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Chronic Pain and Addiction (Part 1)
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Posted on Tue, 26 February 2008 at 10:18 pm
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There are a number of reasons pain clinicians have been historically interested in the area of addiction. At first, chronic pain clinicians had the clinical impression that pain treatment outcome was influenced by addiction issues (Fishbain et al., 1992b). As such, the mantra in the 1980s and the early 1990s was that chronic pain patients (CPPs) should be detoxified from opioids and that placement on opioids leads to addiction. This position radically changed in the late 1980s when publications began to appear claiming success in treating intractable CPPs with chronic opioid analgesic treatment (COAT) without the development of significant addiction (Portenoy, 1989; Portenoy & Foley, 1986). The COAT literature has increased and now contains a significant number of randomized controlled trials. They have recently been the subjects of a metaanalysis (Graven et al., 2000). Findings of this meta-analysis were that patients with nociceptive and neuropathic chronic pain may benefit from COAT, while this positive effect was less clear for patients with chronic idiopathic pain. Thus, because of the clinical interest in COAT as a way of helping intractable CPPs, addiction has become a hot topic within the pain literature.
This interest in COAT and the associated addiction issue has also been influenced by a number of other developments, which have occurred at the same time. First, a significant literature developed that spoke to the chronic undertreatment of pain by health care professionals (Bendtsen et al., 1999). Second, research studies reported that some physicians were prejudiced against the use of
opioids (opiophobia) because of fears of iatrogenic addiction (Bendtsen et al., 1999; Weinstein et al, 2000). Third, in the late 1990s, because of the chronic undertreatment of pain, state licensing boards began to develop policies that supported appropriate opioid prescribing rather than policies that hindered opioid prescribing. Fourth, in the early 2000s, Joint Commission on Accreditation of Health Organizations (JCAHO) incorporated the adequate treatment of pain as a patient right. Fifth, in the early 1990s, drug technology developed a number of controlled-release opioids, which were touted as controlling pain in a more effective manner than the immediate-acting opioids.
At the present time, COAT is mired in controversy. Clinicians who do not accept the current evidence for COAT efficacy still use the addiction issue as an argument against COAT. At the same time, clinicians who use COAT note that there appear to be addiction difficulties with some patients. Thus, at the present time, the issue of addiction is of intense interest to the pain clinician.
As the reader is aware, there are numerous books on the subject of addiction and its treatment. As such, the purpose of this chapter is not to review this literature, but to familiarize the pain clinician with addiction problems and issues that would be relevant to his or her pain practice. Thus, this chapter reviews the most recent research in reference to the following: substance abuse terminology definitions, identification of psychoactive substance use-related disorders or addiction, prevalence of addiction within CPPs, methods for diagnosing addiction in CPPs, risk of addiction in CPPs on opioid exposure, risk of readdiction in addicts with chronic pain on opioid exposure, diversion, aberrant drug-taking behaviors as indicators of addiction, pseudo-addiction, psychiatric comorbidities in CPPs with addiction, use of short-acting opioids versus long-acting opioids for COAT, opioid treatment agreements, opioids and driving, legal issues in addiction and chronic pain, and opioid detoxification methods in addicts and non-addicts. As can be seen, this chapter deals mainly with opioids and addresses other drugs of abuse, such as cocaine and cannabinoids, only peripherally. The reader
is referred to addiction textbooks for in-depth discussion of the addiction issues relating to these drugs.
Author: David A. Fishbain (Weiner’s Pain Management: A Practical Guide for Clinicians (7 edition)
Tags: addiction, chronic pain, opioids, treatment