i googled about chronic pain and pain management and found some interesting information re drug seeking behavior in pain patients.
i don't know if "pseudo-addiction" was the problem with mj, but i think it's an interesting lead. here are some links:
http://medical-dictionary.thefreedictionary.com/Pseudoaddiction
Pseudoaddiction
A drug-seeking behaviour that simulates true addiction, which occurs in patients with pain who are receiving inadequate pain medication
http://www2.massgeneral.org/painrelief/Pain Topics/What is Pseudoaddiction.pdf
What is Pseudoaddiction?
Thomas E. Quinn, MSN, RN, AOCN
January 2004
Pseudoaddiction is the term for an iatrogenic syndrome that appears to mimic behaviors that are commonly believed to be associated with addiction.
It may present in a patient with or without a history of or risk factors for drug abuse or true addiction.
It usually occurs with acute pain, including acute pain that is overlaid on a chronic pain condition.
It is characterized by a climate of distrust and conflict between the patient and the care team related to the use of opioids for pain.
Its etiology is pain that is inadequately treated, leading to patient demands for opioid analgesia that are interpreted by the care team as being excessive.
The result is a progressive cycle of patient complaints of inadequate pain relief, sometimes accompanied by exaggerated pain behaviors, and care team resistance to providing opioids, sometimes compounded by avoidance and isolation of the patient. [...]
http://addictionmanagement.org/Pseudoaddiction versus Addiction in a Pain Population.pdf
Pseudoaddiction versus Addiction in a Pain Population
by Ann T. Kline, MS
Abstract
While addiction is a disease that most in the healthcare profession are aware of, the same does not hold true for pseudoaddiction, a phenomenon which is commonly misconstrued as a form of drug-seeking behavior with the primary aim of abuse.
Many clinicians refuse to treat pain patients complaining of inadequate pain relief, for fear of addiction. Some substance abuse counselors misdiagnose their clients as addicts.
Current research in this area describes the lack of understanding related to this drug-seeking behavior and the negative outcomes for the patient/client as a consequence of both past and current misconceptions on the issue.
Further empirical research and healthcare professional education on the differences between addiction and pseudoaddiction are needed in an effort to elucidate this phenomenon.
http://www.addiction-free.com/blog/addiction-versus-pseudoaddiction/
Addiction versus Pseudoaddiction
Dr. Stephen F. Grinstead
posted January 29th, 2008
There are many questions to be addressed when treating someone who has chronic pain and coexisting substance use disorders. I start most of my Addiction-Free Pain Management™ trainings with three questions:
1. Are we managing pain but fueling the addiction?
2. Are we treating the addiction but sabotaging the pain management?
3. Is it addiction or pseudoaddiction?
The term pseudoaddiction is fairly new to the addiction treatment field but has been used in pain management for quite a while now.
[...]
the above article has an interesting case study of a woman in badly managed chronic pain who was forced to go through detox and follow one of these "12 steps" programs.
also note what "Kay" says in the comment section of the article; note how he writes he thinks he's an addict but his dr doesn't agree.
--
here's also some info about opioid induced hyperalgesia (hypersensitivity to pain), from wiki:
Opioid-induced hyperalgesia
Opioid-induced hyperalgesia[1] or opioid-induced abnormal pain sensitivity[2] is a phenomenon associated with the long term use of opioids such as morphine, hydrocodone, oxycodone, and methadone. Over time, individuals taking opioids can develop an increasing sensitivity to noxious stimuli, even evolving a painful response to previously non-noxious stimuli (allodynia). Some studies on animals have also demonstrated this effect occurring after only a single high dose of opioids.[3]
Although tolerance and opioid-induced hyperalgesia both result in a similar need for dose escalation, they are nevertheless caused by two distinct mechanisms.[4] The similar net effect makes the two phenomena difficult to distinguish in a clinical setting. Under chronic opioid treatment, a particular individual's requirement for dose escalation may be due to tolerance (desensitization of antinociceptive mechanisms), opioid-induced hyperalgesia (sensitization of pronociceptive mechanisms), or a combination of both.
Identifying the development of hyperalgesia is of great clinical importance since patients receiving opioids to relieve pain may paradoxically experience more pain as a result of treatment. Whereas increasing the dose of opioid can be an effective way to overcome tolerance, doing so to compensate for opioid-induced hyperalgesia may worsen the patient's condition by increasing sensitivity to pain while escalating physical dependence.
