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In this case, the treatment of severe pain should be managed with the administration of a potent intravenous opioid anal-gesic such as morphine, hydromorphone, or fentanyl. Before an additional dose of an opioid analgesic is administered, it is expected that the patient will require frequent reevaluation of both the severity of his pain and the presence of potential adverse effects. Given his history of pulmonary disease, he is also at increased risk of developing respiratory depression. Concurrent use of nonopioid analgesics including nerve blocks with a local anesthetic can reduce opioid require-ments and risk of respiratory failure. Reevaluation of his level of consciousness, respiratory rate, fractional oxygen satura-tion, and other vital parameters can help achieve the goal of pain relief and minimize respiratory depression. Concurrent use of sedative agents such as benzodiazepines should be avoided if possible and proceed only with great caution.
Drugs of Abuse
Christian Lüscher, MD
A 15-year-old high school student is brought to the emergency department after his parents found him in his room staring at the ceiling and visibly frightened. Earlier that evening, he attended a party but was depressed because his girlfriend just broke up with him. Jerry is failing this year at school and has stopped playing soccer. His parents are also worried about a change in his behavior over the last few months. He has lost interest in school, at times seems depressed, and tells his par-ents that his pocket money is not sufficient. When questioned by the intern, he reports that space-cookies were served at the party. He also says that smoking marijuana has become a habit (three to four joints a week) but denies consumption of alcohol and other drugs. How do you explain the state he was found in? What is the difference between hashish and marijuana? What may be the link to his poor performance at school? Are all drug users necessarily using several drugs?
Drugs are abused (used in ways that are not medically approved) because they cause strong feelings of euphoria or alter perception. However, repetitive exposure induces widespread adaptive changes in the brain. As a consequence, drug use may become compulsive—the hallmark of addiction.
There is a conceptual and mechanistic separation of “dependence” and “addiction.” The older term “physical dependence” is now denoted as dependence, whereas “psychological dependence” is more simply called addiction.