Pain in the Patient With a Substance Use Disorder
Safe Treatment of Pain in the Patient With a Substance Use Disorder
Conditions associated with severe pain can and do develop in persons who have active addiction or who are in remission from an addictive disease, and these patients may require treatment for pain relief. This presents a challenge to clinicians: How can pain be relieved in these patients without exacerbating or reactivating the addictive disorder?
There is little research data on this topic; however, experiential and anecdotal reports collected over the past 3 decades indicate that there are safe and effective approaches to pain management in these patients. In general, the pain treatment regimen for a person recovering from an addiction involves the use of long-acting opioids, such as sustained-release oxycodone, methadone, or buprenorphine, administered on a fixed dosage schedule, with another person holding the medication. Specific dosing recommendations are provided.
By: Penelope P. Ziegler, MD; Psychiatric Times (CMP Medica), 24(1), 2007.
HTML available online at: http://www.psychiatrictimes.com/showArticle.jhtml?articleID=196902132 (Free registration may be required.)
Brief-TSF professional training is complimentary to pain treatment.
Peers Help Alcoholics in Many Ways
Social network variables in alcoholics anonymous : A literature review
Alcoholics Anonymous (AA) is the most commonly used program for substance abuse recovery and one of the few models to demonstrate positive abstinence outcomes.
Although little is known regarding the underlying mechanisms that make this program effective, one frequently cited aspect is social support.
In order to gain insight into the processes at work in AA, this paper reviewed 24 papers examining the relationship between AA and social network variables.
Various types of social support were included in the review such as
- structural support,
- functional support,
- general support,
- alcohol-specific support, and
- recovery helping.
Overall, this review found that AA involvement is related to a variety of positive qualitative and quantitative changes in social support networks.
Although AA had the greatest impact on friend networks, it had less influence on networks consisting of family members or others.
In addition, support from others in AA was found to be of great value to recovery, and individuals with harmful social networks supportive of drinking actually benefited the most from AA involvement.
Furthermore, social support variables consistently mediated AA’s impact on abstinence, suggesting that social support is a mechanism in the effectiveness of AA in promoting a sober lifestyle. Recommendations are made for future research and clinical practice.
Research report; Groh DR, Jason LA, Keys CB. Social network variables in alcoholics anonymous : A literature review. Clin Psychol Rev. 2007 Aug 7.
Science of Addiction
From: University of Utah, Genetics Science Learning Center.
This website – which is highly interesting, informative, and entertaining — delivers interactive and print-based resources, free of charge, on the neurobiological actions of substances of abuse: heroin, cocaine, methamphetamine, marijuana, LSD, ecstasy, and alcohol. The presentations primarily depict how drugs interact with dopamine neurotransmitters within the brain’s reward pathway. The influences of genetics on addiction are also discussed. Although the simplified mechanisms of drug action and other influences depict only part of the story, even experienced practitioners will find the material of interest as a refresher.
Particularly entertaining yet informative, and well worth a look, is the “Mouse Party,” which takes an interactive look inside the brains of animated mice on drugs, exploring molecular mechanisms of addiction. It provides a small glimpse into the chemical interactions at the synaptic level that cause drug users to feel “high” and want to repeat drug-abusing behaviors.
- Go to the Mouse Party
- Section on How Drugs Alter Brain Reward Pathways
- Main Page on Genetics of Addiction
- Some animations require the Adobe Flash Player (available free at Adobe)
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The Science of Addiction: From Neurobiology to Treatment by Carlton K. Erickson |
Alcoholics can benefit from Al-Anon
Recovering alcoholics can benefit from Al-Anon
R.J. has been clean and sober and an active member of Alcoholics Anonymous for 20 years. He lives the Twelve Step program each day, one day at a time. He attends AA meetings faithfully, reads the literature, meditates, and asks his Higher Power for guidance. He has told his story many times and listened with loving acceptance to the stories of others, as AA members are encouraged to do. He thought nothing about addiction could surprise him at this point in his life and recovery.
