Opioids and Pain Management

"Opioid analgesics are useful in managing acute and chronic pain. They are sometimes underused in patients with severe acute pain or with pain and a terminal disorder such as cancer, resulting in needless pain and suffering. Reasons for undertreatment include
"• Underestimation of the effective dose
"• Overestimation of the risk of adverse effects

How Federal Surveys Estimate the Prevalence Of Substance Use Disorders

"Illicit drug use disorder is defined as meeting DSM-IV criteria for either dependence or abuse for one or more of the following illicit drugs: marijuana, cocaine, heroin, hallucinogens, inhalants, methamphetamine, or prescription psychotherapeutic drugs that were misused (i.e., pain relievers, tranquilizers, stimulants, and sedatives). There are seven possible dependence criteria for specific illicit drugs:
"1. spent a lot of time engaging in activities related to use of the drug,
"2. used the drug in greater quantities or for a longer time than intended,

Marijuana is not a gateway drug

"Our results indicate a moderate relation between early teen marijuana use and young adult abuse of other illicit substances; however, this association fades from statistical significance with adjustments for stress and life-course variables. Likewise, our findings show that any causal influence of teen marijuana use on other illicit substance use is contingent upon employment status and is short-term, subsiding entirely by the age of 21. In light of these findings, we urge U.S.

Admissions to Treatment in the US with Marijuana as Primary Substance, by Referral Source

"• Marijuana/hashish was reported as the primary substance of abuse by 14 percent of TEDS admissions aged 12 and older in 2015 [Table 1.1b].
"• The average age at admission for primary marijuana/hashish admissions was 26 years [Table 2.1b]. Thirty-one percent of marijuana/hashish admissions were under age 20 (vs. 7 percent of all admissions combined), and primary marijuana/hashish abuse accounted for 78 percent of admissions aged 12 to 14 and 75 percent of admissions aged 15 to 17 years [Table 2.1c].

Probability of Transition From First Use to Dependence For Various Substances

Probability of Transition From First Use to Dependence For Various Substances: "In a large, nationally representative sample of US adults, the cumulative probability of transition to dependence was highest for nicotine users, followed by cocaine users, alcohol users and, lastly, cannabis users. The transition to cannabis or cocaine dependence occurred faster than the transition to nicotine or alcohol dependence. Furthermore, there were important variations in the probability of becoming dependent across the different racial-ethnic groups.

Criteria For Defining Substance Dependence

Criteria for Defining Substance Dependence: "The 1988 Surgeon General’s report lists the following general 'criteria for drug dependence,' including nicotine dependence (USDHHS 1988, p. 7): "Primary Criteria "• Highly controlled or compulsive use "• Psychoactive effects "• Drug-reinforced behavior "Additional Criteria "• Addictive behavior, often involves: "– stereotypic patterns of use "– use despite harmful effects "– relapse following abstinence "– recurrent drug cravings "• Dependence-producing drugs often produce:

Tolerance of Opiates and Escalation of Effective Dosage

"During long-term treatment, the effective opioid dose can remain constant for prolonged periods. Some patients need intermittent dose escalation, typically in the setting of physical changes that suggest an increase in the pain (eg, progressive neoplasm). Fear of tolerance should not inhibit appropriate early, aggressive use of an opioid. If a previously adequate dose becomes inadequate, that dose must usually be increased by 30 to 100% to control pain."

Estimated Prevalence of Cannabis Dependence

Estimated Prevalence of Cannabis Dependence: "Some 4.3 percent of Americans have been dependent on marijuana, as defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000), at some time in their lives. Marijuana produces dependence less readily than most other illicit drugs. Some 9 percent of those who try marijuana develop dependence compared to, for example, 15 percent of people who try cocaine and 24 percent of those who try heroin. However, because so many people use marijuana, cannabis dependence is twice as prevalent as dependence on any other illicit psychoactive substance (cocaine, 1.8 percent; heroin, 0.7 percent; Anthony and Helzer, 1991; Anthony, Warner, and Kessler, 1994)."