1/10. Slow metabolism and long half life of methadone in a patient with lung cancer and cirrhosis.In a patient on methadone maintenance treatment, admitted for lung cancer suspicion, a slight decrease in pain dose response to morphine have necessitated adjustments of methadone treatment founded on clinical check-up and methadone assay. plasma methadone concentrations were 4 fold higher than mean plasma concentration for control population at the same dose. half-life was above 70 hours and clearance and metabolic index were strongly decreased. In this patient, daily dose methadone occurred in progressive accumulation and neuro-physiological tolerance without clinical incidence, except decrease in morphine effectiveness compared to our knowledge. Cancer, cirrhosis and adjuvant therapy contributions (fluconazole, omeprazole) to this original methadone kinetic are discussed. methadone and morphine dose clinical adjustments are described. However, the main objective of this case report is focused on plasma methadone assay contribution to therapeutic adjustment of the interval dose in a single patient with a complex clinical situation.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
2/10. Ethical perspectives: opioid treatment of chronic pain in the context of addiction.The authors apply eight ethical domains of analysis to the question of treatment of chronic pain with opioids in patients with histories of substance use disorders: autonomy, nonmaleficence, beneficence, justice, medical condition, patient preference, quality of life, and consideration of specific individual or sociocultural issues. These eight domains are drawn from principle-based and case-based ethical perspectives. The domains are developed by review of available literature and through application to a specific presented case. Factors that interfere with rational, ethical decision-making regarding opioid pain management are identified. chronic pain and substance use disorders share a history of stigmatization, underdiagnosis, and undertreatment. Using the presented case as a point of departure, the authors discuss principles for prescription of opioids for treatment of chronic noncancer pain in the setting of history of substance use disorders.- - - - - - - - - - ranking = 0.2keywords = life (Clic here for more details about this article) |
3/10. Ethical challenges in the management of chronic nonmalignant pain: negotiating through the cloud of doubt.After successful cancer pain initiatives, efforts have been recently made to liberalize the use of opioids for the treatment of chronic nonmalignant pain. However, the goals for this treatment and its place among other available treatments are still unclear. Cancer pain treatment is aimed at patient comfort and is validated by objective disease severity. For chronic nonmalignant pain, however, comfort alone is not an adequate treatment goal, and pain is not usually proportional to objective disease severity. Therefore, confusion about treatment goals and doubts about the reality of nonmalignant pain entangle therapeutic efforts. We present a case history to demonstrate that this lack of proportionality fosters fears about malingering, exaggeration, and psychogenic pain among providers. Doubt concerning the reality of patients' unrelieved chronic nonmalignant pain has allowed concerns about addiction to dominate discussions of treatment. We propose alternate patient-centered principles to guide efforts to relieve chronic nonmalignant pain, including accept all patient pain reports as valid but negotiate treatment goals early in care, avoid harming patients, and incorporate chronic opioids as one part of the treatment plan if they improve the patient's overall health-related quality of life. Although an outright ban on opioid use in chronic nonmalignant pain is no longer ethically acceptable, ensuring that opioids provide overall benefit to patients requires significant time and skill. patients with chronic nonmalignant pain should be assessed and treated for concurrent psychiatric disorders, but those with disorders are entitled to equivalent efforts at pain relief. The essential question is not whether chronic nonmalignant pain is real or proportional to objective disease severity, but how it should be managed so that the patient's overall quality of life is optimized. PERSPECTIVE: The management of chronic nonmalignant pain is moving from specialty settings into primary care. Primary care providers need an ethical framework within which to adopt the principles of palliative care to this population.- - - - - - - - - - ranking = 0.4keywords = life (Clic here for more details about this article) |
4/10. Pharmacokinetic interaction of antimicrobial agents with levomethadon in drug-addicted AIDS patients.morphine and its derivatives are metabolized by the liver microsomal enzyme system with a high first-pass effect after oral application. In four of 44 hiv-infected i.v. drug abusers who participated in a levomethadon maintenance program, we observed sustained symptoms of under-dosage and loss of effect of there to fore well-tolerated substitution therapy during rifampin treatment or therapy with zidovudine or fucidic acid. As a pharmacological model substance for cytochrome p 450 enzymes, measurement of antipyrine in serum by high pressure liquid chromatography revealed induction of cytochrome p 450 isoenzymes. The half-life of antipyrine decreased (patient 1 from 11.3 to 8.4 h and patient 2 from 10.7 to 7.6 h after rifampin, patient 3 from 12.2 to 8.6 h after fucidic acid, and patient 4 from 10.6 to 8.6 h after zidovudine). In i.v. drug abusers on levomethadon maintenance programs, adjustment of the levomethadon dosage may be necessary when specific therapy for hiv infection and associated diseases requires the use of drugs known to be potent inducers of the liver microsomal enzyme system.- - - - - - - - - - ranking = 0.2keywords = life (Clic here for more details about this article) |
5/10. Excluding a psychoactive substance use disorder in forensic psychiatric evaluations.The forensic psychiatrist is sometimes asked to exclude that a person has a psychoactive substance use disorder, for example, in a security worker who has access to weapons, in a health care professional who may be alcohol/drug impaired, or in a parent, in a deprived child or custody hearing matter. After examining the data that are leading to the evaluation, these evaluations require corroborated background information to look for developmental and genetic antecedents that might be consistent with substance abuse and dependence; inquiry into the history of substance use; and an examination of areas, in which problems from substance use can occur, namely in family and other social relationships, at work, in legal settings, in physical health, and in personal and psychiatric reactions, for example, in suicidal behavior. Then a physical exam and laboratory evaluation are conducted to look for medical evidence of substance use and complications therefrom, and a mental status exam is performed and psychological testing is obtained as required, for example, a minnesota Multiphasic personality inventory (mmpi) or neuropsychological testing. When such an evaluation is essentially negative, the examiner can say, within the limits of the evaluation, that a psychoactive substance use disorder does not exist.- - - - - - - - - - ranking = 7.3042470721924keywords = family (Clic here for more details about this article) |
