Jul 16, 2008
To understand how addiction is ambiguously defined in state laws, we must first understand how addiction and its components are defined correctly.
The American Society of Addiction Medicine recently defined terms associated with addiction and the physiologic responses associated with opioid treatment for intractable pain. The terms defined below reflect current thought on the differences between addiction and opioid pain treatment.17
Physical dependence upon an opioid is a physiological state in which abrupt cessation of the opioid, or administration of an opioid antagonist, results in a withdrawal syndrome. Physical dependency on opioids is an expected occurrence in all individuals in the presence of continuous use of opioids for therapeutic or for nontherapeutic purposes. It does not, in and of itself, imply addiction.
Tolerance is a form of neuroadaptation to the effects of chronically administered opioids (or other medications) which is indicated by the need for increasing or more frequent doses of the medication to achieve the initial effects of the drug. Tolerance may occur both to the analgesic effects of opioids and to some of the unwanted side effects, such as respiratory depression, sedation, or nausea. The occurrence of tolerance is variable in occurrence, but it does not, in and of itself, imply addiction.
Addiction in the context of pain treatment with opioids is characterized by a persistent pattern of dysfunctional opioid use that may involve any or all of the following:
adverse consequences associated with the use of opioids
loss of control over the use of opioids
preoccupation with obtaining opioids, despite the presence of adequate analgesia
Individuals who have severe, unrelieved pain may become intensely focused on finding relief for their pain. Sometimes such patients may appear to observers to be preoccupied with obtaining opioids, but the preoccupation is with finding relief of pain, rather than using opioids per se. This phenomenon has been termed ‘pseudoaddiction’ in the pain literature.
Aaron Gilson, Researcher at the Pain and Policy Studies Group at the University of Wisconsin, narrows down the definition of addiction as "drug use despite harm". This would not apply to pain patients as taking opioids actually increases their quality of life.
Ambiguous definition of addiction
According to the American Society of Addiction Medicine, "The clinical implications and appropriate management of physical dependence, tolerance and addiction differ. It is therefore important that clear definitions be established to facilitate identification and appropriate management of these occurrences.11,17
Because many members of state medical boards continue to believe that physical dependence and tolerance associated with opioid pain treatment is the same as addiction, numerous states’ regulations fail to recognize the difference between physiological responses to opioids for intractable pain and the physiological and psychological responses to recreational drug abuse.1,17
A survey conducted by The Pain and Policy Studies Group at the University of Wisconsin, confirmed state medical boards’ false belief that physiological responses to opioids are the same for addiction and intractable pain treatment. One question in the survey asked state medical board members to select terms that encompass the definition of addiction and physiological responses to opioid pain treatment. Physical dependence and tolerance held a large majority of the vote.
Table 1. Terms that state medical board members included within their definition of addiction. Each member was required to choose one or more of the following terms to define addiction: physical dependence, psychological dependence, tolerance, other, and don’t know.11 (A question from a survey conducted by The Pain and Policy Studies Group at University of Wisconsin)
Choose the terms that define addiction
physical dependence 85%
psychological dependence 71%
physical dependence only 10%
psychological dependence only 10%
tolerance only 1%
As a result of the confusion with the definition of addiction, and specifically with the assumption any type of physical dependence or tolerance is associated with addiction, states fail to establish the difference between intractable pain patients and drug addicts and between physicians and drug dealers. State medical board members need to understand that physical dependence and tolerance are not always associated with addiction, thus opioids taken for intractable pain rarely if ever result in addiction. Once this is done, overregulation and prosecution of legitimate physicians may subside to allow for more adequate intractable pain treatment.