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10 Articles in Volume 17, Issue #6
A Plea for Proper Opioid Tapering
Centers of Excellence in Pain Management: Past, Present, and Future Trends
Comorbid Pain and Childhood Obesity
Discussing Migraine With Your Patients: A Common Sense Guide for Clinicians
Justification of Morphine Equivalent Opioid Dosage Above 90 mg
Letters to the Editor: Dependence vs Addiction, Opioid Metabolism
Opioid Rotation From Opana ER Following FDA Call for Removal
Psoriatic Arthritis: Established, Newer, and Emerging Therapies
Sleep-Wake Disorders and Chronic Pain: Reciprocal and Interactive Effects
What are Nav1.7 inhibitors and how are they used in the treatment of neuropathic pain?

Letters to the Editor: Dependence vs Addiction, Opioid Metabolism

July/August 2017
Page 1 of 3

Dependence Does Not Equate to Addiction

In the article, “Trump Orders Commission to Examine Opioid Addiction,” published online,Kelly Pfeifer, MD, director of high value care for the California Health Care Foundation, stated, “Today we know that the percentage of people becoming addicted when taking opioids for pain is anywhere from 10% to 50%, not 1%.” She continued with, “the length of time it may take to develop an addiction to opioids is startlingly brief…there is a big jump up after taking opioids for 5 days, 30 days, and 90 days.”

Are these statistics accurate?    

Anonymous PPM Reader

What is on the minds of Practical Pain Management readers?

Dear Reader, 

Unfortunately, these statements oversimplify the problem and perpetuate a common mistake in properly distinguishing between “addiction” and “physical dependence,” a  misunderstanding that needs correcting. Dr. Pfeifer’s figures of 10% to 50% actually refer to the likelihood of developing physical dependence, not addiction. Also, what is “startlingly brief” is not “the length of time it may take to develop an addiction” to opioids but the length of time it takes to develop tolerance to certain opioid effects. 

For the past 5 years, I have been teaching a national remedial/proactive prescribing course,2 during which I have observed the beliefs of hundreds of physicians, physician assistants, and nurse practitioners with regard to opioids. Before the course, for example, attendees were asked to complete an online assessment. In response to “I anticipate that my patient will become addicted to the opioid that I am prescribing for him/her for chronic pain,” 150 out of 379 prescribers (40%) answered “always” or “frequently.” This response supports a widespread need for education about the nature of addiction, physical dependence, and the meaning of “dependence on drugs.” 

I have addressed this confusion in terms twice in PPM—in an Ask the Expert columnand, more recently, in “The 5 most misunderstood pain terms.”4 To review, “dependence,” as in drug dependence, was the term used in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV),5 the reference book widely used by psychiatrists. In the updated DSM-5, the name for addiction was changed to “opioid use disorder.”6 Currently, the concept of dependence or, more clearly, physical dependence, is defined as “a state in which the body responds to the chronic use of a drug such that when the medication is stopped suddenly, a specific set of symptoms develops (withdrawal syndrome).”6

Some withdrawal syndromes—for example, following an abrupt discontinuation of corticosteroids—can be serious or even fatal, while other experiences, such as acutely stopping the use of opioids, may be very uncomfortable but not life-threatening. The body’s response to some drugs may result in sedation, respiratory depression, and nausea when opioids are taken, leading to tolerance, or a response such that an increased dose may be required to get the same effect. However, this is not the same as addiction.

It is essential that pain practitioners recognize the significant distinction between addiction and dependence, and understand the relationship between tolerance and withdrawal in order to most effectively manage patients with chronic pain.

Jennifer P. Schneider, MD, PhD

Hormone Therapy

As a certified family nurse practitioner (FNPc) in the Northern California Kaiser Health Care System, I regularly work with patients in chronic intractable pain to taper their opioids while continuing to manage their symptoms. Many of these patients develop centralized pain, which I have heard Forest Tennant, MD, DrPH, lecture on and write about in PPM.7,8

I do not share the belief that opioids are bad for everyone or medication doses of 100 mg or more are lethal, as this goes against 17 years of chronic pain management experience. As such, I believe that the guidelines from the Centers for Disease Control and Prevention9  were poorly conceived with insufficient science to back the recommendations. While I follow the practice of prescribing the lowest possible dose for meaningful improvement in function, pushing doses up without knowing what the patients’ hormone levels are or their resultant m-receptor response is an ineffective Band-Aid approach when it would be more efficient to check for and correct a hormone deficiency.

A new challenge has arisen for me with a patient who has centralized pain, has transitioned from female to male, and is on testosterone therapy. Would I need to make any adjustments to hormone treatment—dehydroepiandrosterone (DHEA), estradiol, and progesterone, to meet the specific needs of this patient? 

In addition, I want to promote the value of hormone therapy to the physicians in my practice so we can maximize patients’ comfort while avoiding the need for long-term use of opioids. Alas, it is a hard sell despite the evidence.10-12 While the use of ketamine and bisphosphonates has required some convincing as well, these medications have been more readily accepted.

I find it frustrating that Dr. Tennant’s treatment approach is not embraced as mainstream medicine—at least not yet—and welcome your unique approach to chronic pain management that employs the use of cutting- edge practices to help our pain community. 

Darrel Brown, FNPc 
San Rafael, California

Dear Darrel,

Last updated on: August 16, 2017
Continue Reading:
What are Nav1.7 inhibitors and how are they used in the treatment of neuropathic pain?

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