1. What is addiction?

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. This definition was accepted by the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine in February of 2001. It implies that addiction is neither tolerance nor physical dependence, but a more complex, biopsychosocial phenomenon.

2. Is addiction common in patients treated with opioid analgesics for chronic pain syndromes?

Regarding addiction in patients treated with opioid analgesics for chronic pain syndromes, prevalence figures in various studies have ranged from 1% up to 45%. The low end of the range was based on a study that looked only at patients who had received a single-dose of an opioid during a hospital stay for a non–drug-use-related problem. It is, perhaps, not a figure with great applicability, because it is far lower than the likely true prevalence of opioid addiction in the general population. The higher number was derived from a study that examined a small group of patients with a history of prior opioid addiction now treated with opioids for chronic pain. Although it is a strikingly high number, it also shows that up to 55% of patients—even with a prior history of addiction—can be treated successfully with opioids.

The real addiction risk lies somewhere in between these two figures and is determined by a number of factors. (See Chapter 34, Opioid Analgesics, for a discussion of the issues that must be taken into account when prescribing opioids for chronic pain of noncancer origin.) When opioids are used appropriately for pain management, the risk of de novo addiction is likely acceptably low.

As the work done by the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine has suggested, “Addiction, unlike tolerance and physical dependence, is not a predictable drug effect, but represents an idiosyncratic and chronic adverse reaction in biologically and psychosocially vulnerable individuals. Addiction is a primary chronic disease, and exposure to drugs is only one of the etiologic factors in its development.”

3. List the five main characteristics of addiction

The five C’s can be used as a memory aid for recalling the five main characteristics of addiction:

4. What is physical dependence?

Physical dependence is a state of adaptation that is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of antagonist. The presence of physical dependence does not, in itself, define addiction. It should be kept in mind that physical dependence is not unique to opioids.

5. What is tolerance?

Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. The presence of tolerance does not, in itself, define addiction.

6. A patient is using progressively higher doses of the opioids prescribed and is requiring prescriptions sooner than anticipated. What are some of the possible causes?

7. What is the utility of written medication agreements in patients suspected of opioid abuse?

Although a written agreement may provide some security to the prescriber, it can have mixed effects. It is unclear that it prevents abuse or that it would have any legal standing. In some patients, it may create an unneeded friction between the patient and physician. However, it can be used as a means for the prescriber to outline what he or she expects from the patient with respect to appropriate medication use.

8. What should be done if addiction is suspected?

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