INFO - Addiction versus dependence: A call for public education

[Guest guest]

About.com

Headaches/Migraine

from Proctor

" Addiction versus Dependence: A Call for Public Education " :

People are suffering and dying as a result of misinformation. It must stop.

Pain creates a devastating situation for sufferers and those around them.

Pain, especially chronic pain, is a debilitating, very dehumanizing

condition. Albert Schweitzer said, " Pain is a more terrible lord than death

itself. " The more severe the pain, the more it may overshadow one's

intelligence. All one thinks about is the pain: there is no past, no

pain-free memory, no pain-free future, only the pain-filled present. Pain

destroys autonomy: the person is afraid to make the slightest movement. All

choices are focused on either relieving the current pain or preventing

greater future pain and for this one will sell one's own soul.

According to the National Foundation for the Treatment of Pain (NFTP)

chronic pain is almost universally accompanied by anxiety and depression.

Suicide is not uncommon. Chronic pain is also a damaging, and even deadly,

destructive disease with physical, psychological, and behavioral

consequences. Chronic pain compromises the immune system and slows healing.

It causes cell damage and death. Untreated pain " rewires " the nervous system

so that even when the original cause of pain is removed, pain may continue.

This " rewired " pain can be even harder to treat than the original cause.

Chronic pain is costly to our society, affecting as many as 50 million

Americans to the extent that they cannot work productively and become either

partially or fully disabled. It's one of the most frequent causes for Social

Security Disability Insurance claims and dramatically affects state, federal

and private health care costs. The NFTP estimates the total cost of

untreated and under-treated pain approximates $100 billion a year

attributable to lost workdays, excessive or unnecessary hospitalizations,

unnecessary surgical procedures, inappropriate medication and

patient-incurred expenses from self-treatment.

Untreated and under-treated pain is widespread in the U.S.. Experts estimate

as much as 95% of all pain can be reduced to manageable levels. Yet, it

isn't. An American Pain Society survey in 1999 revealed 54 million adults

experience long-term moderate to severe pain annually, and only 25% received

adequate treatment.

As part of a well-intentioned, ongoing " War on Drugs " the majority of the

media and law enforcement community continue to promote a very limited view

of pain medication and its use/abuse. The one-sided portrait they paint

includes only negatives such as misdirected prescriptions, illegal use/abuse

and addiction, not to mention the horrible consequences associated with such

behaviors. Their crusade to educate the public and medical community of the

perils of prescription drug abuse in some situations causes much more harm

than it does good for it drives pain sufferers away from the proper

treatment of their condition.

Opioid medications can be extremely effective against many types of pain.

They are, among many other uses, one of the last lines of defense when back

or neck surgery is unsuccessful. As other medicines, from insulin to

aspirin, they too have side-effects and must be carefully managed and taken

only as prescribed.

A couple of factors, including the fear of their patient becoming addicted

and/or a fear of sanction or prosecution, substantially reduce physicians'

willingness to prescribe narcotics and, to some extent, the patient's

willingness to accept narcotic therapy. These have been exacerbated by the

recent hysteria in the media surrounding the OxyContin.

Fear of addiction... There is a belief dramatically fostered within the

United States by the spread of misinformation that anyone who takes opioid

medications is at substantial risk of addiction. In fact, the rate of

addiction amongst those who are treated by a doctor with opioid medications

is no greater than that of addiction in the general population. According to

the National Council on Alcoholism and Drug Dependence there is a solid body

of clinical evidence that patients with a history of substance abuse or

alcoholism may have a genetic predisposition to poor control of their

medications and to addiction. Physical dependence and tolerance are

different matters: anyone who repeatedly takes opioids, whether for

medication or to feed their addiction, more than likely will become

physically dependent on the medication and encounter withdrawal if he/she

stops taking it abruptly.

Ability to function divides the addict from the physically dependent pain

patient. The Florida Board of Medicine explains addiction is characterized

by " compulsive use, despite harm. " Addicts become socially less functional

as the drug takes over their lives. All thought revolves on where their next

dose is coming from. Addicts are less able to handle their jobs, family

obligations and social participation.

