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Requisite knowledge of addiction (3.4.1 - 3.4.20)

Updated: Mar 7, 2022

Define the following concepts:

  • Tolerance

Tolerance, as defined by either of the following:

- (a) a need for markedly increased amounts of a substance. to achieve intoxication or a desired effect,

- (b) markedly diminished effect with continued use of the. the same amount of a substance.

  • Physical dependence

A condition in which a person takes a drug over time, and unpleasant physical symptoms occur if the drug is suddenly stopped or taken in smaller doses.

  • Substance use disorder

Substance use disorder (SUD) is the persistent use of drugs (including alcohol) despite substantial harm and adverse consequences


Describe the evolution of the terms:

  • Tolerance

No significant evolution of the term. The concept has been static for some time.

  • Physical dependence

  • Substance use disorder

  • Addiction

The term addiction has lead to prejudice, stigma and ignorance of the difficulties of substance use disorder. It encompasses medical, psychological, sociological, cultural, economic, religious, ethical and legal considerations

The use of terms like 'narcotic' particularly in lay speak and legal settings has also further stigmatised substance use.

The DSM 5 is moving away from the longstanding distinction between substance dependence and substance abuse. SUD is seen as a single continuum from mild, moderate to severe. This is instead of the terms substance dependence and substance abuse.

The abuse was seen as a milder form of dependence however in practice abuse can be very severe. This was therefore altered in DSM 5.

Reasons for change from substance dependence and substance abuse being separate into a combined continuum:

(1) the distinction provided little guidance for treatment

(2) the distinction created “diagnostic orphans” (individuals who endorsed two dependence symptoms and no abuse symptoms and therefore did not meet any diagnostic criteria)

(3) the hierarchical structure did not follow the anticipated relationship between abuse and dependence (that abuse was largely a less severe prodrome4 of dependence)

(4) the separation caused the abuse diagnosis to suffer from significant reliability problems

The legal problems criterion was dropped due to low endorsement, poor fit with other items, and the poor discrimination of this item (almost all people endorsing the legal criteria endorsed other criteria also)


3.4.3 - Discuss the current DSM-5 and ICD-11 criteria for diagnosis of substance use disorder


- ICD-11 and DSM 5 categorise multiple sub-types of substances of dependence differently

- Polysubstance dependence has been removed from both

- Gambling and gaming disorders have been added to both

- DSM 5's SUD criteria is now very broad with over 2000 different possible ways to be diagnosed as a mix of different diag criteria

- Unclear if this will effect its usefulness for treatment

- Craving was added to DSM 5 to keep more in line with ICD11


3.4.4 - Discuss how inappropriate prescribing behaviour may contribute to problematic substance use

  • Increased prescribing of opioids leads to increased availability for patients, the community and illicit use

  • Prolonged prescription increases long term use

  • Restricted availability may lead to illicit use

  • Inappropriate use of opioids to treat non-opioid indicated, or responsive, pain

  • Non-tracking of opiate prescriptions and opioid use

  • Excessive scripts and larger pack sizes


3.4.5 - Describe the impact of the following substances on health and pain experience:



  • Increased physical performance

  • Possibly helps lose weight

  • Increased focus and mental alertness

  • Overall reduction in mortality

  • Reduced cancer risk

  • Reduced stroke risk

  • Reduced Parkinsons disease risk

  • Reduced type 2 diabetes risk


  • An overdose could kill (though ridiculous high amounts)

  • Increased insomnia and restlessness

  • Effects on pregnancy

  • Half-life of 5 hours

  • Can exacerbate anxiety components of pain experience



  • Boosts concentration

  • Improve memory

  • Reduce bodyweight

  • ?Small to medium anti analgesic effect but worsened after dose reduces


  • High risk of physical addiction - as severe as cocaine or heroin

  • Increased metabolic syndrome risk

  • Increases cancer initiation

  • Direct effects on lungs through CNS effects (and also clearly smoking it)

  • Peptic ulcer disease

  • Immune suppression

  • Macular degeneration in mice



  • Acute analgesic benefits lastin 8-10 days however withdrawal can cause hyperalgesia

