In the 1990’s and early 2000’s, it was common for some healthcare providers to believe that addiction to opioid pain medications didn’t necessarily occur, especially if patients appropriately used their medications to manage pain. The belief was that as long as patients used the medications for pain (as opposed to some other reason, such as to get high) they simply wouldn’t get addicted. It was as if to say that as long as a patient has pain and as long as the intention is to take the medications for pain, then these two factors would disqualify someone from getting addicted. Patients too tended to embrace this sentiment. It was, of course, hugely reassuring. Patients could take the medications and healthcare providers could prescribe them without any alarming concerns.

It’s now well-known that people can have chronic pain and get addicted to opioid pain medications at the same time. It is not an either-or issue. It’s also known that addiction can occur in unintended ways. Intentions don’t really matter. No one ever intends on becoming addicted to anything, opioid pain medications included. Addiction to opioid pain medications can happen, even if patients set out to take them only for pain. So, patients should be concerned about it.

The following attempts to set aside the sensitivity of the issue of addiction and simply explain key concepts of addiction when it comes to the use of opioid pain medications, especially in the context of their long-term use for a chronic pain condition. The key concepts are physiological dependence, psychological dependence, and addiction.

Physiological dependence

When taking opioid medications on a daily basis over a long period of time, patients become physiologically dependent. The body becomes adjusted to having the medication in its system. As a result, two things happen. First, patients become tolerant to the medication. Tolerance is when the body becomes adjusted to the use of opioid medications and as a result the medications lose their effectiveness over time. Second, patients experience withdrawal symptoms if the medication is abruptly stopped. All patients develop physiological dependence when taking opioid medications over time.

Patients frequently mistake physiological dependence for addiction. It’s understandable. With any other drug, people consider physiological dependence as part and parcel of addiction. Take, for example, an individual who experiences tolerance and withdrawal from the use of alcohol. Most would consider the individual an alcoholic. It’s understandable, then, that most would consider the chronic pain patient an addict when they develop tolerance to their medication and experience withdrawal if they abruptly stopped the use of the medication.

However, the use of opioid medications for chronic pain is a unique situation, when compared to the use of other addictive drugs, like alcohol. When people use alcohol (or any of the illegal drugs) to the point of tolerance and withdrawal, most people would consider that they are doing something wrong. When chronic pain patients use opioid medications on a daily basis to the point of tolerance and withdrawal, they are doing just what their healthcare provider told them to do. If patients use their medications exactly as prescribed, they inevitably become tolerant and could experience withdrawal. Notice that they are not doing anything wrong. It’s what makes the situation unique from the use of other addictive drugs.

The American Academy of Pain Medicine and the American Pain Society noticed this difference too. A number of years ago, they decided to team up and define a difference between physiological dependence and addiction. They defined addiction to opioid medications using two criteria: a loss of control over the use of the medication or continued use of the medication despite real or potential harm.¹ These criteria are more fully explored in the section on addiction.

While its important to acknowledge the difference between physiological dependence and addiction, it’s also important to acknowledge that tolerance and withdrawal are not benign issues. Even if they are not addiction, many patients are rightfully concerned about them.

Tolerance makes it unfeasible to continue to use opioid medications for pain on an indefinite basis. Patients and their healthcare providers commonly do not consider this problem until it is too late. Patients who have been on opioid medications for a few years become tolerant to even the highest doses of opioid medications. The medications no longer work and yet the patients have the rest of their lives to live. They may need opioid medications for other injuries or surgeries in the future and yet they are now tolerant to the medications. It is a problem for many patients.

The possibility of withdrawal is also a concern for many patients. They simply don’t like their dependency on the medication or their dependency on the healthcare provider who prescribes them. There might be many situations in which patients inadvertently do not have access to their medication or to their provider. This dependency produces a sense of vulnerability. Many patients just don’t like this sense of dependency and vulnerability.

Psychological dependence

When patients use opioid pain medications on a long-term basis, they tend to develop subtle yet strongly held beliefs that lead to a loss of confidence in their own abilities to cope with pain. As such, they come to believe that it is impossible to successfully manage pain without the use of opioid medications. Moreover, they become unwilling to entertain alternative options to their use. As a consequence, patients come to overly rely on the medications long after they are no longer helpful. In other words, opioid medications foster psychological dependence.

This issue is difficult to talk about. It’s difficult because these beliefs are subtle and don’t really come to the foreground unless actually named. It’s also difficult to talk about because it’s a sensitive issue. It can evoke strong emotional reactions.

