CONCERN ABOUT OPIOID ADDICTION AS A …

1 ABSTRACTA cute pain is undertreated for many people inthe United States. Although OPIOID analgesics areextremely important tools for the treatment ofacute pain , their appropriate use is often poorlyunderstood by both clinicians and other issues, confusion ABOUT the risk ofdependence, tolerance, and ADDICTION with opi-oid therapy is a significant contributor to theundertreatment of pain . Dependence (the pres-ence of a withdrawal symptom upon drug dis-continuation) is a feature of OPIOID therapy, but isalso common with many other types of common-ly used medications. Tolerance to the effects ofopioids is an expected response to ongoing treat-ment. ADDICTION is a primary neurobiological dis-ease that occurs extremely infrequently whenpatients without preexisting substance use disor-ders receive OPIOID treatment for acute , inadequate pain relief can causebehaviors that resemble ADDICTION in somerespects, a phenomenon that has been referred toas pseudoaddiction.

2 Although the risk of addic-tion with acute OPIOID treatment is extremely low,rating scales to help identify patients who maybenefit from closer monitoring for development ofaberrant drug-related behaviors may be usefulfor some persons. Undertreatment of acute painis a significant problem in the United States,which is at least partly attributable to the limited education ABOUT pain that most clinicians treatment of acute pain is essential torelieve patient suffering and improve quality oflife, and it may also prevent the development ofchronic pain .(Adv Stud ;5(2):48-51) OPIOID analgesics are among the mostcommon medications prescribed anddispensed byhealthcare professionals,yet they are also among the most poorlyunderstood. Among the many obstacles to effectivepain management is the limited education that mostclinicians receive ABOUT pain or OPIOID , and many healthcare professionals, thinkthat even a short course of treatment with an opioidanalgesic can cause ADDICTION .

3 Largely as a result ofthis perceived risk of ADDICTION , and the need to bal-ance appropriate analgesia with care to keep thesepotent drugs out of the hands of people who do notneed them, opioids are often prescribed cautiously byphysicians and other healthcare providers, and arenot used effectively by patients. However, there isconsiderable evidence that the risk of ADDICTION isextremely low when opioids are used for short-termpain relief by patients who do not have substance useproblems. Another limit to outstanding pain man-agement occurs commonly when pharmacists in thecommunity have incomplete information ABOUT thepatient. Additionally, it is important for pharmaciststo understand that the use of OPIOID pain relievers isnot by itself a marker of current or future ABOUT OPIOID ADDICTION AS A BARRIER TO acute pain MANAGEMENT Scott A.

4 Strassels, PharmD, PhD, BCPS**Assistant Professor, Division of Pharmacy Practice,University of Texas at Austin, Austin, correspondence to: Scott A. Strassels, PharmD, PhD, BCPS, Assistant Professor, Division ofPharmacy Practice, University of Texas at Austin, 2409 University Avenue, PHR , Austin, TX 78712. E-mail: 5, No. 2nJune 2008 University of Tennessee Advanced Studies inPharmacy n49 REVIEWDEPENDENCE, TOLERANCE,ANDADDICTIONIt is essential to understand the distinctions betweendependence, tolerance, and ADDICTION . Confusionabout these concepts is a significant contributor to theundertreatment of pain in the United to a consensus statement by theAmerican Academy of pain Medicine, the AmericanPain Society, and the American Society of AddictionMedicine, dependenceis defined by the presence of awithdrawal syndrome when a substance is suddenlyremoved, the dose is rapidly decreased, the blood levelis rapidly decreased, or the patient is treated with anantagonist that prevents the drug s physiologic analgesics have the potential to produce a broadrange of withdrawal symptoms, including centralarousal (eg, insomnia, irritability, and agitation), auto-nomic symptoms (eg, diarrhea, rhinorrhea, and sweat-ing)

5 , muscle spasms, and gastrointestinal is a normal and expected consequence ofchronic OPIOID treatment, and is also associated with anumber of nonopioid drugs that should not be discon-tinued abruptly, including corticosteroids, anticonvul-sants, antidepressants, and drugs thatproduce physical dependence, the risk of withdrawalsymptoms may be reduced by gradually tapering anddiscontinuing the when the physiological responseto a fixed drug dose diminishes over time, resulting inthe need for increasing drug doses to produce the sameeffect. It should be noted that tolerance to differentdrug effects may develop at different rates. For exam-ple, tolerance often develops relatively quickly to thesedative and respiratory depressant effects of opioids,whereas tolerance to OPIOID -induced constipationdevelops gradually or not at term addictionis particularly misunderstood,even among healthcare professionals.

