Diagnostic and Statistical Manual of Mental DisordersIV

An improved understanding of definitions of addiction, physical dependence, and tolerance would also allow clinicians to more effectively interpret the terminology of the Diagnostic and Statistical Manual of Mental Disorders-IV (21).

If one understands the correct definition of physical dependence, it is clear that the DSM-IV misuses the term dependence. By doing so, this has the effect of confusing a pain patient with one with the disease of addiction. Under the section "Criteria for Substance Dependence,'' DSM-IV defines substance dependence as "a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following during the same 12-month period.'' It then lists seven criteria for determining if this disorder exists (Table 1) (21). Without differentiating between dependence and addiction, five of the seven criteria for substance-use disorder could apply either to a person with the disease of addiction or a chronic pain patient on opioids. (Table 2) Consequently, a pain patient on opioids may be misdiagnosed with the disease of addiction when he or she is physically dependent, which, as the definitions make clear, is a normal physiological consequence of using opioids. A heroin addict could be both physically dependent and addicted as per the definitions.

Table 1 Criteria for Diagnosis of Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by the occurrence of three (or more) of the following during the same 12-month period:

(1) Tolerance, as defined by either of the following:

(a) A need for markedly increased amounts of a substance to achieve intoxication or a desired effect

(b) Markedly diminished effect with continued use of the same amount of a substance

(2) Withdrawal, as manifested by either of the following:

(a) Symptoms characteristic of withdrawal from a substance,

(b) The ability to take a substance or one closely related to it, to relieve or avoid withdrawal symptoms

(3) A need to take a substance in larger amounts or over a longer period than intended.

(4) A persistent desire or unsuccessful efforts to cut down or control substance use

(5) A great deal of time spent in activities necessary to obtain a substance (e.g., visits to multiple doctors or driving long distances), to use a substance (e.g., chain smoking), or to recover from its effects.

(6) Abandonment of or absence from important social, occupational, or recreational activities because of substance use

(7) Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., continued cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer is made worse by alcohol consumption)

Table 2 Five Out of Seven of the DSM-IV Criteria for Substance Misuse Could Be for a Pain Patient Appropriately on

Opioids or Patient with the Disease of Addiction

1. Tolerance does not equal addiction

2. Withdrawal does not equal addiction

3. Length of use of opioids does not equal addiction

4. Desire to cut down the use of opioids does not equal addiction

5. Time and activity to obtain opioid does not always equal addiction

Source: From Ref. 22.

It is instructive to look at the seven criteria DSM-IV uses to make the diagnosis of substance dependence and apply them to a patient on opioids for chronic pain, taking into account the LCPA's definitions of addiction, physical dependence, and tolerance (23).

1. Tolerance can be present either in an addicted patient or in a pain patient on opioids. Tolerance, as the need to increase the dose of an opioid to achieve intoxication, is consistent with addiction. However, tolerance is also a natural and expected physiologic response to opioids. The opioid dose should be maintained just above the Mean Effective Analgesic Concentration (MEAC) that relieves pain but does not produce impairment and is associated with improved function (24). In clinical pain practice, if the health-care professional or the patient feels that an increase of opioid medication is indicated to reach the goal of decreasing pain and increasing function, this is not tolerance but dose titration.

2. Withdrawal can be present in both addiction and in the pain patient on opioids. Withdrawal is a manifestation of physical dependence that can be part of the disease of addiction. A heroin addict abruptly stops the drug and therefore goes into withdrawal, or the same person enters a narcotic treatment program (NTP), and the opioid substitution relieves the withdrawal syndrome and cravings for heroin. A chronic pain patient enters the hospital on opioids for surgery for a failed back syndrome and the order for his opioid medication is mistakenly not conveyed to his surgeon from his prescribing outpatient physician. The pain patient may go into withdrawal, resulting in increased pain, until his daily opioid requirements have been met. By failing to maintain adequate opioid levels in the physically dependent opioid user, an "opioid debt'' may result. "Opioid debt'' may be defined as that condition which results from failure to adequately maintain serum levels of chronically used opioids in those patients who have become physically dependent upon these drugs. This is not addiction but rather a normal physiologic response consistent with the definition of physical dependence (25-27).

3. Both an addict and a pain patient may often take a substance/opioid in larger amounts or over a longer period than was intended. Certainly, the heroin addict takes the drug in larger amounts secondary to tolerance and longer than intended to prevent withdrawal, cravings, or as a result of poor coping skills. The chronic pain patient may have to increase the opioid dose due to tolerance, but also to decrease pain and increase function. The chronic pain patient under proper evaluation desires to decrease the opioid dose, if the source of the pain is decreasing or the pathology is corrected. Although both of these patients would appropriately be classified as substance dependent using the improved definitions, only the heroin addict would appropriately be diagnosed with a substance-use disorder.

4. Both an addict and a pain patient can have a persistent desire or unsuccessful effort to cut down or control substance use. The heroin addict desires to cut down or control his/her drug use for a variety of reasons, not the least of which is cost. The pain patient on opioids typically desires to decrease his/her medication if the physical condition improves or is corrected. In addition, the pain patient is always under control with all the medications and takes them as prescribed (28). Would both of these patients be considered to have substance-use disorders? The heroin user suffering from the disease of addiction would; the pain patient should not.

5. An addicted patient spends a great deal of time in activities necessary to obtain the substance/opioid. Very seldom does one evaluate a "happy" person with the disease of addiction, because most of their waking hours are spent either trying to get their drug of choice or using it once obtained. However, a chronic pain patient who is not treated or inadequately treated for pain may also spend a great deal of time trying to obtain medication, which fits the definition of pseudoaddiction (9). Would both of these patients be considered to have a substance-use disorder? The heroin user suffering from the disease of addiction should; the pain patient should not.

6. Only the addicted patient gives up or reduces important social, occupational, or recreational activities because of substance use. The drug causes a decrease in one's quality of life. This person would correctly be diagnosed as having a substance-use disorder. The goal of opioid therapy for pain, as with any pharmacotherapy, is that the medication increases the quality of life (28).

7. Only the addicted patient continues to use the substance despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. Again, the drug causes a decrease in one's quality of life and the diagnosis of substance-use disorder is correct (Fig. 2).

Broad adoption of standard definitions of addiction, physical dependence, and tolerance would improve the clinical practice of both pain and addiction medicine. The LCPA definitions should be incorporated into the future Substance-Use Disorder section of DSM-V. Until that occurs, clinicians should understand and apply the definitions that reflect accurate and current knowledge in basic science and clinical medicine. Health-care professionals who understand these definitions will be better able to evaluate and treat their patients if opioids are being prescribed for pain and to diagnose the disease of addiction if present (Table 2).

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