Then he discovered his 20-year old son had a drug and alcohol problem. "I felt so stupid," he said. "I know this stuff, and it never entered my mind that my son was using. He was the good boy, the one who got straight A’s. He knows I’m a recovering alcoholic and that his mother (my ex-wife) is a practicing one. I thought knowing about us would keep him sober. But he got to a point where he seemed paralyzed; he couldn’t stay on track. One day I said, sort of in passing, ‘You act like you’re on drugs.’ He said, ‘I am.’ When I asked what kind and he said he’d tried ‘just about everything,’ I was stunned. I didn’t know what to do."
Not knowing what to do, R.J. did nothing the night of his son’s revelation except listen. "I told him I wouldn’t preach or yell, but I asked him if I could tell him when I heard him giving me the ‘standard’ addict’s lines like, ‘I have it under control.’ He said I could, and we talked until 4 a.m."
Next, R.J. sought help from others. His first impulse was to issue an edict telling his son not to come around until he got straight, but a counselor at work cautioned that things could get worse if his son felt abandoned, with no safe places or safe people to turn to. "She suggested I establish clear rules so he wouldn’t come here high or use here, but let him know that I love him and I’d do whatever it takes to help him when he’s ready."
When a long-time friend (also a recovering alcoholic) suggested going to Al-Anon, R.J. said he was "blown away" by the idea. Like many recovering alcoholics, he had always viewed Al-Anon as a Twelve Step mutual-help group for "them"–the family and friends of the alcoholic–and AA as the Twelve Step group for "us"–the alcoholics who affected their lives.
R.J. and his friend went to an Al-Anon meeting where they were the only men. He confessed that he was very nervous at first but said the familiar Twelve-Step meeting structure eased his anxiety. "Then I said, ‘I’m an alcoholic–the reason you’re here–but now I need help.’ It broke the ice, and they welcomed us with so much warmth and generosity."
Because it is not unusual to have more than one problem drinker in a family, it makes sense that recovering alcoholics can also be affected by another’s alcohol or drug use, and that they could benefit from the fellowship and support of Al-Anon. Except for one word in Step Twelve where Al-Anon has substituted the word "others" for AA’s word "alcoholics," the Steps of the two groups are identical.
"At AA we learn that we’re powerless over alcohol. At Al-Anon you discover that you’re powerless over others," explained R.J. He thought the Al-Anon members he met also gained by meeting two recovering alcoholics who embrace the same Twelve Step philosophy they do.
R.J. said it was a profound experience to view addiction "from the other side of the fence" at Al-Anon. "It struck such a chord when a woman there told me I’ve got my story, but my son is still writing his. I can tell him about my path and show him a path exists, but I can’t walk it for him."
Al-Anon meetings are held in 115 countries, and there are over 24,000 Al-Anon groups worldwide. For more information visit http://www.al-anon.alateen.org/.
Alive & Free is a health column that provides information to help prevent substance abuse problems and address such problems. It is created by Hazelden, a nonprofit agency based in Center City, Minn. "Copyright © 2003 Hazelden Foundation. All rights reserved." Any other use of the Web site or the information contained here is strictly prohibited.
At Amazon; How Al-Anon Works for Families & Friends of Alcoholics
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Working with Twelve Step Approaches
Working with Substance Misusers
The 12-step programs are discussed. It is noted that 12-step programs consist of a range of self-help groups, which have their origins in the recovery philosophy of Alcoholics Anonymous.
The Minnesota Model is an adaptation of the 12-step program that is used in some specialist treatment settings.
There is a lack of knowledge and training regarding 12-step methods among professional groups, and misunderstandings are common.
The program does offer a resource which is widely available, free, open to anyone, and that provides support at times when other agencies are unavailable.
The approach may be a useful alternative or adjunct to other treatments for some clients.