Patients who are psychologically dependent on opioids are often intolerant of the notion that it is possible to manage pain well without opioids. They might see it as ridiculous. When a healthcare provider raises the notion, they take it that the healthcare provider is incompetent. At other times, patients see it as evidence that the healthcare provider doesn’t understand what it’s like to have chronic pain. They can also see the notion that it is possible to manage pain well without opioids as invalidating the legitimacy of their pain. In any of these ways, patients can get dismissive or angry. As described, it is a sensitive issue. However, the sensitivity is also indicative of psychological dependence.

Patients who are psychologically dependent on opioid medications are often unwilling to entertain different treatments for their pain, even when those treatments might be more effective. For example, numerous studies and reviews^{2, 3} have shown that chronic pain rehabilitation programs are more effective than long-term use of opioid medications. The psychologically dependent patient tends to forego recommendations to participate in such programs, even though they are more effective. It’s hard to come up with any analogous situation in healthcare. Cancer patients typically don’t insist on using one type of chemotherapy drug when their oncologists recommend using a more effective type. Most patients wouldn’t insist on using an antibiotic that has been consistently shown to be less effective than another medication or treatment. This kind of situation, though, commonly happens when it comes to the use of opioid medications for chronic pain. The difference is that opioid medications have the capacity to foster psychological dependence in the patients who take them. As such, they insist on using opioid medications even when there are other, more effective options for the management of pain.

Patients who are psychologically dependent on opioids rely on the medications long after they cease to be helpful. They tend to demonstrate tolerance to the medication, describing their pain as severe despite taking high doses of opioids. They may also remain disabled by pain, despite the use of opioid medications. Nonetheless, they swear that the medications are helpful. This disconnect between their subjective belief that the medications are helpful and the objective evidence of their reports of continued high levels of pain and disability is an indication of psychological dependence.

It bears remembering that most people with chronic pain do not manage their pain with opioid medications. In an epidemiological study, Toblin, et al., found that a quarter of the population has chronic pain; but among people with chronic pain, they found only 15% using prescription opioids to manage their pain.⁴ Now, it might be argued that the majority of people with chronic pain should be on opioids and that in fact it’s inhumane that in this day and age the majority of people with chronic pain are still being denied the use of such medications. But, that’s not what these researchers found when they asked people with chronic pain in the study. They found that the vast majority – 80% of them – were satisfied with their pain management. So, it’s true that the majority of patients with chronic pain manage their pain without opioid medications.

Patients who are psychologically dependent on opioid medications tend to believe that it is impossible. They are sensitive to the notion that it is in fact possible and can get emotional when it is brought up. They lack an openness to treatment options that might be more effective than opioid medications. Lastly, they maintain the belief that the medications are helpful and necessary despite their continued reports of high levels of pain and despite the fact that they remain disabled.

Addiction

As indicated earlier, the conventional definition of addiction to opioid medications has two criteria, when their use is in the context of chronic pain management.

• Loss of control over use of the medication
• Continued use despite harm

Loss of control occurs when patients do not use the medications as prescribed or in accordance with the agreement that they make with their healthcare providers. In other words, they do not control their use of the medications. Continued use despite harm occurs when patients continue to use the medications even though their use is harming their relationships with others or putting them at physical or legal risk. When patients demonstrate a pattern of behaviors that are indicative of either of these criteria or both, healthcare providers diagnose addiction.

Some examples of a loss of control are the following behaviors:

• Taking more of the medication than prescribed
• Early refill requests
• Multiple reports of lost or stolen medications
• Repetitive emergency room visits to obtain medications
• Use of multiple healthcare providers at the same time to obtain medications
• Use of a friend’s or relative’s medications
• Breaking the long-acting nature of a medication and ingesting it
• Buying medications from people who are not healthcare providers
• Buying medications off the internet

Some of these behaviors are more significant than others. Most healthcare providers would require a pattern of behaviors for the less significant ones. For example, a patient may have a legitimate reason for an early refill request. One instance of this behavior may not be concerning. However, a pattern of such requests almost every month for a number of months does become concerning. Healthcare providers tend to consider such a pattern as indicative of addiction. Other behaviors on the list are more significant. Most healthcare providers become concerned about addiction after even one instance of some of these behaviors. For examples, there are no legitimate reasons to break the long-acting nature of a medication or to buy medications off the streets. When healthcare providers learn about a patient engaged in these types of behaviors, even if it was only once, it is concerning. In fact, it is an indicator of addiction to opioid medications.

Some examples of continued use despite harm are the following behaviors.

