Tolerance Dependence And Addiction

The continued use of opioids leads to tolerance, in which increasingly higher doses of drug must be used to obtain the original level of pain relief. Tolerance develops slowly, occurring over a period of months to years. Cross-tolerance to other opioids develops, although to a lesser extent. Tolerance can be differentiated from physical dependence and addiction.

Physical dependence is a characteristic of opioid use because of the mode of action. It reflects a state of neurological adaptation to the drug. With physical dependency, discontinuation of opioid use leads to withdrawal symptoms (e.g. sweating, tearing, rapid heart rate, nasal discharge, abdominal cramps, nausea, and vomiting). To prevent withdrawal symptoms, patients on long term opioid use are gradually weaned off the medication. Physical dependence on opioids does not lead to addiction, although it may compel the patient to seek opioids to relieve symptoms of withdrawal.

For chronic pain patients taking opioids, tolerance and physical dependence are not indicators of addiction. Addiction is not a characteristic of opi-oid use, rather, it is dependent upon the user. In fact, the medical use of opioids is only very rarely associated with addiction. The agonist-antagonist class of opioids (buprenorphine, butorphanol, nalbuphine, pentazocine, and dezocine) has a low abuse potential.

Any patient taking opioids to treat chronic pain can meet the criteria for addiction set forth by the American Psychiatric Association in the Diagnostic and statistical manual of mental disorders: DSM-IV. Therefore, it is very difficult to diagnose addiction in chronic pain patients who are taking opi-

oids. Chronic pain patients who are being ineffectively treated could display the drug-seeking behavior that is characteristic of addiction, a phenomenon called pseudoaddiction. Alternatively, the patient receiving effective pain treatment may take extreme measures to insure an adequate supply of medication. This behavior is termed therapeutic dependence.

Suggestive signs of addiction within the context of opioid therapy for chronic pain include:

• Loss of control over opioid use;

• Preoccupation with the use of opioids despite adequate pain control; and

• Continued use of opioids even with their adverse consequences.

BIBLIOGRAPHY

Ashburn, M. A. & Rice, L. J. (1998). The Management of Pain. New York, NY: Churchill Livingstone. Ashburn, M. A. & Staats, P. S. (1999). Management of chronic pain. Lancet, 353, 1865-1869. Gallagher, R. M. (Ed.) (1999). The medical clinics of North America: Chronic pain. Philadelphia, PA: W. B. Saunders Company.

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