  • Relaxation acutely


  • Associated with acute pain conditions such as pancreatitis

  • Increased risk of injury

  • Dysregulation of opioids

  • Can stimulate TLR-4 and cause hyperalgesia

  • Ethylgluconiride damage

  • Thiamine deficiency leading to motor damage



  • Acute anxiolytic component

  • Possibly utility in chronic neuropathic pain - however evidence of benefit does not outweight harm

  • NNT 24 (30%) - NNH 6 (Stockings et al 2018 - 104 studies, 10,000 patients)


POINT study -

  • Associated with greater pain intensity

  • Lower self-efficacy

  • Greater pain interference

  • Greater levels of anxiety

Methamphetamine and other stimulants


  • Used for ADHD specifically



3.4.6 - Discuss the contribution of benzodiazepines to problematic substance use in pain medicine

  • Benzodiazepines and opioids are among the most frequently abused psychoactive substances in the world

  • Co use of benzodiazepines and opioids is common - particularly in abuse

  • E.g. 75% of patients admitted to a heroin treatment program had used BZDs in the past 12 months. 25% of those used them regularly

  • Nonmedical use of BZDs in chronic pain approaches 40-60% of patients in some cohort studies

  • Benzodiazepines add little therapeutic benefit for chronic pain patients. They may enhance the euphoric effects of opioids.

  • The use of both substances has a significantly increased risk for drug overdose. Respiratory depression is the most common mechanism.

  • Opioids cause a medullary respiratory centre reduction in response to circulating CO2. Inhibitory GABA receptors are also highly concentrated in these areas and the drugs likely work synergistically. The effect of both together is higher than each separately.

  • Benzodiazepines are the most sold drugs on the internet

  • Chronic pain is associated with a state of hyperarousal - which may explain why benzos are sought after


3.4.7 - Recognise the spectrum of problematic substance use that may be co-morbid with the experience of pain

  • Between 3 and 50% of patients with chronic non-cancer pain have a current substance use disorder

  • Rates are higher than in the general population

  • 94% of SUD patients will experience symptoms BEFORE the onset of their chronic pain

  • Interestingly patients with chronic pain are NO MORE likely than any other patient in a primary care setting to have a current SUD - suggesting chronic pain is NOT associated with a unique risk for substance abuse



3.4.8 - Recognise aberrant drug-taking behaviours

Red flags include:


  • Selling their prescription

  • Prescription forgery

  • Reporting lost/stolen medications

Abnormal pain behaviours

  • Disproportionate pain

  • Negative interactions with pain providers

  • Anxiety or desperation over recurrent symptoms

Maladaptive coping with pain

  • Drinking more alcohol when in pain

  • Raising the dose of opioids on their own


  • Doctor shopping

  • Borrowing or stealing opioids

  • Hoarding medication

  • Performing sex for drugs

  • Opioids from more than one source


3.4.9 - Identify intoxication and withdrawal syndromes associated with:

Opioids / Methdone / Herioin / Morphine


  • Constriction of pupils

  • Itching/scratching

  • Sedation

  • Lowered BP

  • Slowed pulse

  • Hypoventilation


(Short acting - onset 8-24 hrs after use, duration 4-10 days)

(Long acting - onset 12-48 hrs, duration 10-20 days)

  • Nausea and vomiting

  • Anxiety

  • Insomnia

  • Hot and cold flushes

  • Perspiration

  • Muscle cramps

  • Watery discharge from eyes and nose

  • Diarrhoea

Managing Opioid withdrawal

2-3 L of water drank

Vitamin B and C supplementation

Can use clonidine, or buprenorphine/methadone or short acting

Consider benzodiazepines

Clonidine - Helps with sweating, diarrhoea, vomiting, abdo cramps, chills, anxiety, insomnia and tremor. It can cause drowsiness, dizziness and low blood pressure. Cease clonidine if BP drops below 90/5o mmHg or HR <50. Check BP 30 mins after giving first dose of clonidine.

Dose - Day 1 - 150 mcg TDS, increase to 150-300mcg TDS, then reduce at day 4-5.



  • Relaxation

  • Disinhibition

  • Impaired coordination

  • Impaired judgement

  • Decreased concentration

  • Slurred Speech

  • Ataxia

  • Vomiting


  • Anxiety

  • Perspiration

  • Tremors

  • Dehydration

  • Increased HR and BP

  • Insomnia

  • Nausea and vomiting

  • Diarrhoea

  • SEVERE - Seizures, hallucinations, delirium, agitation

Management - Diazepam can be used 10mg QID and then weaned by 10mg /day



  • Disinhibition

  • Sedation

  • Drooling

  • Incoordination

  • Slurred speech

  • Lowered blood pressure

  • Dizziness


(Short acting - 1-2 days after last dose and continues for 2-4 weeks)

(Long acting - 2-7 days after last dose and continues for 2-8 weeks)

  • Anxiety

  • Insomnia

  • Restlessness

  • Agitation and irritability

  • Poor concentration and memory

  • Muscle tension/aches

Management - Usually use steadily reducing benzo amounts.

Convert benzo to diazepam - max 40 mg daily

Then slowly reduce depending on symptoms.

Amphetamines / Cocaine


  • Hyperactivity

  • Restlessness

  • Agitation

  • Anxiety/nervousness

  • Dilation of pupils

  • Elevated BP

  • Increased PR

  • Sweating

  • Elevated temperature

  • Tremor


Symptoms within 24 hrs of last use and last for 3-5 days

Psychotic symptoms can occur such as paranoia, hallucinations, disordered thoughts

  • Agitation and irritability

  • Depression

  • Increased sleeping and appetite

  • Muscle aches


Should drink 2-3 L of water per day

Multivitamin with B and C is recommended

Rarely Diazepam 10-20 mg every 30 mins can be given

Withdrawal phase may last 1-2 months duration with lethargy, anxiety unstable emotions, erratic sleep patterns and craving



  • Relaxation

  • Decreased concentration

  • Decreased psychomotor performance

  • Impaired balance

  • Conjunctival injection


  • Anxiety and feeling of fear and dissociation

  • Restlessness

  • Irritability

  • Poor appetite

  • Disturbed sleep and vivid dreams

  • GI upset

  • Night sweats

  • Tremor


Supportive, calm and symptomatic

Primarily psychosocial care is required



  • Reduced awareness of environment

  • Sedation

  • Decreased focus

  • Disorientation

  • Hallucinations

  • Tachycardia

  • Elevated BP

  • Excessive saliva

  • Increased urination

  • Forgetfulness


  • Memory loss

  • Impaired judgement and disorientation

  • Clumsiness

  • Aches and pains

  • Anxiety



  • Dizziness

  • Tremors

  • Slurred speech

  • Ataxia

  • Double vision

  • Tachycardia

  • High or low BP

  • Diarrhoea


Atypical anti-psychotics and hypnotics

NB: Increasingly olanzapine may have a role in chronic pain wiht associatefd psyciatric comorbidity. May have a role in fibromyalgia and headache/migraine


  • Lethargy

  • Sedation

  • Miosis, tachycarda and orthostatic hypotension (from alpha adrenergic component)

  • Anticholinergic symptoms


  • Nausea

  • Vomiting

  • Insomnia

  • Dizziness

  • Excessive sweating

  • Increased heart rate



3.4.10 - Identify people with or at risk of substance use disorders


  • Family history of substance abuse

  • Personal history of substance abuse


  • History of depression/anxiety

  • Previous treatment programs including AA


  • History of criminal/legal problems

  • Regular contact with high-risk people

  • Past problems with employers, family members, friends

  • Risk-taking behaviours

  • Heavy tobacco use





3.4.11 - Identify fellow healthcare professionals with substance use problems, or at risk of

  • Younger age

  • Cigarette use

  • Moderate alcohol use

  • Sense of immunity to becoming addicted

  • Health professional burnout

  • Being in situations where offered alcohol or drugs

  • Socialising with substance users

  • Early use of tobacco/alcohol

  • Genetics

  • Coexisting psychiatric illness

  • Family history of SUD

  • Easy access to drugs

Yellow flags - Warning signs (lifestyle and stress factors)

