Pain And Opioid Addictiona Continuum Approach

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While pain and addiction can and sometimes do exist as comorbid conditions, they may also present as part of a dynamic continuum with pain at one end of the spectrum and addiction at the other extreme. In cases when the identified substance of misuse is one in which there can be no doubt about the medical inappropriateness of ongoing use, such as with alcohol or cocaine use, a comorbid pain and substance-use disorder should be considered. When the drug in question can arguably be both the problem and the solution, depending on clinician training and perspective, a continuum model may better apply. This can be the

case with opioids used for the treatment of chronic pain. Figure 1 shows diagrammatically this relationship.

With chronic pain, appropriateness of ongoing opioid use may come into question, especially when there is little or no objective improvement in pain relief or function. In this case, the application of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for diagnosis of opioid dependence may lead to inappropriate diagnosis of addiction, potentially compromising patient care.

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