***Update 2014: the contents of the Pain-Topics.org website have been moved to The Pain Community website instead.
Dr. Leavitt of Pain-Topics News/Research reviews and rebuts an article which suggests that complex persistent opioid dependence in pain patients is actually addiction.
Jane Ballantyne, MD, Mark Sullivan, MD, PhD, and Andrew Kolodny, MD, present their opinions regarding addiction in persons who are administered opioid analgesics continuously and long-term [Ballantyne et al. 2012]
In these patients, they contend that, “biologically, opioid addiction can be understood in terms of neuroadaptations,” with two of those being tolerance and dependence.
It’s astonishing that these three medical experts seem to be ignorant of the well-established difference between physical tolerance, dependence, and addiction. Tolerance, dependence, and consequent withdrawals are a normal response to many types of pharmaceuticals (antidepressants, steroids, insulin, painkillers) and even non-pharmaceuticals, like coffee. The claim that the “neuroadaptation” of tolerance and dependence is a sign of addiction would place dozens of other substances into the same category.
The authors assert that withdrawal symptoms are powerful drivers of opioid seeking. In this regard, addiction is further defined by aberrant behaviors that, when persistent, “result in irreversible changes in the brain.”
I wonder how these supposedly brain-altering “aberrant behaviors” compare to the irreversible changes in the brain that occur as a result of untreated pain. Note that these “aberrant behaviors” are only defined in the broadest terms, such as drug-seeking, which is in itself a perfectly reasonable behavior when we seek a doctor’s help in getting a medication for any illness.
However, the authors further acknowledge that drug-seeking behaviors in patients with pain are different from those listed in standard substance-use disorder criteria, and are focused on obtaining opioids from prescribers.
In fact, they state, “pain patients who are treated continuously with opioids may not manifest any aberrant behaviors because they are effectively receiving maintenance therapy, which suppresses craving.” However, the authors believe that opioid craving and addiction behaviors may emerge if opioids are suddenly not available, tolerance occurs, or attempts are made to taper the medication.
So they admit there is no problem as long as opioid therapy is maintained, but because there *might* be a problem if opiates are stopped, they suggest doing exactly that and stopping them. Does this make sense to anyone?
In the past, such behaviors have been attributed to “pseudoaddiction,” which Ballantyne and colleagues assert is “a misleading term that suggests that aberrant opioid seeking is predominantly a consequence of inadequate pain relief and should be addressed by increasing opioid dose.”
As a concept, pseudoaddiction implies that opioid seeking will cease if an “adequate dose is reached,” but the authors assert that this is not apparent in the long-term treatment of chronic pain with opioids.
By definition, if long-term opiate therapy is working, an adequate dose has been reached, so to state that this is not apparent makes little sense. It seems that in cases where opiate therapy is working, they always assume some darker force is in play.
The authors claim that, “The opioid dependence that we once believed to be short-lived or easily reversed is sometimes seen to persist as complex persistent dependence for months after a taper”
Couldn’t chronic pain itself be the cause of this supposed syndrome?
They say that many patients treated long-term with high-dose opioids are unwilling to taper the medication despite “continuing pain and known risks.”
Taking medications despite “continuing symptoms and known risks” is an established tradition of medical treatment, like with antidepressants or blood thinners. Patients are often encouraged to keep taking such medications because that harm is judged to be less than the persistence or worsening of symptoms. Why should opiates be any different?
Additionally, it is never mentioned that there is an equivalent risk from untreated pain damaging the nervous system. My personal experience has been that opioids are effective for us, so tapering them increases our pain. The reasonable response of resisting such forced tapering is seen as further evidence of addiction.
