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11 Articles in Volume 10, Issue #9
Activated Glia: Targets for the Treatment of Neuropathic Pain
Acute Herpes Zoster Neuritis and Postherpetic Neuralgia
Acute Treatment of Cluster Headache
Chronic Overuse Sports Injuries in the Adolescent/Pediatric Population
Clinical Recognition of Central Abnormal Neuroplasticity
H-Wave® Stimulation: A Novel Approach In Electromedicine
Homeopathy Enters Contemporary Pain Practice
Immune-modulating Effects of Therapeutic Laser
Pain and Addiction: Words, Meanings, and Actions in the Age of the DSM-5
Partial Plantar Fasciectomy With Autologous Platelet Concentrate
Tethered Spinal Cord Syndrome: Pathophysiology and Radiologic Diagnosis

Pain and Addiction: Words, Meanings, and Actions in the Age of the DSM-5

Over the past years, I have focused this column on how the nature of pain—as a symptom, disorder and manifest illness—gives rise to both certain moral responsibilities of care and ethical, legal and social issues, questions and problems that affect the pain patient, clinician and profession and the practice of pain management. Intrinsic to my position is that pain reflects (and perhaps is resultant from) the proverbial “mind-body” problem, at least in part, in that a description and explication of the physiological mechanisms and processes of pain fails to completely capture the subjective experience of the pain patient. To be sure, the subjectivity-objectivity gap is manifest in attempts to assess and treat pain and its resultant effects.1

The Nosology of Pain

Nosological descriptions and categorizations of pain and pain syndromes provide important insights to the pathophysiological substrates that contribute to, and are involved in, particular types of pain and so recent efforts to sharpen these classifications are noteworthy and important.2,3 Yet, the clinical and existential benefit of such nosologies and taxonomies (to the clinician and perhaps, most importantly, the patient) remain limited without further explanation of the potential biological, psychological—and perhaps social—manifestations that any pain disorder can, and often will, incur.
Our group and others have posed the viability of a “spectrum construct” that depicts the complexity of substrates and mechanisms that contribute to and evoke pain as a co-morbid constellation of physical and psychological features, signs and symptoms.4-6 Our hope is that clarification of these variables will create a more salient description of pain that enables a more meaningful approach to assessment and therapeutics. But however useful such a nosological nomenclature may be to pain care, it is still situated within more encompassing descriptive frameworks of medicine and, ultimately, society at-large. Thus, it becomes important to consider if—and how—certain terminologies and descriptors are aligned or misaligned with extant terms, concepts and constructs, and the ideas and implications that they generate and/or sustain.

The Language Game and Diagnosis

The philosopher Ludwig Wittgenstein argued that words, in and of themselves, do not have meaning, per se, but rather, assume meaning through the way(s) in which they are used: “…in the practice of the use of language, one party calls out the words, the other acts on them. I shall…call the whole, consisting of language and the actions into which it is woven, the ‘language-game.’ Now what do the words of this language signify? What is supposed to show what they signify, if not the kind of use that they have?”7 Diagnosis—stemming from the antiquarian Greek diagignoskein (to distinguish)—ascribes to and enables this game. In essence, diagnosis applies the language game to the context and activities of medicine. The act of diagnosis links a name to a set of features, frames the term within the boundaries of that set of features, and makes particular claims about what these features “mean.” Such “meaning” is imparted by the signification of the diagnostic term to the clinician (i.e., “What is wrong with this patient and what can and should be done to treat her?”), the patient (i.e., “How will this condition affect my life; what do I know of others with this condition?”), and to society (i.e., “Patients with this condition are called X, and are viewed in particular ways”).8,9

Physician-philosopher John Z. Sadler states that in this way, diagnosis (as a verb) is an epistemic act that reveals and interprets information and, as a noun, is a denotative-signifier that fosters classification.10 In relating these dimensions of diagnosis to the dynamic relationship between knowing and doing, Jay Rosenberg has argued that “diagnosis demands action” which, in the medical context, is actualized through the reciprocity of treatment and prognostication (i.e., a “knowing ahead” to speculate upon the effects of care upon the future course of illness).11 However, I have stated before, and re-claim here, that medicine is not enacted in a social vacuum and therefore we must ask and reflect upon the ways that current and proposed diagnostic schemas can affect, and are affected by, social and legal meanings, values and attitudes.12,13

