Diagnosing Substance Abuse and Addiction

Addiction is a primary, chronic, and neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations (Heit 2003). It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving for the drug (American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine 2001, Rinaldi et al. 1988). This definition emphasizes that addiction is a psychological and a behavioral syndrome. Physical dependence is a state of neuroadaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or an administration of an antagonist. Tolerance, on the other hand, is a state of adaptation in which exposure to the drug induces changes that result in diminution of one or more of the drug's effects over time. Physical dependence and tolerance are neuropharmacological phenomena, while addiction is both a

N. Vadivelu et al. (eds.), Essentials of Pain Management,

DOI 10.1007/978-0-387-87579-8_31, © Springer Science+Business Media, LLC 2011

neuropharmacological and a behavioral phenomenon. Addiction may occur with or without physical dependence. Pseudoaddiction, a term coined by Weissman and Haddox in 1989 (Weissman and Haddox 1989), refers to behaviors that may mimic those commonly associated with opioid abuse but are instead indicative of unrelieved pain. The term is applied to an individual or a pain patient who seeks additional medications, whether appropriately or not, because of undertreatment of pain, and such inappropriate behavior ceases when pain is treated in the proper manner. Unlike addiction, this behavior resolves once the pain is under adequate control. Pseudotolerance is the need to increase medication (e.g., opioids for pain) when other factors, such as disease progression, new disease, increased physical activity, lack of compliance, change in medication, drug interaction, addiction, and/or deviant behavior, are present (Pappagallo 1998). Abuse is the use of medications outside the scope of usual medical practice or the use of illicit substances. Various definitions of abuse, which include the phenomena associated with physical dependence or tolerance, are often, however, not applicable to terminal pain patients (i.e., cancer patients) who receive potentially abusing drugs for legitimate medical indications (Passik et al. 1998, Passik and Portenoy 1998). Diversion is the use of legitimately prescribed medication for illicit, illegitimate purposes, with the intent to sell or distribute.

Evaluation of the drug-abusing patient must be comprehensive in all three key aspects of patient's problem: pain, addiction, and psychiatric component. Patients with a history of substance abuse or drug addiction can be classified into three categories: those who are actively involved in illicit drug use, those with a history of drug abuse, and those in methadone maintenance programs. Evaluation of addiction should include determination of the patient's history of which substances have been used over what time duration, history of prior substance abuse treatment, assessment of the severity of the patient's substance abuse problem and the extent of patient's involvement in treatment programs, what is the patient's level of motivation to change status, what is the duration of sobriety if in recovery, and how sobriety is maintained. In this population, it is not uncommon for pain, substance abuse, and psychiatric problems to act synergistically to lead to development of complex, difficult to manage syndromes. Consulting or involving substance abuse specialists such as psychiatry and/or addiction medicine professional may often be needed to clarify diagnosis and complete evaluation. Current or past history of a personality, anxiety, mood, or psychotic disorder warrants a psychiatric referral and evaluation. Careful chronology may reveal which component (pain versus psychologic versus addictive disorder) exacerbate or cause the other. Table 31.1 enumerates the various criteria used in diagnosing substance abuse and substance dependence as published in Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV).

Assessing severity of abuse is, as established in DSM-IV criteria, based on the number of adverse consequences resulting from use. Not all the criteria in the DSM-IV, however, would be applicable in the chronic pain patient, and in fact some have been a source ofcon-fusion in diagnosing addiction. The form of addiction seen in the patient with pain is often not the same as the type seen in the street addict. The requirement in the DSM-IV criteria for substance dependence about giving up or decreasing social, occupational, or recreational activities because of substance abuse often is not found in the pain patient with dependence. Unlike the illicit addict, the pain patient does not usually compromise their lifestyle (e.g., drive long distances to seek drugs or involve himself in criminal activity or drug diversion).

Table 31.1 Diagnostic criteria of substance abuse and dependence in DSM-IV (American Psychiatric Association 1994).

A. Substance abuse

- maladaptive pattern of substance use leading to clinically significant impairment or distress, manifested by at least one of the following, occurring within a 12-month period, and symptoms have never met the criteria for substance dependence

1. Recurrent use resulting in failure to fulfill major role obligations at work, school, or home (examples: substance-related poor work performance, repeated absences, suspensions, expulsion from school, neglect of children, or household)

2. Recurrent use in physically hazardous situations such as driving a vehicle or operating a machine

3. Recurrent substance-related legal problems such as substance-related misconduct leading to arrests

4.Continued use despite substance use related persistent or recurrent social or interpersonal problems (examples: arguments with spouse about consequences of intoxication, physical fights)

B. Substance dependence

- a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at any time in the same 12-month period:

1. Tolerance - as defined by either of the following:

a. need for markedly increased amounts of the substance to achieve intoxication or desired effect b. markedly diminished effect with continued use of the same amount of the substance

2. Withdrawal - as manifested by either of the following:

a. the characteristic withdrawal syndrome for the substance b. the same or closely related substance is taken to relieve or avoid withdrawal symptoms

3. The substance is often taken in larger amounts or over a longer period than was intended

4. There is a persistent desire or unsuccessful effort to cut down or control substance abuse

5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance, or recover from its effects

6. Important social, occupational, or recreational activities are given up or reduced because of substance abuse

7. The substance use is continued despite knowledge or having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression)

Adapted From Diagnostic and Statistical Manual of Mental Disorders (1994).

Also, the classic sign of compulsive opioid use may not be apparent in the pain patient because opioid is prescribed and is readily available. The signs of prescription drug abuse, in contrast to that of illicit abuse, often are more subtle and may need a combination of multiple observations.

Toxicology screening can be a helpful clinical adjunct to identify aberrant behavior and to monitor problematic opioid use in addiction or diversion. Practitioners believe that all patients with chronic non-terminal pain who were treated with opioids should be subjected to random urine screening. This belief has been supported by survey studies demonstrating that about 40% of the patients with chronic non-cancer pain who were treated with opioids were found to be problematic, and about half of these problematic cases were identified through toxicology screening. The physician is, nevertheless, the ultimate responsible caregiver who determines the severity of the prescription drug abuse in his practice and to make the decision on whether toxicology would be utilized on a routine or an occasional basis.

The chapter covers a review of the most commonly encountered illicit drugs of abuse, their physicochemical characteristics and epidemiology, pathophysiological effects, and clinical manifestations. Management of pain in both the illicit and licit drug-abusing patient is then discussed focusing on the conceptual and practical issues associated with drug abuse in both the acute and chronic pain patient.

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