Williams, C. Twelve step approaches. In: T. Petersen and A. McBride, Eds., Working with Substance Misusers, London, UK: New York, NY: Routledge, 2002. 362 p. (pp. 134-144).
Brief-TSF satisfies these guidelines
Asking about drinking
Bringing Up the Touchy Subject of a Patient’s Drinking
Broaching the subject of alcohol with a patient or client who shows signs of a drinking problem can be awkward. Drinkers often feel ashamed of their problem, at the same time that they downplay its seriousness. Directly confronting them may do no more than provoke a flat denial. For these reasons professionals very often steer clear of the matter. But to wait for that patient or client to bring up the subject amounts to giving up on the issue, according to some with first-hand experience in the matter.
“In 30 years of practice it almost never happens that someone comes in and announces that they have a problem with alcohol,” says Carvel Taylor-Valentine, a licensed clinical social worker.
“Patients would rather that their problems are about anything other than alcohol or drugs. They would rather admit to some kind of mental illness, even schizophrenia, than to call themselves an alcoholic.”
The reason for this, says Ms. Taylor-Valentine, who is a certified addictions counselor, is simple: “They don’t want to stop drinking. Alcohol is a feel-good substance, and they are afraid of giving it up.”
Marsha Epstein, M.D., medical director, Tucker Health Center, a unit of the Los Angeles Department of Public Health, agrees.
“No one is quick to admit to current problems with alcohol or drugs. When I was in private practice years ago, I saw about 2,000 patients over four and a half years and none ever admitted current heavy drinking.”
Dr. Epstein, who also has a master’s degree in public health, remembers a phone call from the daughter of a woman patient disclosing that the mother drank alcoholically. “I believed the daughter, but I never brought up any problem with alcohol to her mother. I did not know how.”
Both Dr. Epstein and Ms. Taylor-Valentine have found that the information forms filled out by new patients are the best place to introduce questions about drinking problems, especially if the questions are about alcohol abuse in a patient’s family.
“It was at a medical conference that I was introduced to a woman who was a member of Al-Anon and who told me about that program,” says Dr. Epstein. [Al-Anon is a Twelve Step program for those who have problem drinkers in their lives.] “When I returned from that conference, I added a question about drinking problems among family members to the medical history forms filled out by patients.”
Happy to Discuss Anyone Else’s Drinking
Whereas practically no patient would talk about their drinking problem, “lots admitted that they had family members who drank too much,” says Dr. Epstein. Nowadays, when the conversations get to a patient’s drinking, Dr. Epstein says, “instead of asking if someone has a problem with alcohol, I ask when was the last time they overdid it. Not asking specific questions is a mistake.”
When a patient opens up about their alcohol abuse, Dr. Epstein steers them to Alcoholics Anonymous. “Here’s the number for A.A. meetings – just go. You don’t have to say anything, and you can sit in the back.”
Back in her time in private practice, Dr. Epstein also made use of Al-Anon. “If they checked ‘yes’ on that question about a family drinking history, I would suggest they go to an Al-Anon meeting and come back and tell me how it was.”
What Dr. Epstein discovered was that some of her patients found their way to Alcoholics Anonymous through Al-Anon.
“Over the course of a few years, five patients who had gone to Al-Anon returned to tell me that they discovered in that program that they had a problem with alcohol. I suspect there were many others who got to A.A. through Al-Anon. It never occurred to me that it would work this way.”
From; About AA; A newsletter for professionals, Spring 2007. www.AA.org
Dilemma of the Alcoholic Marriage
Brain Damage & Cirrhosis
Alcoholics with cirrhosis of the liver have more brain damage than noncirrhotic alcoholics
- Cirrhosis of the liver is one of the most common and serious medical complications linked to alcoholism.
- Heavy alcohol use can also cause brain damage.
- Cirrhotic alcoholics appear to have even more impaired brain function than non-cirrhotic alcoholics.
