Current Diagnosis & Treatment of Pain, 1st Edition
7. Pain & Addictive Disease
Steven D. Passik PhD
Kenneth L. Kirsh PhD
Russell K. Portenoy MD
Addiction and drug
Current Diagnosis & Treatment of Pain, 1st Edition
7. Pain & Addictive Disease
Steven D. Passik PhD
Kenneth L. Kirsh PhD
Russell K. Portenoy MD
Addiction and drug abuse are very common in the United States; 6 to 10% of the population abuses illicit drugs, 15% abuse alcohol, 25% are addicted to nicotine, and 33% of the population samples illicit drugs at least once. Because substance abuse is a risk factor for some sources of chronic pain, these problems will inevitably be seen in a sizable number of patients with chronic pain. There is no reason to believe that abuse rates would be any lower in patients with chronic pain than in the general population. Given this notion, there is an interesting phenomenon concerning the perception of opioid medications both in the United States and within the health care system. Some members of the medical community (in general, specialists in addiction) consider opioids to be a major cause of abuse, associated with dire consequences to the individual and society at large; whereas, others (usually pain specialists) view opioids as essential medications to relieve pain and suffering. Given the opposing nature of these perspectives, it is not surprising that historically there has been little communication between these two groups.
The Traditional Addiction Specialist Perspective
Specialists in addiction have defined such terms as “tolerance” and “dependence,” which are useful in nonpain settings. However, such terminology fails to address the meaning and manifestation of these phenomenon in patients treated with analgesics for painful medical disease. The perspective of addiction specialists is also based on seeing patients who have typically started opioid medications or been exposed to them solely for the purposes of recreational use. In addition, many (if not all) of these patients are vulnerable to the medications, and the addiction specialist is likely to only see the negative consequences of opioids, which can also foster the sense of these medications as being a “gateway” to illicit drug use. Thus, it is typical for these specialists to believe that exposure to the drugs will cause addiction.
The Traditional Pain Specialist Perspective
Pain management professionals have cycled through various stages in their beliefs regarding the abuse potential of opioids. The old mythology stated that addiction was so fearsome and unavoidable that opioids should be with held until patients were close to death. Luckily, a revolution in pain management, along with the use of opioids that began in oncology and spread to pain of all types, showed that this perception was false. But this myth has been replaced by another, which suggests that patients with chronic pain are somehow immune to problems of aberrant drug-taking, abuse, or diversion. These conclusions were erroneously based on questionable data, such as in the Boston Collaborative Drug Surveillance Project. In that study, the authors evaluated 11,882 inpatients who had no prior history of addiction and were administered an opioid while hospitalized; only four cases of addiction could be identified subsequently. The study focused on treatment of acute pain and was not concerned with chronic pain issues; it must be noted that the Boston Collaborative Drug Surveillance Project was not a developed study but merely a letter to the editor that well-intending professionals used as a rationale to treat more chronic pain with opioids. The potential for opioid addiction is a constant consideration in the management of acute and chronic pain; however, the criteria that define this outcome or the factors that may contribute to it are not well understood.
Thus, there has been a natural divide between these two sets of professionals. However, due to the increased media coverage of the growing abuse of prescription drugs, a new level of discourse has begun. The interaction between pain and addiction specialists has led to the beginning of a shared knowledge that enhances each other's ability to comprehend clinical phenomena and formulate questions for research.
This chapter brings together these two perspectives through an examination of the issues raised by each of two situations commonly encountered in clinical practice: the management of pain in patients with a history of opioid abuse, and the risk of opioid abuse in patients with no such history who are given opioid drugs for medical purposes. Throughout this text, an effort is made to balance the clinical imperative to provide adequate relief of pain with legitimate concerns about the consequences of opioid abuse. Opioids are the focus of this discussion because they have a unique position as both major analgesics and drugs of abuse, and thereby encourage a comprehensive examination of the issues. It should be noted, however, that many of the topics explored herein
apply equally to other drug classes, such as the use of benzodiazepines for anxiety and other disorders.
Redefining Abuse & Addiction
Both epidemiologic studies and clinical management depend on an accepted, valid nomenclature for substance abuse and addiction. Unfortunately, this terminology is highly problematic as the pharmacologic phenomena of tolerance and physical dependence are commonly confused with abuse and addiction, as well 