Type I would refer to relatively uncomplicated cases, such as patients overusing non-opioid-

and non-barbiturate-containing medication, and the absence of significant psychopathology. Type II would refer to patients overusing opioid- or barbiturate-containing medications, and/or the presence of significant psychopathology.57-59 Several other researchers Antiinfection Compound Library purchase have supported the importance of drawing a distinction between MOH subtypes.[60] Rossi et al proposed a distinction between simple vs complicated MOH based on the presence of at least 1 of the following: (1) diagnosis of coexistent, significant, and complicating medical illnesses; (2) current diagnosis of mood, anxiety, eating, or substance addiction disorder; (3) relapse after previous detoxification; (4) significant psychosocial and environmental problems; and (5) daily use of multiple doses of symptomatic medication.[61] Radat and Lanteri-Minet emphasize the distinction between MOH with minimal psychological

contribution and MOH where addictive behavior plays a central role.[31] Caution should be exercised in generalizing from successful outcomes with simple MOH or primarily triptan-related MOH to the more complicated form. CM patients can transition back to EM in a rate of 57% over 1 see more year and 66% over 2 years.[62, 63] However, relapse to medication overuse can be high: 28-31% within 6 months of withdrawal, to 41% at 1 year, and 45% at 4 years. Relapse rates for analgesics can be as high as 71% 4 years after treatment. Adding a behavioral component to treatment can significantly reduce relapse, to as low as 12.5% at 3-year follow-up.[64] medchemexpress Risk factors for relapse include high baseline intake of overused drugs, return to

use of previously overused drugs, failure to improve at 2 months post-withdrawal, smoking, and alcohol use.[65] Opioid- and barbiturate-related MOH increase the risk for relapse, particularly if the patient is given even limited access to these drugs as rescue medications, a very slippery slope. Alternative rescue medications with low risk for MOH should remain the first choice for breakthrough pain. Although psychiatric comorbidity was unrelated to relapse at 1 year, patients with less depression and anxiety had the most favorable outcome at 4 years post-withdrawal.[65, 66] Appropriate therapy can be rewarding, but patients should be seen frequently and over prolonged periods of time to assess their progress. Although relapse is common, it can be treated effectively if the patient remains in treatment.