated naloxone-induced withdrawal symptoms in
opioid-tolerant rats (Hasanein 2014 BS).
Gabapentin reduced withdrawal symptoms in patients
during methadone-assisted detoxification (Salehi 2011
Level III-1).
Pregabalin added to methadone in maintenance program
patients reduced methadone requirements and withdrawal
symptoms compared with placebo (Moghadam 2013
Level II, n=60, JS 5).
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Discharge Planning
Close liaison with ongoing prescriber/supplier:
– GP
– Pharmacist
– Drug Abuse Service
Planning of ongoing analgesia in consideration of
risks for the patient, but also the community
(diversion increased exposure, overdose risk!)
Adjustment of opioid substitution to preadmission
doses
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