Fast Fact and Concept #68: Is it pain or addiction?

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Title: Fast Fact and Concept #68: Is it pain or addiction?

Author(s): David E. Weissman

The single most requested educational topic by physicians, concerning pain, surrounds differentiating the patient in pain vs. the patient with a substance abuse disorder. The key to proper assessment lies in understanding 1) the definitions of tolerance, physical and psychological dependence (a.k.a. addiction), 2) the components of an addictions assessment and 3) the differential diagnosis of the symptom of "pain".

Definitions: Tolerance: the need to increase a drug to achieve the same effect. In clinical practice, significant opioid tolerance is uncommon. Tolerance may be present in the pain patient or the addict; by itself it is not diagnostic of addiction.
Physical Dependence: development of a withdrawal syndrome when a drug is suddenly discontinued or an antagonist is administered. Many patients on chronic opioids become physically dependent; its presence cannot be used to differentiate the pain patient from the addict.
Psychological Dependence (Addiction) : overwhelming involvement with the acquisition and use of a drug, characterized by: Loss of Control, Compulsive Drug Use, and Use Despite Harm. Data suggests that opioids used to treat pain rarely leads to psychological dependence.

Addiction (Substance Abuse) Assessment: Assess for addiction in the following domains. (see Sees and Clark) Note: one positive item from the list does not establish a substance abuse disorder, rather, the diagnosis rests on a pattern of behavior that includes several positive findings (see Passik, et al).

Differential Diagnosis: The differential diagnosis for a patient reporting "pain" includes physical causes (broken leg, sciatica, pseudoaddiction-see Future Fast Fact); psychological (depression, anxiety, hypochondriasis, somatization disorder, etc.); spiritual (impending death, grief); substance abuse; and secondary gain/malingering/criminal (desire for attention, or disability benefit or financial gain).

Also See:
Fast Fact #69: Pseudoaddiction

References: Sees KL and Clark HW. Opioid use in the treatment of chronic pain: assessment of addiction. J Pain Symptom Manage 1993; 8:257-264.

Savage SR. Addication in the treatment of pain: significance, recognition and management. J Pain Symptom Manage 1993;8:265-278.

Eisendrath. SJ Psychiatric aspects of chronic pain. Neurology 1995; S26-S34.

Passik SD, Kirsh KL and Portenoy RK. Understanding aberrant drug-taking behavior: addiction redefined for palliative care and pain management settings. Principles and Practice of Supportive Oncology Updates 1999; 2: 1-12.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing Fast Facts and Concepts #68 Is it pain or addiction. Weissman DE. April, 2002. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 5/2002

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: General Public, Lawyers, Patients/Families, Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Addiction, Chronic non-malignant pain, Controlled substance regulations, Pain, Pain assessment, Pain treatment

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).