2Pain, Addiction and theComplicated PatientR. Corey Waller MD, MS, FACEP, ABAMDirector, Center for Integrative MedicineSUD...
3PAIN
Pain“If you are distressed by anything external, the pain is not dueto the thing itself, but to your estimate of it; and t...
Pain Treatment• Opioids• NSAIDS• α2δ (alpha2delta) modulators (gabapentin, pregabalin)• SNRIs• Tricyclics• ASA• Actaminoph...
The Android Effect
Behavioral• Mindfulness, Meditation• Brain Mechanisms Supporting the modulation of pain by MindfulnessMeditation. F. Zeida...
9Addiction(now SUD - mild, moderate or severe)
Addiction“I have absolutely no pleasure in the stimulants in which Isometimes so madly indulge. It has not been in the pur...
11Short Definition of Addiction:Addiction is a primary, chronic disease of brain reward, motivation,memory and related cir...
What is driving addiction?Positive Reinforcement - rewards that strengthen aconditioned response after it has occurred, su...
AddictionPain
Medication assisted treatmentOpioids Methadone, Suboxone, VivitrolAlcohol Vivitrol, acamprosate, disulfiram, topiramat...
DBS for AddictionCentral and Lateral bedof the AmygdalaAnterior cingulate gyrus(ACG)Nucleus Accumbens(NAc)Ventral Tegmenta...
Behavioral Self Help CBT MET Mindfulness Solution Based Therapy17
18TheComplicatedPatient
Confounding Issues Early Life Trauma Superimposed MI Social Instability Familial Predisposition The Current Health Ca...
What Next? Truly Integrated behavioral and medicalcare Payment System Reform Standards of Care for the treatment ofMI a...
Questions?23
Safe Prescribing Practice Conference for Medical Professionals, June 2013
Safe Prescribing Practice Conference for Medical Professionals, June 2013
Safe Prescribing Practice Conference for Medical Professionals, June 2013
Safe Prescribing Practice Conference for Medical Professionals, June 2013
Safe Prescribing Practice Conference for Medical Professionals, June 2013
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Safe Prescribing Practice Conference for Medical Professionals, June 2013

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Participants will:
Report their intent to support and/or actively work towards incorporating best practices in responsible prescribing guidelines into their everyday practice of medicine.
Report an increased knowledge of the Michigan Automated Prescription System (MAPS) and the benefits of reporting regularly to MAPS.
Report intent to support and/or actively work towards incorporating consistent use of the MAPS into their everyday practice of prescribing controlled substances.
Report that at the training they received easy to use tools that can help them to better educate their patients on the importance of taking medications as prescribed.
Gain an increased knowledge of local, state, and national substance abuse and mental health treatment resources.

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  • Safe Prescribing Practice Conference for Medical Professionals, June 2013

    1. 1. 2Pain, Addiction and theComplicated PatientR. Corey Waller MD, MS, FACEP, ABAMDirector, Center for Integrative MedicineSUD Medical Director, Network180Chief, Division of Pain Management
    2. 2. 3PAIN
    3. 3. Pain“If you are distressed by anything external, the pain is not dueto the thing itself, but to your estimate of it; and this you havethe power to revoke at any moment.”― Marcus Aurelius, Meditations4
    4. 4. Pain Treatment• Opioids• NSAIDS• α2δ (alpha2delta) modulators (gabapentin, pregabalin)• SNRIs• Tricyclics• ASA• Actaminophen6
    5. 5. The Android Effect
    6. 6. Behavioral• Mindfulness, Meditation• Brain Mechanisms Supporting the modulation of pain by MindfulnessMeditation. F. Zeidan et al. Journal of Neuroscience, Vol. 31, No.14, 5540-5548; April 6, 2011• Operant, CBT, DBT, MET etc.• Henschke N, Ostelo RWJG, van Tulder MW, Vlaeyen JWS, Morley S,Assendelft WJJ, Main CJ. (2010). Behavioural treatment for chronic low-back pain. Cochrane Database of Systematic Reviews (7)8
    7. 7. 9Addiction(now SUD - mild, moderate or severe)
    8. 8. Addiction“I have absolutely no pleasure in the stimulants in which Isometimes so madly indulge. It has not been in the pursuit ofpleasure that I have periled life and reputation and reason. Ithas been the desperate attempt to escape from torturingmemories, from a sense of insupportable loneliness and adread of some strange impending doom.”― Edgar Allan Poe10
    9. 9. 11Short Definition of Addiction:Addiction is a primary, chronic disease of brain reward, motivation,memory and related circuitry. Dysfunction in these circuits leads tocharacteristic biological, psychological, social and spiritual manifestations.This is reflected in an individual pathologically pursuing reward and/orrelief by substance use and other behaviors.Addiction is characterized by inability to consistently abstain, impairmentin behavioral control, craving, diminished recognition of significantproblems with one’s behaviors and interpersonal relationships, and adysfunctional emotional response. Like other chronic diseases, addictionoften involves cycles of relapse and remission. Without treatment orengagement in recovery activities, addiction is progressive and can resultin disability or premature death.
    10. 10. What is driving addiction?Positive Reinforcement - rewards that strengthen aconditioned response after it has occurred, such as thefeeling of euphoria after taking a hitNegative Reinforcement – stimuli (e.g., stress) that areremoved when the desired response (e.g., drug use) hasbeen obtained■ Escape conditioning - learning to escape an unpleasant or aversivestimulus (using drugs to reduce stress)■ Avoidance conditioning – Learning to avoid an aversive stimulus (e.g.,stress) before it occurs (e.g., using drugs before going to a stressfulmtg)
    11. 11. AddictionPain
    12. 12. Medication assisted treatmentOpioids Methadone, Suboxone, VivitrolAlcohol Vivitrol, acamprosate, disulfiram, topiramateStimulants Citalopram, Modafinil15
    13. 13. DBS for AddictionCentral and Lateral bedof the AmygdalaAnterior cingulate gyrus(ACG)Nucleus Accumbens(NAc)Ventral Tegmental Area(VTA)Anterior CingulateGyrus
    14. 14. Behavioral Self Help CBT MET Mindfulness Solution Based Therapy17
    15. 15. 18TheComplicatedPatient
    16. 16. Confounding Issues Early Life Trauma Superimposed MI Social Instability Familial Predisposition The Current Health Care System19
    17. 17. What Next? Truly Integrated behavioral and medicalcare Payment System Reform Standards of Care for the treatment ofMI and SUD My own personal therapist22
    18. 18. Questions?23

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