Part III: Dependence and Addiction
Series Introduction – Appriss Health has long held that chronic pain and addiction (substance use disorder) are separate medical conditions and that each deserve a unique clinical approach. We have spent years developing clinical decision support tools and in doing so have obtained the feedback from countless medical professionals, including many pain providers. Through those providers we have also heard (directly and indirectly) from many chronic pain patients as well.
To continue this conversation, over a long series of blog posts, we will explore our approach to benefit/risk assessment, data presentation, and clinical support…and how they relate to our goal of creating a usable and balanced, clinical viewpoint that protects access to care while highlighting areas of risk that clinicians and patients should be aware of.
“Will I get addicted?”
In the emergency department, I’ve been asked this question many times. It usually gets asked during a conversation about treating chronic (and sometimes acute) pain, and it usually goes something like this:
Me: Well… There are many ways to treat pain, the best of which is to eliminate the source. Eliminating the source of pain may be accomplished through physical therapy, medical massage, stretch and strengthening, and other treatments. Sometimes time itself is all that is needed. While sometimes patients need surgery or other more invasive treatments. When the source of pain cannot be eliminated, it is still best to work to minimize the pain as much as possible without opioids, and then consider them if it’s still needed to get the pain down to a level where you can function and have a good quality of life. Importantly, it may not be the best course of action to strive for eliminating all pain, but rather you should take medications to achieve a good balance between tolerable pain and quality of life.
Patient: Okay, I get it, but I’ve tried everything including physical therapy and no one will operate on me. They say nothing can be done. They want me to take pain medications but I’m afraid of becoming addicted, of getting hooked on them.
Me: It’s good to be cautious. There are many risks and benefits of opioids to consider but it’s important to understand the difference between addiction and dependence. Dependence is fully expected if you take opioids for a long time. What that means is your body gets used to the medication being present, so much so that your body now depends on it being there. If you were to abruptly stop taking it, you would probably go through withdrawal. But, that doesn’t mean you’re addicted. Addiction can be hard to describe, and is often referred to as “substance use disorder”… It is more of a combination of detrimental actions, behavioral changes, and patterns of thoughts associated with the use of a medication or substance. Addiction ruins whatever quality of life you were hoping to achieve. Everyone who takes opioids for a long time becomes dependent, but not everyone becomes addicted.
Patient: You mean you can go through withdrawal even if you’re not addicted?
Patient: How do I know if I’m going to become addicted?
Me: You don’t know. And, it’s hard to predict. If you’ve had a problem with other substances like alcohol, tobacco, or other drugs in your life then you’re at an increased risk. Other things like a history of depression, or post-traumatic stress also increase risk. There are formal assessments that can and should be done before starting on opioids. Again, it’s not a simple decision.
Patient: Why do you say I shouldn’t strive to be out of pain entirely?
Me: In general, opioids for chronic pain should be used at the minimum dose needed to accomplish your ADLs (Activities necessary for Daily Living – like walking, bending, sitting, shopping, cooking, eating, brushing your teeth, etc.) and have a good quality of life. Only you can decide what that level of “good” is, but the higher the dose of medication you take, the greater the risks. Additionally, one related issue to dependence is tolerance, which means that after a while, your body tends to require higher opioid doses for the same effect, so you should leave room for increases over time
This is the typical conversation I’ve had in the ED with patients (and typing it out makes me realize how much doctors talk compared to patients, something else that has been in the news lately).
The important points I’m trying to convey when I have these talks with patients are:
- Opioids are not without risks when used for chronic pain. You and your doctor should talk about the benefits and risks and decide together if they’re appropriate.
- If you both decide to use opioids, you as a patient should expect to become dependent on them, but that shouldn’t deter you if that is your only or best option.
- Opioid use should improve your quality of life. If opioids become more of a problem than a solution for you, your quality of life may be much worse than not taking them at all.
- You should define the goals you’re trying to obtain (being able to work, being able to stand for 30 minutes or walk for one mile, being able to hold your grandchild, etc.) and convey them to your doctor. Then strive for the lowest dose necessary to obtain those goals.
As an emergency physician, I am usually meeting my patient for the first time. If pain or altered mental status is a part of the reason for the visit I often check the state’s prescription drug monitoring program (PDMP) even if I don’t anticipate prescribing opioids or other medications. Years ago, I helped design a program that made both checking the PDMP and understanding the patient’s prescription history easier.
Next up, in blog post number IV, we’ll examine PDMPs a bit more closely and begin to look at how we at Appriss Health have taken great efforts to make sure the information in the PDMP is presented in a useful, balanced manner to help patients and providers alike.
To read more on this series: