Psychiatry - December 2008 - (Page 23)

so that you don’t have significant withdrawal symptoms, and then see if you are functioning better or worse. The trade-off may be between being more alert but a bit more anxious. Patient: I am going to see her next week. I will tell her I want off. Psychiatrist: Remember that Dr. N started those pills for you in order to be helpful with your anxiety. Any time a medicine doesn’t work the way we hope it will, or has ill effects that make the medicine not worth the trouble, then we need to rethink the plan. Doctors need to get feedback to know if their prescriptions are helping or not. Patient: Yeah, she’s really helped me. Psychiatrist: I think that decreasing clonazepam will be a move that will help you reach your goal of being a support to your family again. Just remember you will need to decrease it slowly over time. If Dr. N prefers, I’d be glad to write out a schedule for you on how to do it. I’d be glad to talk with her again. Just let me know. TABLE 2. The “4 Cs” for recognizing addiction 1. 2. 3. 4. Negative consequences of medication use Loss of control over use Compulsive use Craving or preoccupation related to medication use Adapted from: Compton P. Should opioid abusers be discharged from opioid-analgesic therapy? Pain Medicine. 2008; 9(4):383–390; Savage SR. Assessment for addiction in pain-treatment settings. Clin J Pain. 2002;18:S28–S38. PRACTICE POINT: MAKE CLINICAL DECISIONS BASED ON IMPROVING FUNCTION With the use of benzodiazepines or opioids, or any prescribed medication for that matter, the driving issue must be function. Is this intervention making it easier or more difficult for this patient to manage and enjoy life? It is surprising that many patients and their pain specialists come to the conclusion that recommended drugs, even opioids, are not worth the side effects. Then, the disappointing medications are discontinued, and a new tactic must be tried. WHAT IS THE DIFFERENCE BETWEEN PHYSIOLOGIC DEPENDENCE/TOLERANCE, DRUG ADDICTION, AND PSYCHOLOGICAL DEPENDENCE? Patients often fear addiction even more than the prescribing physicians do. Even more than dependence and 23 tolerance, per se, is the fear of being thought of as an addict.13 Physiologic dependence is the term used to describe the phenomenon of a withdrawal syndrome that most individuals will experience if they take opiates for a long enough time in high enough doses and then abruptly reduce the dose. Physiologic tolerance is the associated term that describes the phenomenon of needing to take more of a medication to achieve the same effect that many individuals will experience if they take an opiate for a long enough duration. These are effects that can happen to any of us if we are prescribed opiates for more than a few days, and although they do not represent true addiction, the terms are often used in a way that suggests they do. It may be necessary to clarify to a pain patient that the development of physiologic dependence on an opioid does not indicate that the patient has become an addict. Addiction, or the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IVTR) diagnosis of opioid dependence involves issues far beyond that of physiologic dependence, including the classic “four Cs” (Table 2).14–16 If opiates are appropriately prescribed and monitored, this is unlikely. Case example: evaluating and interpreting surreptitious opiate use. Ms. M was given an appointment by an alcohol and drug program for the express purpose of being evaluated for buprenorphine (Suboxone®) treatment for opioid dependence due to overuse of hydrocodone with acetaminophen (Vicodin®). One might have expected [VOLUME 5, that the type of motivation that would be needed in a case like this would be for sobriety. Psychiatrist: Your drug counselor has told me you are interested in treatment for dependence on Vicodin. Patient: Well actually, it’s my husband who wants me to quit. Psychiatrist: Tell me more about that. Patient: Well, I was seeing Dr. X for the pain in my back. I was told I should have surgery, but I have to work. I can’t take that kind of time off! The trouble all started when I ran out of my medicines and I couldn’t get any more. The doctor prescribed Vicodin every eight hours, but I can’t get out of bed unless I take two about an hour before I have to get out of bed. Then I need two more to be able to go to work. I was in pain and I just couldn’t hack it! My mother gave me hers so that I could at least function. Trouble is my husband found out about it and it has been hell ever since. Psychiatrist: So your use of Vicodin was helping you to do what you needed to around the house as well as to work, but you didn’t have enough, so you took your mother’s which has gotten you into some marital strain. Are there any other problems you have run into with your using Vicodin? Patient: Well, I feel really guilty about using more than I was prescribed… I know it’s not a good example for my children…and it doesn’t fit in with my concept of myself as a good Christian. Psychiatrist: So other than the guilty feelings relating to your doctor, 12, DECEMBER] NUMBER Psychiatry 2008 23

Table of Contents Feed for the Digital Edition of Psychiatry - December 2008

Psychiatry - December 2008 Editor’s Message Contents Editorial Advisory Board Antidepressant Prescribing by Specialty and Treatment of Premenstrual Dysmorphic Disorder Pain, Pain, Go Away: Antidepressants and Pain Management Why Psychotherapy Helps the Patient in Chronic Pain General Medical Drugs Associated with Depression Katatonia: A New Conceptual Understanding of Catatonia and a New Rating Scale Thermoregulation and the Role of Calcium Signalling in Neurotransmission Cognition and Schizophrenia: Is There a Role for Cognitive Assessments in Diagnosis and Treatment? Journal Watch Information for Authors

Psychiatry - December 2008

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