Trajectories — Opioids: A Population Health Dilemma
Staff Contact: Alison Williams
The March issue of Trajectories discusses how opioids are a population health dilemma not only in Missouri, but also nationwide. Addiction is poorly defined. Several leading pain management organizations developed a consensus definition regarding addiction — a “primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations.” Characteristic behaviors include impaired control over drug use, compulsive use and continued use despite harm and craving. Addiction differs from physical dependence, which is a “state of adaptation manifested by a specific withdrawal syndrome produced through abrupt cessation, rapid dose reduction, decreasing blood levels of the drug and/or administration of an antagonist.” Physical dependence is expected in patients with chronic opioid treatment, but should not be assumed as a sign of addiction. The idea of “pseudoaddiction” describes behaviors commonly witnessed in hospital emergency departments and clinics — repeated requests for higher doses, running out of medications early, taking more than prescribed, etc. — stemming from undertreatment of pain. This is an important distinction to consider, as ineffective pain control and the resultant drug-seeking behavior lead to labeling patients as addicted to opioids and a belief that pain and addiction cannot occur simultaneously. Finally, the concept of aberrant drug-related behavior, while still poorly defined, should be considered. Doctor shopping, “losing” prescriptions, tampering with prescriptions, demanding behaviors and positive urine toxicology results for illicit drugs and/or negative results for prescribed opioids, are all signs of ADRB. Patients who engage in ADRB may be addicted or have physical dependence on prescription narcotics, or may be diverting them for sale. Patients undergoing chronic opioid treatment may exhibit signs of all four clinical syndromes, but each requires different treatments to manage causal factors.
Each of these four clinical syndromes are not believed to be caused by a single factor. Rather, a combination of genetic, environmental and physical factors are believed to make a person more susceptible to misusing opioid prescription drugs leading to possible addiction or addiction-like behaviors.
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