What are the current findings about addiction and dependency? Many health care providers are still confused about the difference between dependency and addiction. They consider patients who take opioids on a daily basis to be addicted and label them as such in documentation. Many are unaware that dependency is not addiction and that the behaviors they associate with addiction may be in reality a sign of undertreated pain. Many of these patients are relief seekers, not drug seekers. Patients who take opioid medications for pain are labeled as addicted when, in truth, they are dependent on the medications. The following information should clarify the differences between the two clinical presentations.
True addiction is not as common as most health care providers think it is. The patient who knows what medication works for him or her or calls in early for a prescription may be demonstrating aberrant behaviors, but they are not addicted.
Abberant behaviors are those behaviors that are often considered to be reflective of addiction but in truth may just be an indication of undertreated pain. Some of the behaviors that are less predictive of addiction include, hoarding drugs, asking for a specific medication or dose or self escalating doses one or two times. Behaviors which seem to be more predictive of addiction are injecting oral formulations, stealing or selling drugs, and obtaining medications from non-standard sources. (Portnoy & Fine, 2004). Knowing which behaviors will be problematic can help the prescriber understand when further screening and assessment is needed. Addiction is based on the 4 C's (Table 9.1):
■ Craving for the favored substance
■ Compulsive use
■ Lack of control over the drug
■ Continued use despite harm (American Pain Society [APS], AAPM, American Society of Addiction Medicine [ASAM], 2001)
Addiction is a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations (APS, AAPM, ASAM, 2001). Addicts present to the health care provider in a very different way than other patients. Their focus is the drug of choice, and they will often have physical signs, such as track marks between toes or skin popping scars over their extremities from injecting drugs. They can also report various methods of using drugs, from injecting to skin popping, injecting oral drugs, and diversion of all types of medications. Although there have been a multitude of efforts to create a medication that cannot be misused, addicts will smoke, inject, or snort any type of opioid if it provides the physical pleasure response that they are seeking.
Thie one important point here is that the addict is entitled to pain relief. Many patients who are addicts are seen only through one lens, as an addict, and the pain complaints that they have are overlooked. These are very needy patients who have the right to pain
Table 9.1 ■ Definitions Related to Opioid Use
Addiction A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following:
■ Impaired control over drug use
■ Compulsive use
■ Continued use despite harm
Physical dependence A state of adaptation that is manifested by a drug class—specific withdrawal syndrome that can be produced by the following:
■ Abrupt cessation
■ Rapid dose reduction
■ Decreasing blood level of the drug and/or administration of an antagonist
Tolerance A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time
Pseudoaddiction Patient behaviors that may occur when pain is undertreated. These may include the following:
■ Becoming focused on obtaining medications
■ "Clock watching"
■ Seemingly inappropriate "drug seeking"
■ Illicit drug use
Unlike true addiction, pseudoaddiction resolves when the patient's pain is treated effectively
Source: American Academy of Pain Medicine, 2001. American Pain Society [APS], AAPM, American Society of Addiction Medicine [ASAM], 2001.
management but who are time consuming and very difficult to deal with in the average primary care visit. Health care prescribers cannot provide medications to a patient to continue addiction, but they can provide medications to these patients for the treatment of pain. To ensure safe prescribing practices, see the opioid agreement for documenting treatment plans and progress toward goals. The primary care practitioner should also use a variety of specialists when dealing with this type of patient to support the care they are providing. Psychologists, addicitionologists, pain specialists, social workers and counselors are just a few specialties that can assist with patients who have substance abuse issues.
Dependency, on the other hand, is a different condition when compared with addiction. All addicts are dependent on their opi-oids, and all patients who take opioid medications for more than 30 days are dependent. Dependency is defined as a state of adaptation that is manifested by a drug class—specific withdrawal syndrome that can be produced by the following:
■ Abrupt cessation
■ Rapid dose reduction
■ Decreasing blood level of the drug and/or administration of an antagonist (APS, AAPM, ASAM, 2001)
Thie dependent patient may work and can have good family relationships. The patient who is dependent on opioid medications will use these medications to better their life, not destroy it.
It is important for the health care provider to establish a trusting relationship with the patient who has chronic pain and takes opioids regularly. Once the opioids are prescribed, there is an understanding and validation of the pain complaint and recognition on the patient's part that medication will be provided for pain relief. Respecting this understanding is important for both the patient and the prescriber. Most patients who take opioids regularly do not go on to become addicts.
Two additional conditions that are related to addiction and dependency are tolerance and pseudoaddiction. Tolerance is not a sign of addiction. A patient who takes any type of medication can become tolerant to some effect. Tolerance is simply the lessening of a medication effect over time. For example, if a patient becomes nauseated when they start a new medication, and the nausea lessens over time as the patient continues to take the medication and accommodates to it, that would be considered tolerance.
Most often, the term "tolerance" is applied to a patient when they frequently request dose increases because the medication is no longer providing the type of pain relief it once did. The lessening of the pain relief is considered to be tolerance. When patients report increased pain, it is worthwhile to ask if they are taking the medication as prescribed, if they started any new activity that might cause pain, or if they have changed the way they take the medication (e.g., before bed, in the morning, etc). The only side effect that the patient will never become tolerant to is constipation. All opioids cause constipation, and it must be treated effectively for the patient to continue to take the medication.
Once the patient reaches a stable pain state, he or she should be able to find a medication dose that controls the pain. Stable pain equates to stable medication dose. If, for some reason, this is not happening, trying to increase the dose, changing the medication i nterval, or using an opioid rotation strategy can help the patient retain adequate pain relief.
Pseudoaddiction is really a sign of undertreated pain. Pseudoad-diction is a condition in which the patient is perceived to be drug seeking when in reality they are relief seeking. These are the patients who are considered "drug seekers" or "clock watchers," or seem to be on the call light all the time requesting pain medication.
Behaviors that are often associated with pseudoaddiction center on the need for more pain medication. In clinical settings, when adequate pain medication is provided for these patients, the behaviors often disappear.
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