FAST FACT AND CONCEPT #68: Is It Pain or Addiction?

2nd Edition

Author: David E. Weissman, MD

A very common requested educational topic by physicians, concerning pain, surrounds differentiating the patient in pain vs. the patient with a substance abuse disorder. The key to proper assessment lies in understanding 1) the definitions of tolerance, physical and psychological dependence (a.k.a. addiction), 2) the components of an addictions assessment and 3) the differential diagnosis of the symptom of “pain”.

Definitions

Tolerance: the need to increase a drug to achieve the same effect. In clinical practice, significant opioid tolerance is uncommon. Tolerance may be present in the pain patient or the addict; by itself it is not diagnostic of addiction.

Physical Dependence: development of a withdrawal syndrome when a drug is suddenly discontinued or an antagonist is administered. Most patients on chronic opioids will develop physical dependence; its presence cannot be used to differentiate the pain patient from the addict.

Psychological Dependence (Addiction): overwhelming involvement with the acquisition and use of a drug, characterized by: Loss of Control, Compulsive Drug Use, and Use Despite Harm . Data suggests that opioids used to treat pain rarely leads to psychological dependence.

Addiction (Substance Abuse) Assessment

Assess for addiction in the following domains. (see Sees and Clark) Note: one positive item from the list does not establish a substance abuse disorder, rather, the diagnosis rests on a pattern of behavior that includes several positive findings (see Passik, et al).

• Loss of control of drug use (has no partially filled med bottles; will not bring in bottles for verification)
• Adverse life consequences--use despite harm (legal, work, social, family)
• Indications of drug seeking behavior (reports lost/stolen meds, requests for high-street value meds)
• Drug taking reliability (frequently takes extra doses, does not use meds as prescribed)
• Abuse of other drugs (current/past abuse of prescription or street drugs)
• Contact with drug culture (family or friends with substance abuse disorder)
• Cooperation with treatment plan (does not follow-up with referrals, or use of non-drug treatments)

Differential Diagnosis

The differential diagnosis for a patient reporting “pain” includes physical causes (broken leg, sciatica, pseudoaddiction—see Fast Fact #69); psychological (depression, anxiety, hypochondriasis, somatization disorder, etc.); spiritual (impending death, grief); substance abuse; and secondary gain/malingering/criminal (desire for attention, disability benefit, or financial gain).

References

1. Sees KL and Clark HW. Opioid use in the treatment of chronic pain: assessment of addiction. J Pain Symptom Manage 1993; 8:257-264.
2. Savage SR. Addication in the treatment of pain: significance, recognition and management. J Pain Symptom Manage 1993;8:265-278.
3. Eisendrath. SJ Psychiatric aspects of chronic pain. Neurology 1995; 45: S26-S34.
4. Passik SD, Kirsh KL and Portenoy RK. Understanding aberrant drug-taking behavior: addiction redefined for palliative care and pain management settings. Principles and Practice of Supportive Oncology Updates 1999; 2: 1-12

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman DE . Is it pain or addiction. 2nd Edition. Fast Facts and Concepts #68; July 2006. End-of-Life / Palliative Education Resource Center www.eperc.mcw.edu .

Creation Date: 5/2002

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Pain>evaluation; psychiatric disorders

Specific Disease and Organ System Category(s): Psychiatric Disorders