Misconceptions about pain control, particularly the use of opioids, are common among the public and health professionals alike. Concerns about addiction and abuse, efficacy and side effects lead many to be wary of medications that are in fact an essential tool in the arsenal of pain relief.
Those who treat pain should have the facts made clear, both to bolster their own practice and to help them reassure patients and families when they express fears and ask questions.
Addiction, Physical Dependence and Tolerance
When discussing addiction, physical dependence and tolerance in the use of prescription opioids, it is important to define those terms clearly. Using them imprecisely,sometimes interchangeably, can lead to serious misunderstanding and confusion that result in diminished relief of suffering for those in pain. Addiction,physical dependence and tolerance are in fact distinct phenomena that need to be understood as such.
Addiction is a disease characterized by craving, compulsive use, and destructive patterns of use despite harm. Addiction is uncommon in patients who are taking opioids by prescription for pain relief, especially in the absence of the genetic, psychosocial and environmental risk factors that generally influence its development. Even in the case of patients who have a history of drug abuse, a somewhat higher risk of addiction is still outweighed by the benefits of pain relief; and careful monitoring is usually enough to avoid problems. Healthcare providers should also be alert to signs that may seem to point to addiction, such as "watching the clock" for the next dose, but may actually indicate that the pain is not being treated adequately. Concerns about possible addiction can best be addressed after pain is brought under control.
Physical dependence is a normal response to the use of many classes of medication taken over an extended period of time. The body adapts to the medication in such a way that withdrawal symptoms can result if use of the drug is rapidly reduced or ceased all at once. Physical dependence is expected in patients using opioids and is well addressed by carefully tapering off the medications and monitoring the patient for signs of withdrawal rather than stopping them abruptly.
Tolerance is said to occur when a patient requires a higher dose of a medication over time to achieve the same pain-relieving effect. Like physical dependence, tolerance is common, and it is not the same as addiction. Tolerance develops at different rates for different opioids, so the option of switching medications as well as raising the dose is available. In most cases, patients stabilize on a dose for an extended period. Delaying treatment for fear that relief will not be available later on has no rational basis. And it should be noted that there is no maximum dose of opioids for pain. When pain increases because of tolerance or changes in the underlying disease, the medication can be safely increased accordingly.
For a fuller discussion, see Definitions Related to the Use of Opioids for the Treatment of Pain, a consensus document from the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine issued in 2001.
In 2004, the three organizations also jointly issued a Public Policy Statement on the Rights and Responsibilities of Healthcare Professionals in the use of Opioids for the Treatment of Pain.