Dr. SB. Leavitt’s response:
COMMENTARY: Unclear Distinctions
the authors seem to conflate addiction in patients treated for pain with their concept of a persistent dependence syndrome and suspected aberrant behaviors.
conclude, “Whether or not it is called addiction, complex persistent opioid dependence is a serious consequence of long-term pain treatment that requires consideration
At this point, they are essentially stating that all successful long-term opiate therapy is actually just addiction, and not a successful medical therapeutic intervention.
it has long been understood that during continuous administration, there is a potential for physiologic dependence to develop over time,
is this sort of dependence so vastly different than occurs with other medications for chronic conditions, such as certain antidepressants or cardiac agents and many other long-term pharmacotherapies?
Would a fully informed patient with chronic pain, knowing the risks of dependence, still consent to long-term opioid therapy? Without the prospect of better, more effective alternative therapies, it might be surmised that a great many patients would likely answer “yes.”
Even if I knew opiates would take 10 years from my life, I would still take them. 10 years of pain without opiates are a punishment, not a blessing.
Of course, a key difference is that persons with depression or heart conditions typically do not have to worry about receiving ongoing and adequate prescriptions for their medications;
the continuation of adequate opioid therapy for chronic pain is much less certain in today’s climate of opioid regulation
Furthermore, in an interesting article on the subject, Alford et al.  describe a condition of “therapeutic dependence” whereby patients exhibit what is considered drug-seeking because they fear the reemergence of pain and/or withdrawal symptoms from lack of adequate medication; their ongoing quest for more analgesics is in hopes of insuring an acceptable level of comfor
Both “therapeutic dependence” and “pseudo-opioid resistance” only occur because these medications are considered “voluntary” by many in the medical profession. For those of us with a lifelong severe pain condition, they are as voluntary as insulin for a diabetic.
These authors also propose “pseudo-opioid resistance” as describing patients with adequate pain control who continue to report pain or exaggerate its presence, as if their opioid analgesics are not working, to prevent reductions in their currently effective doses of medication.
Psychological and physical dependence may arise independently of addiction in persons with pain, and problematic opioid use and other aberrant behaviors once thought to be cardinal symptoms of addiction or substance abuse are inapplicable in the pain management setting.
A body will become tolerant and dependent on many ingested substances, such as coffee, laxatives, and anti-depressants, and anyone who has ever tried to stop taking these will have confronted some nasty withdrawals. None of this has anything to do with addiction.
in some cases, tolerance may relate more to disease progression or a change in pain status requiring added medication and can be mistaken for analgesic tolerance
“One of the great difficulties of quantifying, recognizing, and treating iatrogenic opioid addiction is the subjective nature of the judgment on whether behaviors have crossed an ill-defined boundary between problematic opioid use and addiction. This judgment then becomes dependent on the reporting person’s experience, prejudices, and knowledge.”
Much addictive behavior is actually desperation.
if symptoms that could be related to seeking pain relief are discounted, radically fewer patients meet criteria for addiction.
it still might be expected that substance abuse or addiction could be present in the population of persons with chronic pain to an extent worthy of concern. This is accepting that the prevalence of abuse/addiction in persons with pain might match that of the general population, which some authorities estimate to be 13%
the opioid itself is only one component of much more complex circumstances involving psychosocial, genetic, and other factors that foster addiction.
Addiction is independent of the particular substance.
Opium and its opiate derivatives were openly and legally used in the U.S. and many other countries until the beginning of the 20th century, and alcohol was thought to cause far more health damage — in fact, opium or morphine was used as an alcohol substitute to treat alcoholics.
in August 2011, the American Society of Addiction Medicine (ASAM) came out with a new Policy Statement [here] presenting their definition of the disease of addiction. The short version states:
“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.”
In further comments, Dr. Leavitt adds:
It appears that erroneous understandings of addiction are being used as one more reason in a lopsided dialogue to curtail the prescribing of long-term opioids for chronic noncancer pain.
if you developed severe diabetes, would that doctor say you are too young to go on insulin for the rest of your life? Or, if you developed clinical depression, would antidepressants be forbidden? While long-term opioid analgesics may not be the only or the best course of treatment for everyone, the prejudices and ignorance surrounding that therapy among some practitioners are rather frightening.