Sustained exposure to alcohol can cause scarring and dysfunction of the liver, referred to as cirrhosis. Heavy alcohol use can also cause brain damage. An examination of gene expression in the frontal cortex has found that brain function is even more impaired in cirrhotic than non-cirrhotic alcoholics.
Results are published in the September 2007 issue of Alcoholism: Clinical & Experimental Research.
“The liver’s main function is to remove poisons from the blood,” explained R. Dayne Mayfield, research scientist at the Waggoner Center for Alcohol and Addiction Research at The University of Texas at Austin. “It also helps the body absorb certain nutrients like fats and fat-soluble vitamins. You cannot live without a functioning liver.” Mayfield is also the corresponding author for the study.
He added that about 10 to 20 percent of heavy drinkers develop cirrhosis. It is the seventh leading cause of death among young and middle-aged adults in the United States; approximately 10,000 to 24,000 deaths from cirrhosis each year may be due to alcohol consumption. “Cirrhotic patients [have] dysfunctional livers that cannot remove poisons from the blood stream,” he said. These poisons are able to move into the brain and disrupt normal function.
“When a gene or deoxyribonucleic acid (DNA) is ‘turned on,’” said Mayfield, “it serves as a template for synthesis of ribonucleic acid (RNA), which in turn produces protein, the key element in cell function. These ‘genes’ hold the key or code for the ultimate production of proteins that control all functions of the brain. We know that heavy alcohol drinking changes the regulation of genes in the brain. We predicted that alcohol-related changes in brain genes would be magnified in alcoholics with cirrhosis.”
Researchers obtained brain samples from the Brisbane Node of the National Health & Medical Research Council Brain Bank and the Tissue Resource Centre at the University of Sydney, Australia. They compared roughly 47,000 element cDNA microarrays taken from two groups (n=21): seven cirrhotic and 14 non-cirrhotic alcoholic cases.
“We found that the levels of many important brain genes changed in the cirrhotic patients,” said Mayfield. “These genes are important in regulating cell death and how individual cells in the brain talk to each other in a meaningful way.”
“The level of gene expression differed significantly between tissue from cirrhotic and non-cirrhotic alcoholics,” added John H. Krystal, Robert L. McNeil, Jr. professor of clinical pharmacology and deputy chairman for research in the department of Psychiatry at Yale University School of Medicine and the VA Connecticut Healthcare System. “Out of 1,125 genes, 482 genes showed increased expression and 643 genes showed reduced expression in the cirrhotic individuals. With the levels of so many genes changing, this study suggests widespread effects in many cellular pathways related to cirrhosis in the alcoholic group.” Krystal is also a principal investigator at the NIAAA Center for the Translational Neuroscience of Alcoholism and the VA Alcohol Research Center.
More specifically, those genes involved in neurite growth, neuronal cell adhesion, and synaptic transmission showed greater inhibition at the mRNA level among the alcoholic cases.
“Cells in the brain have to maintain connections in order to operate,” explained Mayfield. “This is similar to the way the internet works to transmit information across the globe. The internet would slow down or stop if enough connections are interrupted or changed. Similarly, the genes outlined above are responsible for proper connections and communication between cells in the brain. Without them, normal function would not be possible.”
Krystal suggested several possible interpretations of the findings. “One, alcoholics who develop cirrhosis likely drink more heavily than those alcoholics who do not develop cirrhosis,” he said. “Therefore, some of the findings may be related to the effects of heavy drinking upon the brain. A second contribution could be the effects of impaired liver function upon the brain. The liver plays a major role in the production and metabolism of a large number of substances that influence brain function, and impaired liver function would be expected to affect the brain. A third possibility is that cellular processes that are stimulated by alcohol consumption might influence both liver and brain. That is, the cirrhotic and non-cirrhotic groups differ in their cellular resilience to the toxic effects of alcohol rather than differences in their level of alcohol consumption. A fourth possible contributing factor could be changes in diet. If patients with cirrhosis have a more profound disruption of their nutrition than patients who do not develop cirrhosis, differences in brain damage may be related to nutritional deficiencies.”
