Pain Treatment Terminology

Addiction

Definition: A chronic disease with many factors influencing its development and symptoms.

Clinical Use:

Addiction to opioids as a result of pain management is uncommon among people living in nursing homes.

Tolerance and physical dependence are normal physiologic responses to chronic medication administration, whereas addiction is a disease that is not a normal or common response to opiate use.

Addiction is more likely to occur in older adults with multiple risk factors for addiction, such as a genetic predisposition, a history of addictive behavior, or a history of abuse and/or neglect.

It is recommended that pain be adequately controlled before reaching conclusions about concerns related to addictive behaviors.

An individual’s behaviors that may suggest addiction sometimes reflect unrelieved pain or other problems (See Pseudoaddiction, below) unrelated to addiction.

Good clinical judgment must be used in determining whether the observed pattern of behaviors signals addiction or reflects a different issue such as unrelieved pain or psychological distress.

Behaviors that are associated with problematic drug use and possible addiction are:  use of analgesic medications for other than analgesic effects (e.g., to feel euphoric, less anxious) non-compliance with recommended non-opioid treatments or evaluations; insistence on rapid-onset formulations/routes of administration; reports of no relief whatsoever by any non-opioid treatments. Observation of these behaviors should be documented and investigated further with the older adult and other pain-team members.

Recognition of the disease is made in the presence of one or more of the following behaviors: impaired control over drug use, compulsive use, continued use despite harm, and craving.

No single event is diagnostic of an addictive disorder. Rather, the diagnosis of substance abuse/addiction is made in response to a pattern of behavior that usually becomes obvious over time.

Physical Dependence

Definition: The body’s normal response to the continued use of several classes of medications.

Clinical Use:

Physical dependence is a normal physiologic response that occurs with many classes of medications (e.g., beta blockers, alpha-2 adrenergic agents, corticosteroids, opioids and others).

Withdrawal can be precipitated by: stopping the medication abruptly, rapidly reducing the dose, decreasing blood level of the drug, and/or administration of an antagonist (e.g., naloxone).

Withdrawal symptoms are typically expected if the medication has been used consistently for more than 10 days.

Gradual, planned tapering of the medication can usually eliminate any withdrawal symptoms.

Monitoring of clinical symptoms during the tapering process is recommended.

Pseudoaddiction

Definition: Development of abuse-like behaviors that are driven by desperation surrounding unrelieved pain and are eliminated by effective pain management.

Clinical Use:

Behaviors that fall under the term ‘pseudoaddiction’ include those behaviors in which older adults with unrelieved pain become focused on obtaining medications, start “clock watching”, or otherwise seem inappropriately “drug seeking”.

Behaviors considered to be related to pseudoaddiction may place the older adult, prescriber, or others at risk.  When these behaviors occur, a careful assessment of the effectiveness of the current pain treatment plan should take place.

Addiction and pseudoaddiction can both be present at the same time.

Caution must be taken not to ignore a coexisting addiction even when some behaviors are considered to be pseudoaddiction. When more obvious, overt and potentially harmful drug-related behaviors (e.g., forging prescriptions) are also present, the pain team must assess for a coexisting addiction.

Tolerance

Definition: The body’s normal response to continued exposure to a medication, resulting in a reduction of one or more of the drug’s effects over time.

Clinical Use:

Tolerance may occur to both the desired (i.e., analgesia) and undesired (e.g., nausea) drug effects.

Tolerance tends to develop at different rates for different effects; for example, in the case of opioids, tolerance usually develops more slowly to the pain relieving effects than to respiratory depression, and tolerance to the constipating effects often do not occur at all.

Tolerance to the pain relieving effects of opioids will likely occur in some, but not all, older adults.

When tolerance to the pain relieving effects of opioids does occur, an increase in dose is recommended.

Pain Treatment Terminology  - PDF version

References

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, 2009.

Public Policy Statement on the Rights and Responsibilities of Healthcare Professionals in 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. Available at: https://www.semanticscholar.org.

Promoting Pain Relief and Preventing Abuse of Pain Medications: A Critical Balancing Act, a Joint Statement. From 21 Health Organizations and the Drug Enforcement Administration, 2001. Available at: http://www.deadiversion.usdoj.gov/pubs/advisories/painrelief.pdf.

Fine, P. G., & Portenoy, R. K. A Clinical Guide to Opioid Analgesia, New York: McGraw Hill, 2007.