A Painful Judgment: Part 2

July 29, 2010

The most widespread misunderstanding is of the difference between physical dependence and addiction. Many patients, the public and sadly healthcare professionals fear that anyone taking opioid medications on a long-term basis will become addicted.

The most widespread misunderstanding is the difference between physical dependence and addiction. Many patients, the public, and, sadly, healthcare professionals fear that anyone taking opioid medications on a long-term basis will become addicted. As a result, the patient is often labeled as drug seeker and worst of all, their pain frequently remains under-treated.

Understanding the terminology is the first step. Addiction is a neurobiological disease that has genetic, psychosocial, and environmental factors. It is characterized by one or more of the following behaviors: poor control over drug use, compulsive drug use, continued use of a drug despite physical, mental and or social harm, and a craving for the drug. In contrast physical dependence is the body’s adaptation to a particular drug. The body gets used to receiving a regular dose of a certain medication and if that medication is abruptly stopped or the dosage reduced too quickly, the person will experience withdrawal symptoms. Tolerance is a condition that occurs when the body adapts or gets used to a particular medication, lessening its effectiveness. When that happens, either the dosage needs to be increased or another type of medication needs to be given in order to maintain pain control.

Another term, pseudoaddiction, is used to describe patient behaviors that may occur when their pain is not being treated adequately. Patients with severe unrelieved pain are often desperate for relief. They may end up doing things like watching the clock until it’s time for their next medication or asking for increased doses of medication or specific medications. These are all often seen as “drug seeking." The difference between pseudoaddiction and true addiction is that the behavior stops when the patient’s pain is effectively treated.

Most chronic pain patients need to take opioids on a long-term basis. They will most likely become physically dependent on them, but very few will become addicted to them. In a review of 24,000 patients who were medically prescribed opioids, only seven could be found who got into trouble with addiction taking them (Richards, 2010). The few patients who do develop addiction are often more susceptible to addiction due to genetic predisposition. So, the chronic pain patient becoming addicted to opioid medications is definitely the exception rather than the rule.

But will you see patients who are addicted to medications? Certainly. People who become addicted to opioid drugs usually report getting a feeling of euphoria and they soon need increasing amounts of the drug to maintain that same feeling. Some behaviors that may be suggestive of possible addiction include: taking medications more frequently or at higher doses than prescribed; ingesting drugs in ways other than directed such as crushing, snoring or injecting; frequent reports of lost or stolen prescriptions; doctor shopping; or using multiple pharmacies. When you encounter a patient that you suspect may be dealing with addiction, it is your duty to address that in as caring a way as possible and attempt to help the person with that disease. But, as we know, unless and until they want to find help, it’s not going to be very effective.

There are some key differences between addicts and pain patients. Addicts take drugs to get high and avoid life. Pain patients take drugs to function normally and get on with life. Addicts isolate themselves and become lost to their families while pain patients, when they get adequate relief, are active members of their families. Addicts are unable to interact appropriately with society. When pain patients get adequate relief, they interact with and make positive contributions to society. Addicts are often eventually unable to hold down a job while pain patients when getting adequate relief, are often able to go back to work. Finally, the life of an addict is on a continual downward spiral while the pain patient with adequate relief has a life that progresses in a positive, upward direction.

Hopefully, you’ve gained some insight into the differences between patients who are seeking relief from their pain and those who are truly addicted. But even more so, that you’ve learned that certain behaviors, actions, requests, or even demands do not necessarily deem a patient a drug seeker--maybe just a pain relief seeker.