The DSM-5

The Fifth Edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (i.e., the DSM-5) is currently in phase I field trials, with phase II trials scheduled for 2011 and 2012. Pending university and solo practitioner-setting field trials’ revision, the DSM-5 is scheduled to be released for open use in mid-2013. The DSM-5 is the culmination of a 10-year planning process that conjoined the American Psychiatric Association, National Institutes of Health (NIH), World Psychiatric Association (WPA) and the World Health Organization (WHO) in evaluating the relative merits, limitations, and weaknesses of the DSM-IV toward developing and implementing a new series of assessment and diagnostic criteria that would be coordinated with International Classifications of Disease (ICD) categories. While the planning committee(s) recognized the benefit of (some level of) continuity with the prior edition of the DSM, it was deemed equally important to not limit the formulation of clinically useful, research-based new criteria, and thus the scope and extent of changes from the DSM-IV were not restrained, a priori.14

In the main, the DSM-5 aims to establish clearer boundaries between normal and pathologic states, assume a more biologically-based, nosological categorization of psychiatric disorders, recognize disorders’ spectra, and thereby (1) appreciate signs and symptoms that cut across various conditions, and (2) institute dimensional classifiers that better describe presentation of characteristic features of spectrum pathology. While many classifications of the DSM-IV remain unchanged, several categories have been revised, a number have been eliminated and new classifications added. While a complete review of the DSM-5 is beyond the scope of this essay,15 two diagnostic categories of the DSM-IV that will be revised are of particular importance to pain medicine, namely Pain Disorder, and Substance Abuse/Dependence.

Pain Disorder

Pain Disorder (Associated with Psychological Factors and with Psychological Factors and General Medical Condition; see DSM-IV descriptions provided in Table 1) will be subsumed under the new broad category of Complex Somatic Symptom Disorder (see Table 2).

Table 1. DSM-IV(TR) Categories of Pain Disorders

Pain Disorder Associated With Psychological Factors (307.80): psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a general medical condition is present, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) This type of Pain Disorder is not diagnosed if criteria are also met for Somatization Disorder. Pain Disorder Associated

With Psychological Factors and General Medical Condition (307.89): both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The associated general medical condition or anatomical site of the pain is coded on Axis III.

 

Table 2. Proposed DSM-5 Revisions:
Pain (Disorder) as a Component of Complex Somatic Symptom Disorder

Complex Somatic Symptom Disorder (CSSD) to include DSM-IV diagnoses of:
  • Somatization disorder
  • Undifferentiated somatoform disorder
  • Hypochondriasis
  • Pain disorder associated with both psychological factors and a general medical condition, and
  • Pain disorder associated with psychological factors
To meet criteria for CSSD, criteria A, B, and C are necessary:

A. Somatic symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.

B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least two of the following are required to meet this criterion:

  1. High level of health-related anxiety.
  2. Disproportionate and persistent concerns about the medical seriousness of one’s symptoms.
  3. Excessive time and energy devoted to these symptoms or health concerns.

C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic (at least 6 months).

For patients who fulfill the CSSD criteria, the following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:
  • Predominant somatic complaints (previously, somatization disorder)
  • Predominant health anxiety (previously, hypochondriasis). If patients present solely with health-related anxiety with minimal somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder.
  • Predominant pain (previously pain disorder). This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.
For assessing severity of CSSD, metrics are available for rating the presence and severity of somatic symptoms.

Therein, Pain Disorder will remain a sub classification defined as: “…reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B (i.e.- Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns.) Patients with other presentations of pain may better fit other psychiatric diagnoses such as major depression or adjustment disorder.”16

While these new categorizations are not problematic in and of themselves, I believe that it is important to recall the operational definition of pain provided by the International Association for the Study of Pain (IASP), which states that pain is ”…an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. It is unquestionably a sensation…but it is also always unpleasant and therefore also an emotional experience.”17

The inextricability of the psychological experience and physiological event of pain is important to any construct or conceptualization of its presentation and diagnosis. Thus, while physical insult may occur anywhere along the nociceptive neuraxis, somewhat colloquially it is not erroneous to consider that pain (qua pain; i.e. , as a noxious experience with emotional manifestations) is always “in the head.” This is not to minimize the event or castigate the sufferer as being factitious or a malingerer. In fact, I have argued to the contrary that a deeper and more meaningful appreciation of the neurocognitive dimensions of pain are important to 1) insuring the primacy of patients’ best interests in the selection and provision of care; 2) re-establish the necessary multidisciplinary resources to assess and treat pain as a multi-factorial, bio-psychosocial disorder, and 3) de-stigmatize psychiatric and psychological approaches to pain care—and the patients who require and obtain these services.18 To be sure, the DSM-5 may offer an opportunity to both better characterize pain and, in this way fulfill the active role of diagnosis in framing and claiming the type and extent of care required. For example, an Axis I diagnosis of chronic pain as a presentation of CSSD—when coupled to an Axis III general medical condition (such as diabetogenic neuropathy) and/or Axis IV psychosocial stressors—would certainly depict pain as a complex, multi-dimensional and multi-symptomatic disorder.

