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Patients Who Misuse Substances : Assessment, Management and Complications
Sharon Morgillo Freeman, PhD, MSN, APRN-CS
A significant number patients admitted to acute medical facilities have a co-occurring substance misuse
problem. The numbers are even higher in mental health practices, inpatient units and counseling centers
worldwide. Treatment of these individuals expends large quantities of resources in staff time, energy, facility
utilization and financial support. Accurate identification, management and referral of these patients is critical to
avoid unnecessary delays and costs in provision of care, loss of work time and social or psychiatric sequelae.
Despite the stigmatization and discrimination that is often attached to substance misusing persons, the disease
of addiction boasts higher rates of remission than other behavior dependent medical disorders such as
diabetes, heart disease and obesity.
Co-morbid psychiatric and medical conditions can make identification of substance abuse or addiction in these
patients difficult. Specifically, coexisting personality disorders. Many substance dependent persons are
misdiagnosed as having a personality disorder due to confusing, overlapping criteria. Once addiction has
been identified, the therapist must decide to confront, treat, or refer to an addiction specialist. The choice of
treatment option is based on clinical criteria, patient motivation for change, ability to change and environmental
variables. This workshop will focus on general assessment guidelines for addictive disease with and without
confounding co-morbid conditions and recommendations regarding medical and psychiatric management of
these problems. Psychotherapeutic management with Cognitive Behavior Therapy (CBT) will be integrated
throughout the workshop.
This workshop should be formatted for a minimum of two full days for a professional audience. The workshop
would focus on assessment and introduction of conceptual frameworks in addiction treatment on day one. The
second day would focus in specific treatment and management situation with case reviews and discussion.
The Relationship of Opioid Treatment in Chronic Pain Conditions:
Implications on Brain Reward Response
An area of scientific understanding that remains unexplained is the effect of chronic pain conditions on the
brain reward response to opioids. Substance misuse remains one of the most baffling areas of scientific
evaluation, identification and intervention given that very little is known about the mechanisms differentiating
inevitable physiologic responses to opioids and dysfunctional or abnormal responses to long-term opioid
administration. The effects of opioids on the brain reward system are of significance to clinicians, and given
the paucity of information available on opioid therapeutic use vs. misuse in this population, the clinician is left to
develop subjective conclusions about differentiation. Inevitable responses include the linked concepts of
tolerance to opioids, development of withdrawal phenomena, hyperalgesia and pharmacologic resistance to the
antinociceptive properties of opioids. This paper will evaluate current knowledge regarding relationships of
these neuroadaptive responses to chronic opioid treatment coupled with chronic pain conditions and the
combined effect of these factors on the brain reward system.
Sharon Morgillo Freeman, PhD, MSN, APRN-CS
A significant number patients admitted to acute medical facilities have a co-occurring substance misuse
problem. The numbers are even higher in mental health practices, inpatient units and counseling centers
worldwide. Treatment of these individuals expends large quantities of resources in staff time, energy, facility
utilization and financial support. Accurate identification, management and referral of these patients is critical to
avoid unnecessary delays and costs in provision of care, loss of work time and social or psychiatric sequelae.
Despite the stigmatization and discrimination that is often attached to substance misusing persons, the disease
of addiction boasts higher rates of remission than other behavior dependent medical disorders such as
diabetes, heart disease and obesity.
Co-morbid psychiatric and medical conditions can make identification of substance abuse or addiction in these
patients difficult. Specifically, coexisting personality disorders. Many substance dependent persons are
misdiagnosed as having a personality disorder due to confusing, overlapping criteria. Once addiction has
been identified, the therapist must decide to confront, treat, or refer to an addiction specialist. The choice of
treatment option is based on clinical criteria, patient motivation for change, ability to change and environmental
variables. This workshop will focus on general assessment guidelines for addictive disease with and without
confounding co-morbid conditions and recommendations regarding medical and psychiatric management of
these problems. Psychotherapeutic management with Cognitive Behavior Therapy (CBT) will be integrated
throughout the workshop.
This workshop should be formatted for a minimum of two full days for a professional audience. The workshop
would focus on assessment and introduction of conceptual frameworks in addiction treatment on day one. The
second day would focus in specific treatment and management situation with case reviews and discussion.
The Relationship of Opioid Treatment in Chronic Pain Conditions:
Implications on Brain Reward Response
An area of scientific understanding that remains unexplained is the effect of chronic pain conditions on the
brain reward response to opioids. Substance misuse remains one of the most baffling areas of scientific
evaluation, identification and intervention given that very little is known about the mechanisms differentiating
inevitable physiologic responses to opioids and dysfunctional or abnormal responses to long-term opioid
administration. The effects of opioids on the brain reward system are of significance to clinicians, and given
the paucity of information available on opioid therapeutic use vs. misuse in this population, the clinician is left to
develop subjective conclusions about differentiation. Inevitable responses include the linked concepts of
tolerance to opioids, development of withdrawal phenomena, hyperalgesia and pharmacologic resistance to the
antinociceptive properties of opioids. This paper will evaluate current knowledge regarding relationships of
these neuroadaptive responses to chronic opioid treatment coupled with chronic pain conditions and the
combined effect of these factors on the brain reward system.
