In considering the contemporary role of opioids it must be borne in mind that, although these substances are subject to abuse, the intention for which opioids exist is the treatment of pain. Far too often, the potential for abuse interferes with the appropriate use of pain medications for those in need. Although drug abuse is a compelling public health problem, allowing abuse potential to limit access to opioids for those with medical illnesses is an unjust response. A useful analogy is our system of using checks to pay for purchases which is circumvented when ìbadî checks are ìbounced,î —- but we donít respond by banning checks as legal tender, a policy decision that would punish everyone. If you believe in a higher power, especially one that did not put us here to suffer unnecessarily, then we can reason that God gave us the opioids and their derivatives to better cope with pain and suffering. Unfortunately, as a culture we have been tragically ineffective in distinguishing between drug abuse and the treatment of pain, and thus when it comes to pain medications, it has been a classic case of a few bad apples ruining things for the whole bunch: todayís patients with pain have become the innocent victims of a war on drugs that should have nothing to do with them.
Research consistently demonstrates that exposure to pain medications does not foster addiction. In fact, under-prescribing is more likely to fuel addictive behavior, because pain is never relieved, and patients are left feeling abandoned, left to continually seek help that becomes increasingly elusive. With chronic treatment, patients may become tolerant or accustomed to the effects of opioids (thus requiring higher doses over time), and physical dependence (the onset of withdrawal or an abstinence syndrome when treatment is abruptly stopped) may arise, but addiction, a reversible complication, is extremely rare, occurring in no more than a few per cent of patients exposed to analgesics in the course of treatment. Tolerance and physical dependence are inevitable biologic consequences of chronic opioid use, that are independent of the patientís background, values and circumstances. The onset of tolerance and physical dependence are expected, are unrelated to addiction and are not problematic since they can be overcome by simply adjusting doses pf medications gradually. Addiction, which is the same as psychological dependence, is an infrequent outcome that is highly dependent on the patientís prior history, experiences and values. Addiction involves compulsive, nonmedical use of drugs that persists despite the presence or threat of physiologic or psychological harm, and indeed is a highly disruptive phenomena. Rare in otherwise well-adjusted individuals, exaggerated perceptions of its dangers causes a great many patients with legitimate pain to be mistrusted and undertreated. Unfortunately, when pain is ignored, most other aspects of healing (rest, mood, nutrition, energy and rehabilitation) also falter. Too often, we operate from the mistaken belief that simple exposure to painkillers produces addiction, while in fact addiction appears to be much more person- and style-specific than substance-specific. Predisposition to addiction has much more to do with an individualís style of coping with adversity, stress and illness. Addicts are less functional as a result of their drug use and become more isolated from the mainstream of life, family and work, while patients using drugs appropriately are consequently more functional, less isolated, and more prone to resuming activities they once avoided because of pain.
In the course of twenty years of educating physicians and nurses, patients and their families, administrators and policymakers and other interested parties about pain management, the topic of addiction never fails to elicit great interest. As a means to convey my thinking about this complex issue and especially the thorny distinction between addiction and the treatment of painful medical disorders with drugs. I created and have come to rely on a vignette that, by employing an analogy focuses our attention in a way that may help us think more clearly about issues that appear bewilderingly complex but are perhaps more simple than they appear to be.
So….heaven forbid, your teenage child or grandchild ìborrowsî the key to the family car, say a Ford Taurus, goes on to drink a six pack of beer and then wraps said car around a tree. Fortunate enough to walk away from the event, employing another example of adolescent logic, he/she draws the following conclusion: ìFord Taurusí are bad cars.î
The obvious corollary is that drugs, in and of themselves are neither ìgoodî nor ìbad,î although their use can produce dramatically opposed good or bad outcomes depending on how they are prescribed, dispensed and taken (ìdriven,î if you will). Our culture strives to ascribe pat answers to complex phenomenon, and thus arises the oversimplistic temptation to denounce a substance as being responsible for a behavioral problem, because it is often easier than looking honestly at our own maladaptive behaviors. As we have come to recognize the dangers of alcohol and tobacco, it becomes clear that the problem of addiction transcends the domain of illicit drugs, and viewed from an even broader perspective we have come to recognize the hazards of addictions to activities as diverse as gambling, risk-taking and sex.
The recent media feeding frenzy condemning a newer opioid compound, Oxycontin is a prototypic example of how unless such hysteria can be curbed many of the advances that have been made on the behalf of patients with chronic pain can be summarily annihilated. Oxycontin is simply a preparation of an opioid drug that is slowly released over twelve hours to promote even relief without the roller coaster effects and the clock-watching associated with short-acting painkillers. The recognition by abusers that this when crushed, chewed, sniffed or injected, the safety of this miraculous ìtiny time pillî could be bypassed led major news organs to irresponsibly capitalize on the sensationalist aspects of this criminal misuse of a product that used properly has helped countless sufferers. This irresponsible journalism has not only disseminsated an otherwise obscure strategy of abuse in the minds of susceptible addicts, but has terrified patients who have been benefitting from an otherwise appropriate treatment for years, and has frightened prescribing physicians and pharmacist who are now reluctant to dispense an otherwise very helpful drug. Just like a truly resourceful burglar will find a way to circumvent even the most stringent security system, an addict who is truly intent on abusing drugs will find a mechanism to abuse almost anything. The bottom line message is not to throw out the baby with the bathwater: the answer to curbing addiction to prescription drugs is not to limit their availability, but to teach doctors, patients and pharmacists to communicate more effectively about a problem that is distressing to all of us.
Patients should be aware that while the risk of addiction is exaggerated by even (well meaning) experts, it still exists. Addiction may arise in between 0.1-10% of patients, but it is a treatable disorder, and shouldnít interfere with the consideration of trials of opioids in patients with lower risk profiles. Individuals who have had difficulties with drugs, alcohol and tobacco in the past are at high risk for addiction and are generally considered poor candidates for treatment. Patients in denial who expect a ìquick fixî and wish to eliminate rather than manage pain are also likely to encounter difficulties with treatment.