Challenges of Responsible Pain Management

Risk of Addiction

Many healthcare professionals agree that opioids can be a safe and effective component of pain management.^7,8 However, concerns remain among some clinicians regarding the risk of addiction among patients who take opioid medication.^7,13

The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine define addiction as a “primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations.”¹⁴

Some behaviors that suggest addiction to a substance such as an opioid include

• Impaired drug use control¹⁴
• Compulsive use¹⁴
• Continued use, even in the face of harm¹⁴
• Craving¹⁴
• Prescription forgery¹⁵
• Obtaining drugs from multiple sources, licit or illicit¹⁵
• Diversion—sales of prescribed drugs to others¹⁵
• Stealing or borrowing drugs from others¹⁵
• Repeatedly running out of medication early after being given a dose that the patient agreed was effective⁹
• Injecting oral or topical opioids⁹

Proper screening of patients prior to the prescription of controlled substances can help you assess their risk of addiction. There are several helpful tools you can employ when discussing the risk of addiction with your patients.

Use the screening tools available on this site.

Addiction vs Tolerance or Physical Dependence

Addiction is a medical and psychological illness that results in certain behaviors and a loss of control over the use of a substance.^9,13 Signs of addiction include a constant use of or need for the drug⁷ or preoccupation with the use of the drug or the ability to obtain it.¹³ Patients who become addicted to opioids may also attempt to steal or tamper with prescriptions, or sell the prescribed medication.¹³

Patients who take opioid pain medication may experience physical dependence. This is not the same as addiction.¹³ Physical dependence can occur with various medications.⁹ It means that patients have adapted to the medication and may experience withdrawal symptoms with a sudden cessation, quick dose reduction, decreased blood levels, or antagonist administration.^9,14

Patients may also develop a tolerance or “pseudotolerance” to opioids, which is, again, not the same as addiction. Tolerance is defined as the diminution of drug effects because of the body’s adaptation over time.¹⁴ Patients manifest pseudotolerance through their need for increasing doses due to disease progression, drug interaction, lack of compliance, changes in physical activity, or addiction.¹⁶

While pseudoaddiction may lead to possible addiction-related behaviors,¹⁴ it is often resolved after the appropriate dose of medication is given.¹⁴ Pseudoaddiction is defined as the drug-seeking behaviors resulting from undertreatment of pain. Patients become focused on obtaining medication and how long it will provide them with relief.¹⁴

Before prescribing opioids, healthcare professionals should ask patients questions about their past behaviors and use of alcohol or drugs.^7,8 They may also take into consideration a patient’s family history of substance abuse when determining whether or not to prescribe opioids.¹³

Regulatory Issues

The patient has a right to pain relief. The state has a responsibility to safeguard the public against the abuse, misuse, and diversion of powerful medications. This places the healthcare professional squarely in the middle of forces and priorities that occasionally come into conflict. The solution to this conflict is to be familiar with the state and federal guidelines and requirements regarding the prescribing of controlled substances such as opiate medications.

Some opioids are Schedule II drugs. Schedule II drugs are defined as those that have a high potential for abuse with severe psychological or physical dependence.¹⁷ State regulations governing the prescription and use of Schedule II drugs vary from state to state.¹⁷ Therefore, it is important that both healthcare professionals and patients understand the regulatory guidelines and requirements regarding the prescription and use of controlled substances such as opioid medications.

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