Red Flags - Practitioner needs to stop working (Severe depression, anxiety, substance use)



3.4.12 - Outline factors in determining suitability for opioid pharmacotherapy


  • Screener and Opioid Assessment for Patients with Pain (SOAPP-R)

  • Opioid risk tool (Though recently less sensitivity)

Assessing in current use

  • Current Opioid Misuse Measure (COMM)


3.4.13 - Statement on Medicinal Cannabis

THC recently rescheduled from S9 to S8

Political and community demands have created this imperative

FPM is concerned about adverse effects including:

  • Impaired respiratory function

  • Psychotic symptoms

  • Cognitive impairment

Cannabis is the third most used substance after alcohol and tobacco worldwide

Unauthorised use of cannabis in Australia is widespread

90% of people stated that hydroponic cannabis was easy or very easy to acquire

Cannabinoids are:

  • Delta9-tetrahydrocannabinoil (THC)

  • Cannabidol

  • Cannabinol

Sativex - Licence in Aus for MS spasticity


  • 18% bioavailability

  • Inaccurate dosing

  • Rapid onset and offset (falls in 2h)

Oral and transmucosal

  • Poor absorpbtion

  • <10% bioavailability

  • Difficult to titrate

Cannabinoid evidence

Stockings et al, 2018

  • 10,000 participants, 50 RCTs, and 50 observational studies

  • CNCP cannabinoids were more likely than placebo to reduce pain 30%. NNTB = 24

  • No evidence it reduced pain by 50% compared to placebo

  • Reduction in pain intensity but unlikely clinically significant

  • Patients who had cannabinoids had twice the chance of withdrawing from the trial due to adverse events.

  • NNTH = 6


Discuss the uses and limitations of drug testing in pain medicine practice

  • Can be used to assess compliance (particularly in opioid substitution programs) and also detect other drugs of abuse

  • Consent must be sought first

  • Usually an immunoassay screen of drugs of dependence or abuse

  • If positive, can do a chromatography-mass spectrometry - (less false positives)

  • Saliva tests are less intrusive but also less accurate


Compile a comprehensive medication record

  • Reconciliation of quantity, identification of discord,

  • Consultation with community prescribers and dispensing points

  • Identification of pharmacodynamic interactions


Discuss strategies to minimise problematic substance use

Strategies to improve appropriateness of opioid use

  • Standardised definitions and laws across states and territories

  • Effective national surveillance and scripting program

  • Up-scheduling of codeine

  • Improved analysis of PBS prescriptions

  • State and territory systems to support continual and coordinated care for complex patients

  • Improved use of opioid stewardship in acute settings

  • Support for the 'medical home' concept

  • Adequate education and support for general practice

  • Improved collaboration with pharmacists

  • Education of health professionals of non-pharmaceutical EBM treatments

Reference: RACGP Guidelines S8 drugs book


Explain the regulations for prescription, restrictions and monitoring in relevant jurisdictions

Real-Time Prescription Monitoring (RTPM) - Counter system alerting prescribes to patient medication history before they prescribe

If the concerned patient is a doctor-shopper - they can call Medicare Australia's Prescription Shopping Information Service

NB: No evidence that these programs decrease or increased overdoses


Explain the operation of:

Prescription shopping information service

PSP criteria include:

  • PBS item prescribed by 6 or more prescribers

  • Total of 25 or more PBS target items

  • Total of 50 or more target or non-target items

Can call DDU QLD - S8 scripts, QOTP, drug dependent, regulatory requirements, approval

  • Real-time online monitoring of controlled drugs

Script is not yet active in QLD


Explain controlled opioid substitution therapy programs in your jurisdiction

  • AOD services

  • Voluntary service

  • Often there is a wait list

  • OST is at no cost - however, community pharmacy often adds dispensing fees

  • 2 in 3 opioid pharmacotherapy long-term patients are male

  • 1 in 10 are aboriginal

  • Daily dosing at a community pharmacy is standard

  • Most are now Suboxone


Outline the principles of collaborative management of patients with substance use disorders

Be collaborative...


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