If an individual is taking opioids for a chronic non-cancer pain condition, and cannot achieve effective pain relief despite increases in dose, they may be experiencing opioid-induced hyperalgesia. In this case, they may benefit from complete withdrawal from opioid therapy. Many individuals report reduced pain levels when opioids are withdrawn.
src:
http://en.wikipedia.org/wiki/Opioid-induced_hyperalgesia
i wonder whether this could have been part of mj's problem?
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re the implant mj used, is was a naltrexone implant according to ABC7 tweets, not a naloxone (narcan) implant as klein seemed to assume:
Koskoff: You have no knowledge whether the Narcan implant had anything to do with the reaction in June?
Fournier: No
Fournier said he never heard Narcan as an implant, had never seen one.
"I was told by two of his physicians there was one," Fournier said. He spoke with doctors Klein and Metzger about it.
Koskoff: If Dr. Farshchian said it was Naltrexone implant and he [klein?] thought it was the same as Narcan, it would be a mistake, correct?
Fournier: Correct. They are two different drugs.
Dr. Klein told Fournier MJ had a Narcan implant, he went home, research it and could not find anything on it.
"I know the effects of Narcan," Fournier said. It can cause cardiac arrest, tachycardia, defibrillation.
Naloxene, which is Narcan -- Fournier has familiarity with it.
Fournier is not used to Naltrexone, but said it's also an opioid inhibitor.
Koskoff: Do you know the effects of Naltroxene in anesthesia?
Fournier: It would have the same effect of this kinds of drugs, antagonist opioid effect and it's dose-dependent.
src: ABC7 Court News @ABC7Courts
naloxone (narcan) is not available orally or as an implant tmk. it's an antagonist used in "detox" situations, e.g. in case of an od, or after operations to undo the effects of analgesia applied during anesthesia.
it is different from naltrexone which does not completely reverse the effects from opioids; naltrexone is a partial antagonist which is used for longterm treatment. it's effects can be overridden, but require higher doses of opioids than usual to manage pain.
about naltrexone, from wiki:
Naltrexone should not be started prior to several (typically 7-10) days of abstinence from opioids. This is due to the risk of acute opioid withdrawal if naltrexone is taken, as naltrexone will displace most opioids from their receptors. The time of abstinence may be shorter than 7 days, depending on the half-life of the specific opioid taken. [...]
It is important that one not attempt to use opioids while using naltrexone.
Although naltrexone blocks the opioid receptor, it is possible to override this blockade with very high doses of opioids.
However this is quite dangerous and may lead to opioid overdose, respiratory depression, and death.
Similarly one will not show normal response to opioid pain medications when taking naltrexone.
In a supervised medical setting pain relief is possible but may require higher than usual doses, and the individual should be closely monitored for respiratory depression.
All individuals taking naltrexone are encouraged to keep a card or a note in their wallet in case of an injury or another medical emergency.
This is to let medical personnel know that special procedures are required if opiate-based painkillers are to be used.
src:
https://en.wikipedia.org/wiki/Naltrexone
mj definitely should have told the anesthesia nurse about the implant; that he told klein, but not the nurse, to me is an indicator he maybe didnt understand very well what the implant was doing. - did farshchian explain to him that pain relief during a procedure would require higher doses of opioids?
i'm also stunned that klein seemed to assume mj was getting narcan (not naltrexone), but only told this the nurse during the procedure. no wonder the nurse was upset.
if mj had indeed received narcan, i'm not sure pain relief during a procedure would have been possible.
i don't understand why klein went ahead with planned procedures without discussing the implant with the anesthesia nurse to find out if sedation/pain relief was actually possible; especially since he wrongly assumed it to be a narcan implant.
here's some more information from the fda re naltrexone and response to opioids:
When Reversal of Naltrexone Hydrochloride Blockade is Required
In an emergency situation in patients receiving fully blocking doses of Naltrexone hydrochloride, a suggested plan of management is regional analgesia, conscious sedation with a benzodiazepine, use of non-opioid analgesics or general anesthesia.
In a situation requiring opioid analgesia, the amount of opioid required may be greater than usual, and the resulting respiratory depression may be deeper and more prolonged.
A rapidly acting opioid analgesic which minimizes the duration of respiratory depression is preferred. The amount of analgesic administered should be titrated to the needs of the patient.
There is also the possibility that a patient who had been treated with Naltrexone will respond to lower doses of opioids than previously used, particularly if taken in such a manner that high plasma concentrations remain in the body beyond the time that Naltrexone exerts its therapeutic effects.
This could result in potentially life-threatening opioid intoxication (respiratory compromise or arrest, circulatory collapse, etc.).