• Pressuring, manipulating, belittling, or threatening a healthcare provider into prescribing opioids
• Refusing to participate in therapies other than opioid medication management
• Firing an otherwise competent healthcare provider because of disagreements over whether to prescribe opioid medications
• Continued use of opioid medications despite expressed concerns about addiction from friends, relatives and healthcare providers
• Using such high doses of medications that the patient becomes incoherent or falls asleep while engaged in activities
• Using a false identity to obtain opioid medications
• Stealing medications from others
• Altering a prescription

These behaviors also exhibit a loss of control, but the emphasis is on the fact that they are done despite some type of harm to the patient. The loss of control has not been perceived as ‘a wake-up call’ and so the behaviors have crossed a threshold of jeopardizing the patient in some manner. Some of these behaviors harm the relationships that the patient has – relationships with healthcare providers, friends or relatives. Some of these behaviors place the patient or others at risk of physical harm. An example is using medications at such high doses that a patient falls asleep while engaged in a wakeful activity or otherwise is unable to fully track or pay attention to the activity. Other behaviors place the patient at risk of legal harm. Examples are using a false identity or stealing medications or altering a prescription. These activities are, of course, illegal and yet the addicted patient might still do them. In all these examples, the loss of control is evident to others but the patient might not see it or might make excuses for it because obtaining the medication has become more important than the risks. All these behaviors are indicative of addiction.

How often does addiction occur in chronic pain patients?

In the context of chronic pain management, addiction is a significant problem. In their literature review, Hojsted & Sjogren⁵ cited studies that showed rates of a wide range of addictive behaviors, varying from 0% to 50%. In their meta-analysis published in the same year, Martell, et al.,⁶ found that 5-24% of patients on opioid pain medications demonstrate the above-mentioned problematic behaviors, depending on the behavior.

In more recent studies, Hojsted, et al.,⁷ used two different methods for diagnosing addiction. Depending on the method, they found either 14.4% or 19.3% of chronic pain patients meeting criteria for addiction to opioid medications. Within the context of a larger study, Skurtveit, et al.,⁸ had 686 chronic pain patients who regularly used opioid medications and they identified 191 of them as engaged in problematic behaviors indicative of addiction. The percentage is about 28%. In their study of people prescribed opioids across multiple Western countries, Morley, et al.,⁹ found a range of misuse and abuse from 8 to 22%. These rates rose considerably when patients were also prescribed benzodiazepines or were taking illegal drugs.

Risk factors for addiction to opioid medications

A number of research studies have looked at risk factors among chronic pain patients that make it more likely for them to be identified as engaged in addictive behaviors.

In the study cited above, Skurtveit, et al.,⁸ observed that new users of opioids as a group have a considerably smaller chance of becoming addicted than regular users as a group. Sullivan, et al.,¹⁰ found that having a history of substance dependence, high daily use of opioids, being young and having multiple pain complaints were risk factors. Hojsted, et al.,⁷ found that high daily use of opioids, use of benzodiazepine medications, use of alcohol, and anxiety and depression were risk factors for addiction. As indicated above, Morley, et al., found rates of misuse and abuse rose significantly amoung those who also take benzodiazepine medications (sedatives, which are also addictive) and/or illegal drugs.⁹

For more information

For cutting edge thougts on the distinction between physiological dependence to opioids and opioid addiction, please see our page, Should the Definition of Opioid Addiction Change?

References

1. American Academy of Pain Medicine and the American Pain Society. (1997). The use of opioids for the treatment of chronic pain: A consensus statement. The Clinical Journal of Pain, 13, 6-8.

2. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

3. Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

4. Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152, 1249-1255.

5. Hojsted, J. & Sjogren, P. (2007). Addiction to opioids in chronic pain patients: A literature review. European Journal of Pain, 11, 490-518.

6. Martell, B. A., O’Connor, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., Fiellin, D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127.

7. Hojsted, J., Nielsen, P. R., Guldstrand, S. K., Frich, L., & Sjogren, P. (2010). Classification and identification of opioid addiction in chronic pain patients. European Journal of Pain, 14, 1014-1020.

8. Skurtveit, S., Furu, K., Borchgrevink, P., Handal, M., & Fredheim, O. (2011). To what extent does a cohort of new users of weak opioid develop persistent or probable problematic opioid use? Pain, 152, 1555-1561.

9. Morley, K. I., Ferris, J. A., Winstock, A. R., & Lynskey, M. T. (2017). Polysubstance use and misuse or abuse of prescription opioid analgesics: A multi-level analysis of international data. Pain, 158, 1138-1144.

10. Sullivan, M. D., Edlund, M. J., Fan, M., DeVries, A., Braden, J. B., & Martin, B. C. (2010). Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and Medicaid insurance plans: The TROUP Study. Pain, 150, 332-339.

Date of publication: March 25, 2013

Date of last modification: October 5, 2019