6 According to theAmerican pain Society, the American Society ofAddiction Medicine, and the American Academy ofPain Medicine, ADDICTION is a primary neurobiologicaldisease with genetic, psychosocial, and definition does not refer to anyspecific level of OPIOID dosing or length of time thatthe drug has been used. ADDICTION is characterized bya range of behaviors that may include diminished abil-ity to control drug use, compulsive substance use, con-tinued use of the substance despite harmful effects,and craving of the it is appropriate to be concerned aboutthe potential for ADDICTION and other adverse effectswith OPIOID therapy, several studies have demonstrat-ed very low rates of ADDICTION among patients receiv-ing opioids for acute pain . One chart review of nearly12 000 hospitalized patients who received opioidmedications identified only 4 patients with evidenceof iatrogenic ADDICTION (ie, ADDICTION after treatmentamong patients who did not have a history of sub-stance abuse before treatment).

7 5 Perry and Heidrichconducted a survey of pain management strategiesand outcomes associated with debridement at 93burn units in the United , the physi-cians and nurses surveyed had treated more than 10 000 patients for debridement pain , and most ofthese patients had received opioids. Only 12% of therespondents reported that they knew of any patientswho developed OPIOID ADDICTION after hospital dis-charge. In every case but one, addicted patients had ahistory of previous substance abuse problems. Thesingle reported case of iatrogenic ADDICTION in apatient with no history of substance use was a 3-year-old child who was described as addicted tomethadone upon hospital discharge. Sickle cell crisisis a hereditary condition that can produce severe painof the bones, liver, lungs, and gut, which is oftenundertreated due to concerns ABOUT the risk of iatro-genic of patients who were treat-ed with opioids for sickle cell crisis have suggestedvery low rates of iatrogenic ADDICTION among thesepatients.

8 For example, one survey of OPIOID -associat-ed adverse events among 101 patients with sickle cellcrisis identified 3 patients with OPIOID surveys have found rates of OPIOID addictionamong patients treated for sickle cell crisis of fewerthan 1 in 500 studies demonstrate that patients who useopioid medications for the short-term relief of evenverysevere acute pain are unlikely to develop opioidaddiction. However, inadequately treated pain oftenresults in pseudoaddiction, apattern of behavior thatsuperficially resembles some behaviors of an individ-ual with ADDICTION . These behaviors include using orrequesting pain medication before the next scheduleddose, returning to the physician s office to requestother medications, or other behaviors that mayresemble ADDICTION but that are an understandableresponse to inadequate pain con-trast with ADDICTION , these behaviors resolve whenpain is 5, No.

9 2nJune 2008 Finally, it should be noted that pain is a complex,subjective phenomenon that is often difficult to pre-cisely describe or categorize. Although pain is definedas an unpleasant sensory and emotional experiencethat is associated with tissue damage, there is often noclear relationship between the extent of tissue damageand the type or severity of pain must therefore rely on the subjective self-reports of patients ABOUT their pain . In addition, painis often categorized as either acute or chronic. Acutepain is generally defined as pain of recent onset andrelatively limited duration (eg, following surgery or aninjury), whereas chronic pain is defined as pain thatpersists for longer than is required for the injury toheal, or that continues for an undefined, extendedperiod of , these distinctions are some-times misleading, as different types of pain may occursimultaneously or sequentially in the same example, patients with cancer may experienceongoing chronic pain that is punctuated by episodes ofacute pain , and patients with chronic painful condi-tions such as rheumatoid arthritis may experienceinjuries or require noted previously in this article, the risk of iatro-genic ADDICTION among patients without a history ofsubstance abuse who are receiving opioids for acutepain is very low.

10 Although it would be beneficial toidentify the small subset of patients who are at greatestrisk of developing ADDICTION , it is difficult to accurate-ly identify these rating scaleshavebeen developed to identify patients who have orare at risk of substance use problems with OPIOID ther-apy. The Revised Screener and OPIOID Assessment forPatients with pain (SOAPP)-R is a 24-question ratingscale that was primarily designed to evaluate aberrantbehaviors associated with long-term OPIOID therapy forpatients with chronic on theSOAPP-R include: How often have you taken more pain medicationthan you were supposed to? How often do you have mood swings? How often have you felt a craving for medication? How often have others expressed CONCERN over your use of medication?