6/10. Narcotic dependence in inflammatory bowel disease.Thirteen of 43 patients (30%) with inflammatory bowel disease referred for psychiatric consultation were found to be drug dependent, most commonly on oral narcotics. Drug dependence was more frequent in patients with Crohn's disease than ulcerative colitis and many had a borderline personality disorder. The study suggests that drug dependence is not recognized often enough in patients with inflammatory bowel disease and that patients with certain psychiatric disorders are at higher risk of developing it. Recognition of drug dependence is aided by interviewing family members. It is best prevented by seeking and treating the specific cause of pain and by having only one physician assigned to prescribe and manage narcotics.- - - - - - - - - - ranking = 7.3042470721924keywords = family (Clic here for more details about this article) |
7/10. Treatment of iatrogenic drug dependence in the general hospital.Despite the vast literature on drug dependence, little has been written about patients who become addicted while taking medically prescribed drugs for organic pathology. Observations from a psychiatric consultation-liaison service reveal that these patients are frequently middle-aged with no history of drug abuse before the onset of a chronic medical condition. Associated with their medical condition is a dependence on narcotics and/or psychotropic medications for such complaints as pain, headache, insomnia, and anxiety. Thea addiction may persist for years without acknowledgement by a patient, doctor, or family, although there is usually a progressive constriction of social and occupational functioning. The primary physician is highly valued by the patient; this manifest appreciation trends to facilitate the primary physician's continued prescription of large doses of addicting drugs. Treatment involving detoxification typically goes through a series of stages, each of which has characteristic hazards and pitfalls that can lead to failure of treatment.- - - - - - - - - - ranking = 7.3042470721924keywords = family (Clic here for more details about this article) |
8/10. How AA works and why it's important for clinicians to understand.alcoholism is associated with tremendous suffering, psychological denial, and physical and emotional debilitation. Much of the suffering that plagues alcoholics is rooted in core problems with self-regulation involving self-governance, feeling life (affects), and self-care. alcoholics anonymous is effective because it is a sophisticated group psychology that effectively accesses, corrects, or repairs these core psychological vulnerabilities. The traditions of storytelling, honesty, openness, and willingness to examine ("take inventory") character defects allow people to express themselves who otherwise do not feel or speak and help those who otherwise are deceitful (to self and others) and would deny vulnerability and limitation to openly admit to it.- - - - - - - - - - ranking = 0.2keywords = life (Clic here for more details about this article) |
9/10. role reversals in families of substance misusers: a transgenerational phenomenon.Fifty adult methadone maintained opiate misusers were seen with their spouse and/or family of origin in outpatient therapy as part of a veterans Administration research project supported by NIDA. Family treatment was offered in an attempt to improve and enhance family relationships/social supports and to aid in the decrease or cessation of drug use. In this study, 42 of the 50 patients had parents who were substance misusers. The subjects were evaluated by constructing a Three-Generational Family Tree to define and clarify the nature of problems across the generations. Success or failure was measured by the Addiction Severity Index (ASI) which assessed drug use, problems with family, health, social relationships, legal difficulties, and employment as well as psychiatric symptoms. A recurrent problem of the "absent father" was identified across both generations studied. Thirty of the 50 opiate misusing men had absent fathers (usually due to alcohol or other drug misuse) and 27 of these 30 became absent fathers (also usually due to substance misuse) when they had children of their own. The absence of a father produced major developmental problems seen in these families. Particularly important was the "Parentified child," forced to prematurely assume adult responsibilities. This age inappropriate role assumption was common in both the patients and their children, and was seen as a contributor to the initiation of drug misuse. A structured clinical intervention is described using the three-generational family tree to bring out these relationship issues, followed by supportive family therapy to restructure wounded family relationships from the family of origin and to bring about appropriate role expectations in the marital families. The findings suggest an improvement in legal difficulties, drug use, and psychiatric symptoms.- - - - - - - - - - ranking = 51.129729505347keywords = family (Clic here for more details about this article) |
10/10. Levo-Alpha Acetyl Methadol (LAAM). Its advantages and drawbacks.Levo-Alpha Acetyl Methadol, or LAAM, is a medication therapy for individuals addicted to opiates that provides an alternative to methadone. Because it is administered only three times a week and, therefore, requires fewer clinic trips, patient acceptance can be higher than with methadone. While blocking the effects of other opiates and preventing withdrawal, LAAM does not produce a subjective high. However, because most patients are not familiar with LAAM, they may be initially more anxious and need more counseling and support when receiving the medication than they would with the more familiar methadone medication. On balance, LAAM enables clinic administrators and counselors to offer an alternative medication to methadone that some clients prefer once they become adjusted to it because of LAAM's even, stable effect. Through hypothetical but true-to-life case studies of LAAM use, it is possible to gain a clearer understanding of the advantages and drawbacks of using LAAM.- - - - - - - - - - ranking = 0.2keywords = life (Clic here for more details about this article) |
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