However, while the changes proposed for DSM-5 are intended to clarify diagnosis of pain syndromes, I wonder whether pain medicine—if not the medical field and its administrative and economic infrastructures (i.e., insurance providers, etc) more generally—are “prepared” for such change(s). Simply put, without a preemptive, or at least concomitant, shift in the current climate and conduct of pain care to recognize the profoundly interactive physiological and psychological dimensions and presentations of pain (and the pain patient), I fear that the nomenclature and descriptions used to define pain disorders in the DSM-5 might create ambiguity concerning 1) the “reality” of pain, 2) the need for both physiological and psychological care, 3) the type (and exigencies) of pharmacotherapeutics required, and 4) the disposition of economic resources necessary to sustain such approaches.

Opioid Use, Abuse, Dependence and Addiction

These issues are brought to the fore when considering the proposed DSM-5 changes to classifications of substance use/abuse/dependence disorders. Without doubt, the categories used in DSM-IV(TR) were less than wholly adequate (see Table 3) and there has been, and continues to be, debate about the validity and merit of terms such as “abuse,” “dependence,” and “addiction” in pain medicine, psychiatric and non-psychiatric medical contexts. Reiteratively, the intended goal(s) of the DSM work group on Substance Use Disorders was to impart some homogeneity of meaning and thus clarify the terms used to describe 1) physiological properties of rightward shifts in dose-response effects as a consequence of repeated administration of opioids (under medical supervision); 2) inappropriate unsupervised use of opioid agents (even if prescribed); and 3) physiological and psychological craving and compulsion for opioids (and/or other drugs; see Table 4).

Table 3. DSM-IV Classification of Opioid Abuse and Dependence

Opioid Abuse. One or more of the following symptoms must occur at any time during a 12-month period (and cause significant impairment or distress) in order to meet diagnostic criteria for opioid abuse:
  • Interference with role fulfillment: The individual’s use of opioids repeatedly interferes with the ability to fulfill obligations at work, home, or school.
  • Danger to self: The individual repeatedly uses opioids in situations in which it may be physically hazardous (for example, while driving a car).
  • Legal problems: The individual has recurrent opioid-related legal problems (such as arrests for possession of narcotics).
  • Social problems: The individual continues to use opioids despite repeated interpersonal or relationship problems caused, or made worse, by the use of opioids.
Opioid Dependence. Three or more of the following symptoms must occur at any time during a 12-month period (and cause significant impairment or distress) in order to meet diagnostic criteria for opioid dependence:
  • Tolerance: The individual either has to use increasingly higher amounts of the drug over time in order to achieve the same drug effect or finds that the same amount of the drug has much less of an effect over time than before.
  • Withdrawal: The individual either experiences the characteristic abstinence syndrome (i.e., opioid-specific withdrawal) or the individual uses opioids or similar-acting drugs in order to avoid or relieve withdrawal symptoms.
  • Loss of control: The individual either repeatedly uses more opioids than planned or uses the opioids over longer periods of time than planned.
  • Inability to stop using: The individual has either unsuccessfully attempted to cut down or stop using the opioids or has a persistent desire to stop using.
  • Time: The individual spends a lot of time obtaining opioids, getting money to buy opioids, using opioids, being under the influence of opioids, and recovering from the effects of opioids.
  • Interference with activities: The individual either gives up or reduces the amount of time involved in recreational activities, social activities, and/or occupational activities.
  • Harm to self: The individual continues to use opioids despite having either a physical or psychological problem (depression, for example) that is caused or made worse by the opioid use.

