The 5 Most Misunderstood Terms in Pain Medicine
I am happy to offer a perspective on 5 words or terms that are often used in reference to medication use and abuse, but are often misunderstood and incorrectly applied in clinical care. A consistently correct use of these terms will improve care, lessening a breakdown in communication.
1. Real Pain
Too often, people believe that pain is valid only if it has a known cause, such as a burn, broken bone, compressed disk, or arthritic joint. What about headaches? Low back pain? Phantom limb pain? These pain-producing conditions are widely accepted as real, yet the actual source of the pain is not visible or readily evident.
It is now understood (and validated by functional magnetic resonance studies)1,2 that pain may result from damage to tissue or nerves and/or manifest with psychological aspects such as post-traumatic stress disorder, any and all of which may produce pain that is very real.
In 2011, the Institute of Medicine published a paper on pain in which the authors stated: “Our committee recognizes the need for a transformed understanding of pain. We believe pain arises from the nervous system but represents a complex and evolving interplay of biological, environmental, and societal factors that go beyond simple explanation.”3
This view was reinforced by Davis and Vanderah,4 who made a case for approaching pain differently as “a new way of thinking about pain that occurs in the absence of a pathophysiologic process or injury that may alter our approach to conditions like fibromyalgia. Clinicians theorize that a functional change in the central nervous system (CNS) may occur in response to certain emotional states or traumatic experiences (eg, domestic violence, war, accidents). When such experiences occur, mildly painful stimuli may be amplified and processed through highly sensitized, dysregulated, ramped-up emotional and somatosensory pain circuits in the brain. Adverse childhood experiences (eg, physical abuse, sexual assault) can lead to long-term changes in the nervous system circuitry, particularly in pain processing.”
The bottom line: All pain is real, whether it’s physical and/or psychological, whether the source is evident or not. Instead of telling patients that the pain is “in your head,” we should be explaining that the pain is likely resulting from an overexcited nervous system, which is not unusual when pain becomes a chronic condition.
2. Dependence (Not Addiction)
Many years ago, dependence on a drug was understood to mean that taking the medication was a physical necessity. However, physical dependence has come to reflect a state in which the body responds to chronic use of a drug such that when the medication is stopped suddenly, a specific set of symptoms, or withdrawal symptoms, develop. Some withdrawal syndromes—for example, an abrupt discontinuation of corticosteroids—can be serious or even fatal, while other experiences, such as ending the use of opioids, may be very uncomfortable but are not life-threatening.
Some drug classes that produce withdrawal symptoms when stopped abruptly are potentially addictive (eg, opioids, benzodiazepines, alcohol), while other medications (eg, prednisone, paroxetine) are not associated with abuse or addiction. Simply put, physical dependence is not the same as addiction, nor do these physical responses automatically go hand in hand.
Furthermore, a physical dependence is not necessary to make a diagnosis of addiction, although most addictive drugs can also produce withdrawal syndromes when stopped suddenly. The way to avoid withdrawal symptoms is to taper or wean the patient off the medication gradually. Tapering also permits the body to adjust slowly and to return to its prior physiological condition. For example, reducing the dosage of prednisone permits the body time to resume production of endogenous steroids.
Confusion Between Physical Dependence and Addiction
Addiction, by contrast, is a different phenomenon from physical dependence and is defined primarily by psychological criteria. Its main elements are:
- Loss of control, or compulsive use. The individual takes more of the medication than intended and has difficulty deciding not to use the drug.
- Continuation despite significant adverse consequences, such as relationship problems, medical side effects, or legal problems.
- Preoccupation or obsession with obtaining, using, and recovering from the effects of the substance, so that the quality of life diminishes.
Why do most people, including most health professionals, erroneously believe that addiction will occur in most patients who are treated with opioids for more than a short time?
The reason may originate from publication of the American Psychiatric Association’s 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which gave the disease of addiction a new name: dependence.5 Patients with heroin and other opioid addictions have since been labeled as opioid dependent. Not surprisingly, over the next 20 years, drug addiction became widely known as drug dependence, and patients who were prescribed opioids for chronic pain were widely stigmatized because their physical dependence was misinterpreted as addiction.
In 2013, an attempt to fix this misperception took place when the DSM-5 was published.6 In this newest edition, the term for opioid addiction/opioid dependence was replaced with opioid use disorder. Of course, confusion about the use of the term “dependence” lingers.