Both Mayfield and Krystal said that the central message of the study is that alcoholism, especially when accompanied by a serious medical complication such as cirrhosis of the liver, can produce widespread changes in the body and brain.
“One hopes that a better understanding of the cellular processes related to the destructive impact of alcoholism upon the brain may help to guide the development of treatments that might protect people from neural damage related to alcoholism, and help them to recover from alcoholism,” said Krystal. “Important questions are: ‘How reversible are the changes in gene expression in the brain when alcoholics stop drinking"’ and ‘How dependent is the recovery of the brain upon the recovery of the liver"’"
AA Fact File
A Few Basic Facts About AA
Alcoholics Anonymous is well-known as an organization for people who want to stop drinking. At the same time, there are some points about A.A. that may be unclear to the general public and even to professionals working to help problem drinkers.
Founded in the United States in 1935, when one alcoholic discovered he could stay sober by helping another alcoholic, Alcoholics Anonymous now has more than two million members in some 180 countries.
A.A.’s sole purpose is helping people recover from the disease of alcoholism, and it has no affiliation with any other group or organization. Members anywhere in the world can come together to form an A.A. group, of which there are an estimated 106,000 worldwide.
Among other facts about Alcoholics Anonymous are:
Membership is free. A.A. groups usually pass a basket around at meetings to cover the cost of renting the meeting room and for other incidental expenses, such as coffee.
A.A. is not a religious organization; it is not allied with any religious organization, and requires no religious belief as a condition of membership. Members include Catholics, Protestants, Jews, Muslims, Hindus, agnostics, and atheists.
A.A. does no recruiting. The only requirement for membership is a desire to stop drinking. There are no other requirements to be met, no initiation fees to be paid, and no forms to be filled out. It is completely up to anyone considering joining A.A. to determine if they have a problem with alcohol and whether they will deal with it in Alcoholics Anonymous. A person becomes a member of A.A. simply by deciding they want to be a member.
A.A. groups are autonomous and run by the members themselves.
A.A. is not a temperance society. Members acknowledge their inability to drink safely but have nothing to say about the drinking of others. It is a principle of A.A. that it has no opinion on what are termed outside issues.
A.A. is not affiliated with any hospital or rehab, or any other such facility. No professional services of any kind are offered or performed under A.A. sponsorship.
A.A. meetings take several forms, but at any meeting there will be alcoholics talking about how drinking affected their lives and what life as a sober member of A.A. is like.
Anonymity is respected. Newcomers can turn to A.A. with the assurance that their attendance at meetings will be kept private.
“Open” Meetings of A.A. are meetings which anyone may attend to observe how A.A. works. “Closed” meetings are reserved for those with a drinking problem.
Contacting A.A. Information on how to find local A.A. meetings can be found in telephone directories and at numerous Internet sites, including www.aa.org.
From; About AA; A newsletter for professionals, Spring 2007.
Alcoholic is good and sober
Alcoholic is good and sober; Sentiment change in AA.
An alcoholic is a stigmatized, deviant identity.
This longitudinal study of 55 Alcoholics Anonymous (AA) participants found that even chronic alcohol abusers viewed alcoholics negatively, in keeping with normative understandings.
However, following mandated AA attendance, there was significant change in social sentiments for alcohol-related concepts and meanings for feelings and objects related to drinking, as sentiments became similar to AA subculture understandings.
In AA "an alcoholic" is good.
Sentiment change, AA ideology, and the implications for identity and normative behavior are discussed.
Section headings in this article include:
(1) theoretical background in the development of meaning;
(2) alcoholism and AA; and
(3) sentiments and sentiment measurement.
Research report; Thomassen, L. Alcoholic is good and sober: Sentiment change in AA. Deviant Behavior, 23(2):177-199, 2002.
