DEPENDENCE VERSUS ADDICTION … AND OPIOID USE DISORDER

pain

It’s no secret that things are changing day by day for chronic pain patients.  The CDC guidelines have not been viewed as “guidelines”; rather they have been viewed as law, causing States to implement their own stringent restrictions on opioid prescriptions by legitimate physicians, regardless of the patients’ medical condition, their confirmed medical diagnoses, and past history of the “tried and failed” methods of conservative treatment.  When there is no conservative treatment or even invasive procedures available to help, many people suffering from severe, chronic pain, must rely upon opioid treatment in order to attain and maintain the highest quality of life possible.

Many patients have gone years or decades on a successful pain management plan; a plan which many times includes opioid treatment.  These treatment plans provided pain relief which would allow these patients to remain functional.  Do these patients “depend” on this treatment to maintain their ability to function?  Yes, of course.  Do diabetics rely on medicine, in conjunction with lifestyle changes to maintain function?  Yes, of course. Do diabetics always incorporate exercise, diet, and lifestyle changes to control their disease?  Many times … not so much.  The same scenario goes for a multitude of disease processes.  Further, the prescription medication used to control these disease processes have side effects and some can be abused.  So to be dependent upon medication which keeps the patient stable is not necessarily a bad thing, even if it includes opioids.

Most physicians and patients know that when one has used opioid therapy for years, decades or more, a sudden discontinuance of opioids can and does lead to severe consequences for the patient.  In fact, it can be fatal.  Does this mean that the patient is addicted?  Of course not.  The patient simply relies upon the medication to keep them functional.  When taken appropriately, opioids are not necessarily a bad choice for patients.  The CDC guidelines even state that opioids are to be used “when the benefits outweigh the harm”.  Let’s take a look now at addiction.

Addiction is defined, according to the American Society of Addiction Medicine as follows:

“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.  Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

By the very definition of addiction, it is clear that chronic pain patients who use their medication appropriately are NOT addicted.  They are dependent on the medication necessary to maintain quality of life and avoid loss of function.

Our final area of discussion is relatively new, yet perhaps as important as understanding the difference between dependence and addiction … Opioid Use Disorder.  This diagnosis is relatively new and this author could find no clear definition or criteria which  defined the criteria used for diagnosis of this disorder.  From what I could ascertain, the best, most clearly stated definition of Opioid Use Disorder is from the American Psychiatric Association. http://pcssmat.org/wp-content/uploads/2014/02/5B-DSM-5-Opioid-Use-Disorder-Diagnostic-Criteria.pdf

The American Psychiatric Association gives the following as criteria for use of the diagnosis “Opioid Use Disorder”:

A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Opioids are often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
4. Craving, or a strong desire or urge to use opioids.
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
8. Recurrent opioid use in situations in which it is physically hazardous.
9. Continued opioid 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.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of an opioid.

Note: This criterion is not considered to be met for those taking opioids solely under
appropriate medical supervision.
11. Withdrawal, as manifested by either of the following:
a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal).
b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

With some States now having “involuntary commitment laws”, it is important that if your doctor places this diagnosis on your billing statement or on your medical records, unless you meet the criteria for this diagnosis, you may wish to consider discussing it  with your doctor.  Unless he has reason to believe that you meet the criteria for this diagnosis, it should be taken off your chart.  Perhaps your doctor doesn’t fully understand or maybe he has another source of information from which he is basing his opinion.

In this time of ever-changing laws and “guidelines” with respect to the treatment of chronic pain, it is important to stay vigilant and be involved in the decision-making process of your medical care.  Stay informed.  Take the time to discuss things you don’t understand with your doctor.  Let your doctor know of any decline in functioning and describe the things that you were formerly able to do which you now suddenly cannot do if your medicine is decreased, discontinued, or changed.  Communication is the key to a successful approach to your illness or disability.

 

Author:  Lana Kirby (317) 441-2888

#Veterans & Americans United for Equality in Medical Care

 

 

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