 

Table 4. DSM-5 Proposed Substance Use Disorder (Including Opioids)

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

3. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

4. Tolerance, as defined by either of the following:

  1. need for markedly increased amounts of the substance to achieve intoxication or desired effect
  2. markedly diminished effect with continued use of the same amount of the substance (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)

5. Withdrawal, as manifested by either of the following:

  1. characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
  2. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)

6. Substance is often taken in larger amounts or over a longer period than was intended

7. There is a persistent desire or unsuccessful efforts to cut down or control substance use

8. Great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects

9. Important social, occupational, or recreational activities are given up or reduced because of substance use

10. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

11. Craving or a strong desire or urge to use a specific substance

Severity specifiers:
  • Moderate: 2-3 criteria positive
  • Severe: 4 or more criteria positive

Specify if:

  • With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
  • Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)

Charles O’Brien, chair of the work group, has stated that clarification of these terms will be important to differentiate patterns of opioid use observed in chronic pain patients and that the DSM-5 terminology will be useful in ensuring that pain patients are not deprived or denied the proper pharmacological treatment(s) they require.19,20 I agree with Dr. O’Brien but remain cautious for a number of reasons. First, there is a building body of evidence to suggest that certain pain patients may be predisposed to opioid insensitivity due to pain-induced changes in endogenous analgesic substrates.21 Such patients may require fairly high doses of opioids that must be frequently rotated and/or escalated to elicit therapeutically relevant effect(s). As O’Brien has noted, “…some types of physical dependence are completely normal for some medications such as opioid painkillers.”22 This undergirds my second concern: given that opioid prescription remains one of the most legally contentious areas of pain care, I believe that problems can and will arise if the final accepted nomenclature for these disorders is re-titled “Addiction and Related (Substance Use) Disorders,” as had been proposed at one point. As O’Brien, Volkow, and Li rightly claim: “…addiction is a perfectly acceptable word” when used in appropriate medical contexts.23 However, as these authors note, the term “addiction” is not only socially pejorative but may incur medical and legal implications and burdens, as well.

The DSM-5 work group on Substance Use Disorders has “…had extensive discussions on the use of the word ‘addiction.’ It has been confusing to physicians and has resulted in patients with normal tolerance and withdrawal being labeled as ‘addicts.’ This has also resulted in patients suffering from severe pain having adequate doses of opioids withheld because of fear of producing addiction.”24 Here we once again confront Wittgenstein’s language game in practice. The naming, framing and claiming functions of diagnosis can also generate “blaming” effects and significant problems can arise when a physician is (a) confronted with a patient who has been diagnosed as having “addiction” (and thus labeled “an addict”) and/or (b) chooses to accept and treat such a patient. The clinician is faced with the “to treat or not to treat” question and all of the medico-legal ramifications that follow thereafter (potential medical and legal sanctions; dealing with issues of abandonment, etc.).24 This speaks to my third concern: the proposed DSM-5 classifications of pain disorders (i.e., as a Complex Somatic Symptom Disorder), either alone or in combination with Addiction and Related Disorders/Substance Use/Opioid Use Disorder, may implicitly ascribe pain to a psychological malady and may bias clinicians against the use of opioids—or not treating such patients altogether for fear of incurring medico-legal sanction. Of course, even addicted patients can suffer pain and the presence of the former is not prima facie justification for refusing to care for the latter. However, in the current environment of pain care, this situation is becoming increasingly common and so the question is not “to treat or not to treat?” but how to treat the pain patient who is on escalated doses of opioids (in ways that are biomedically right, ethically sound, and within the parameters of professional guidelines and the law)?

A Path Forward: From Words to Action

Clearly, the DSM-5 has been developed to enhance diagnostic acumen and, in so doing, establish better criteria from which to plan and execute clinical care. But perhaps the more important issue is whether medicine is prepared to accept the responsibilities of providing and insuring care for more precisely-defined disorders. Clarifying pain as a complex somatic disorder is at least intuitively appropriate, as this classification reflects the activity and effects of multiple neural, endocrine, and immunologic substrates. Similarly, identification of the role and effects of psychological factors in pain is critical to both its definition and treatment. The same can be said of substance use disorders and addiction. Clarifying diagnostic terms is vital to standardize what they signify. But as Rosenberg argues, diagnosis demands action,25 and so merely establishing diagnostic definitions is at best little more than an academic exercise and, at worst, creates conditions that we are unprepared—or unwilling—to treat. The changes proposed by the DSM-5 should be seen as a call for pain management to assert the need for multi-disciplinary bio-psychosocial interventions, addiction medicine and personalized care. To quote Wittgenstein, “…one party calls out the words, the other acts upon them.”26 For once we engage the language game, we are also bound by the rules.

Last updated on: March 7, 2011
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