Opioid dependence and addiction during opioid treatment of chronic pain

Abstract

Throughout the long history of opioid drug use by humans, it has been known that opioids are powerful analgesics, but they can cause addiction. It has also been observed, and is now substantiated by multiple reports and studies, that during opioid treatment of severe and short-term pain, addiction arises only rarely. However, when opioids are extended to patients with chronic pain, and therapeutic opioid use is not confined to patients with severe and short-lived pain, compulsive opioid seeking and addiction arising directly from opioid treatment of pain become more visible. Although the epidemiological evidence base currently available is rudimentary, it appears that problematic opioid use arises in some fraction of opioid-treated chronic pain patients, and that problematic behaviors and addiction are problems that need to be addressed. Since the potentially devastating effects of addiction can substantially offset the benefits of opioid pain relief, it seems timely to reexamine addiction mechanisms and their relevance to the practice of long-term opioid treatment for pain. This article reviews the neurobiological and genetic basis of addiction, its terminology and diagnosis, the evidence on addiction rates during opioid treatment of chronic pain and the implications of biological mechanisms in formulating rational opioid treatment regimes.

Defining Racial and Ethnic Disparities in Pain Management

“…(4) While opioid analgesics are only one of several pain treatment modalities included in the biopsychosocial model of pain management articulated by Gallagher [35] and now being recommended as the model for pain care at the Veterans' Affairs [57], the careful use of such drugs has been endorsed for relief of acute postoperative cancer and chronic nonmalignant pain by professional and public health agencies including the American Academy of Pain Medicine [22], the American Pain Foundation [1], and the World Health Organization (WHO) [106]. Assumed and empirically documented risks of abuse, dependency, or medication diversion have made many physicians fearful and reluctant, or even unwilling, to prescribe opioids [5,8,13]. (5) Most physicians have not had sufficient training in the neurobiology of pain or the clinical approaches to effective pain management to be comfortable providing care to a complex pain patient [13,100].…”

Measurement of adherence to clinical practice guidelines for opioid therapy for chronic pain

“…Other problems include misuse, litigation against physicians, and overdose [4,5]. Misuse can include a wide array of behaviors [6,7], such as abuse, addiction, potentially harmful use patterns, and problematic nonuse, each of which has medical, social, and functional consequences for the users, their loved ones, and the public. Some misuse behaviors can lead to serious health consequences, ranging from poor management of pain to death.…”

Patterns of pharmacotherapy and health care utilization and costs prior to total hip or total knee replacement in patients with osteoarthritis

“…Approximately 60% of patients received opioids at some point during the 2-year period prior to joint replacement, with use increasing substantially as (13), and concern about dependence (14,15), opioids are usually reserved for persons with pain refractory to treatment with other medications and/or nonpharmacologic interventions (2,14,15). Given that all patients in our study ultimately opted for joint replacement, our findings suggest that levels of pain in this patient population could not be well managed with currently available therapies.…”