In stark contrast, patients taking opioids to relieve pain usually become

more functional, able to rejoin the lives of their families and community

and return to work. They're less depressed, less anxious and often view the

change as " life-saving " . Thus, the Florida Board of Medicine instructs

physicians that " tolerance and physical dependence are normal consequences

of sustained use of opioid analgesics and are not synonymous with

addiction. " This advice hasn't penetrated deeply even into the medical

community. The general public and majority of the media still equate

physical dependence and addiction; even those patients who have not been

well counseled by their doctors may wrongly believe they are addicted.

Even some patients now currently taking opioids as a component of their pain

management plan, haven't been taught that when properly prescribed and taken

as prescribed, opioids are very effective for the treatment of moderate to

severe pain.

They've only been exposed to the media, which tends to hype the dangers

(without mentioning that the problems almost always occur only when the

drugs are misused or abused) and causes a hideous stigma to be attached to

those who take opioids, legally or illegally. Out of prejudice, patients who

take opioids are assumed to be addicts. The label " addict " is highly

stigmatizing. Society is inordinately concerned with drug abuse, rightly so.

However, when the stigma spills over to affect the availability of proper

pain management to those who need it to function better, it becomes a

serious wrong. Pain patients have lost their jobs simply on the strength of

employer awareness that they take opioids.

To further cloud the differences between addiction and dependence, there is

a third issue that must not be overlooked. Pseudo-addiction or

pseudo-addictive behavior is a reaction to the harsh reality of the opioid

prescribing climate: doctors are afraid to prescribe opioids to therapeutic

levels for chronic pain patients. Across the U.S., doctors have been

arrested and jailed when patients lie to them about drug use/abuse or

intentions, and someone dies of an overdose. The law-enforcement mind-set

works to the great detriment of patients. Physicians aren't ignorant. Rather

than risk professional licenses or personal freedom, they routinely refuse

to prescribe opioids to patients they know would benefit from them. Those

who do prescribe opioids frequently self-impose a dose limitation that falls

short of therapeutic levels for the individual. These choices are ethically

and clinically wrong, but the chances may be good that a doctor who puts his

patient first may be putting himself legally or professionally in danger.

Legislative and Medical Board actions accepting and encouraging opioid use

for chronic pain seem worthless in a context of punitive and ill-informed

law enforcement. Physicians are well aware of instances where colleagues are

being " punished " by the law-enforcement community since those instances are

usually overly-well publicized by the media. Physicians are meant to be

healers, but fear their patients' misdeeds, and now must fear criminal

prosecution.

Many patients who are victims of doctor's fears will try to persevere.

Others feel driven to the pseudo-addictive behavior of doctor-shopping to

get a self-adjudicated therapeutic level of pain relief. This is harmful

since he/she is then deceiving their doctors and committing a crime. He/she

also foregoes the fully-informed medical management of any side-effects.

Though a crime, doctor shopping for pain relief is above all a victimless

one, committed by a patient who is a victim of a climate of fear. Many who

have untreated or under-treated pain will set out to find adequate pain

relief. What they feel forced to do is then labeled " drug seeking

behavior " - including " doctor shopping " and purchasing on the illegal market

(in the same way that both real addicts and the criminal drug diverters do).

One obviously cannot condone this but can well understand why it occurs. The

difference is that unlike addicts, for pseudo-addicted patients, when they

can find a way to adequately treat their pain, their ability to function and

the quality of their life improves dramatically.

There is only one solution, public education. It must be done on a large

scale through the media just as the highly stigmatizing campaign against

addiction/dependence was promoted. It must include distinctions between

dependence and addiction and highlight the fundamental causes of

pseudo-addictive behaviors. In addition, proper and reasonable pain

management parameters must be shared with governmental administration and

law enforcement community to dispel fears about pain medications and teach

that all opioid use is not bad. Education could further help to remove the

stigma associated with addiction by pointing to the fact that though it

doesn't reduce responsibility, addictive or compulsive behaviors may well be

genetics rather than choice.

http://headaches.about.com/od/advocacyissues/a/addict_depend.htm

Not an MD

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org