Patients should be aware that they may be more sensitive to lower doses of opioids after Naltrexone treatment is discontinued.
src:
http://www.drugs.com/pro/naltrexone.html
i wonder why mj had stopped breathing during one procedure; maybe the problem was that he needed higher doses of opioids than usual which caused hypoxia?
as we know from the autopsy, mj had reduced lung capacity which probably made him more susceptible to respiratory depression.
--
when googling these subjects i also came about some interesting info re so called "low-dose" naloxone/naltrexone therapy.
low-dose therapy is different from normal dosage as used for detox or to prevent relapse.
unfortunately, naloxone and naltrexone loose these low-dose therapeutic effects when given at higher doses.
here's an interesting article about this topic:
http://pain-topics.org/pdf/OpioidAntagonistsForPain.pdf
Opioid Antagonists, Naloxone & Naltrexone — Aids for Pain Management
March 2009
Researcher/Author: Stewart B. Leavitt, MA, PhD
the article says there are case reports and small studies indicating that naloxone/naltrexone at low doses can help to make opioid therapy more effective, ameliorate pain, reverse tolerance and help to overcome hyperalgesia (opioid induced pain), help with the tapering process from opioids, and ameliorate opioid side effects; they may also help with chronic pain in certain autoimmune diseases such as fibromyalgia.
the article says the biggest problem which needs to be ovecome to profit from these effects is accurate dosage.
here's also a scientific article about research done in this area:
http://www.la-press.com/ultra-low-d...o-improve-opioid-analgesia-the--article-a2351
Ultra-Low-Dose Naloxone or Naltrexone to Improve Opioid Analgesia: The History, the Mystery and a Novel Approach
16 Nov 2010
Authors: Lindsay H. Burns and Hoau-Yan Wang
pdf:
http://www.la-press.com/redirect_file.php?fileId=3207&filename=CMT-2-Wang-et-al&fileType=pdf
if this new approach is successful it could be a breakthrough in the management of pain and opioid therapy.
i wonder whether mj ever heard about this new "low-dose" lead in pain therapy. the naltrexone implants he used don't have these therapeutic effects however, since the dosage is too high.
--
finally, i did some research on "12 steps" and substance abuse treatment programs and i'm posting some links to sources critical of today's common approach in sat (substance abuse treatment):
http://www.casacolumbia.org/templates/NewsRoom.aspx?articleid=678&zoneid=51
Addiction Medicine: Closing the Gap between Science and Practice
June 2012
CASAColumbia’s new five year national study reveals that addiction treatment is largely disconnected from mainstream medical practice.
While a wide range of evidence-based screening, intervention, treatment and disease management tools and practices exist, they rarely are employed.
The report exposes the fact that most medical professionals who should be providing treatment are not sufficiently trained to diagnose or treat addiction, and most of those providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to provide the full range of evidence-based services, including pharmaceutical and psychosocial therapies and other medical care.
This landmark report examines the science of addiction--a complex disease that involves changes in the structure and function of the brain--and the profound gap between what we know about the disease and how to prevent and treat it versus current health and medical practice. [...]
full report:
http://www.casacolumbia.org/upload/2012/20120626addictionmed.pdf
http://www.amazon.com/Inside-Rehab-Surprising-Addiction-Treatment/dp/0670025224
Inside Rehab: The Surprising Truth About Addiction Treatment-and How to Get Help That Works
Anne M. Fletcher
2013
Customer Reviews:
http://www.amazon.com/Inside-Rehab-Surprising-Addiction-Treatment/product-reviews/0670025224
^i think these customer reviews make an interesting read, you get to hear different opinions and approaches on the subject
another article on skepdic.com:
http://www.skepdic.com/sat.html
substance abuse treatment
reader comments:
http://www.skepdic.com/comments/satcom.html
and a study about the lack of scientific data showing the effectiveness of aa (alcoholics anonymous) 12 steps:
http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
Alcoholics Anonymous and other 12-step programmes for alcohol dependence
2006 Jul 19
Ferri M, Amato L, Davoli M.
Source: Agency of Public Health, Project Unit: EBM and Models of Health Assistance, Via di Santa Costanza 53, Rome, Italy 00198.
ferri@asplazio.it
[...]
Authors' conclusions
No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [12 steps] approaches for reducing alcohol dependence or problems. One large study focused on the prognostic factors associated with interventions that were assumed to be successful rather than on the effectiveness of interventions themselves, so more efficacy studies are needed.