Joining us at Outlook on Outcomes this week and next is Dr. Steven Moskowitz, a physical medicine and rehabilitation specialist.  As our first guest blogger, Dr. Moskowitz will cover a very important topic in our healthcare system and particularly in workers’ compensation.  Thanks for sharing your expertise!  – Dr. Holt

Dr. Holt asked me to comment on why treating prescription medication addiction is not as simple as a forced referral to a drug and alcohol detoxification or rehabilitation program.  I believe chronic pain patients present a greater challenge for several reasons, including maladaptive coping with ongoing pain complaints, fear of activity and debilitation, high incidence of untreated concurrent psychological problems, and, lastly, the availability of community clinicians willing to repeatedly treat subjective pain complaints with opiates without addressing the accompanying psychosocial issues.  Such physicians increasingly treat chronic pain patients with escalating or high doses of opiates despite dependence, addiction, the development of complications, and limited overall clinical and functional improvement.  To break this pattern, we must consider the unique profile of a chronic pain patient and identify appropriate resources for the management of addiction.

This week, I’ll illustrate the main features of iatrogenic addiction in patients with chronic pain and argue that this particular profile requires a comprehensive response.  Next week, part two will answer the question of what that methodology for treating iatrogenic addiction looks like.

Defining addiction and dependence

Two major problems with treating chronic pain with opiates are addiction/dependence and side effects.  The actual definitions of drug addiction and dependence are very controversial and have been the subject of much debate in the development of the updated criteria for the Diagnostic and Statistical Manual of Mental Disorders, version 5 (DSM-5), due out in 2013.  The American Society of Addiction Medicine defines addiction as “a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.”  It is characterized by behaviors that include impaired control over drug use, compulsive use, continued use despite harm, and cravings.  The term dependence is often used to denote a physiological dependence composed of tolerance and/or withdrawal symptoms, but sometimes is used to describe psychological dependence on a drug.  For our discussion, I’ll use these terms interchangeably since the real concept is problem drug use.

What is iatrogenic addiction?

Iatrogenic addiction refers to addiction that is caused by healthcare professionals.  The National Institute of Health’s MedLine Plus online dictionary defines iatrogenic as “induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.”  Unlike addiction to non-prescription drugs (e.g. alcohol, cocaine, heroin), addiction to prescription opiates requires a clinician who prescribes the medication.  It is tempting to classify those with prescription medication problems as “addicts” and to believe all can be fixed by “detox.”  This may be true for a small portion of these patients; professionals in the fields of addiction and law enforcement are well aware of illicit drug addicts who find their way into the medical system specifically to acquire prescription drugs.  But it is difficult to know exactly what percentage of chronic pain patients is primarily driven by the desire to acquire drugs versus a secondary addiction or psychological dependence as a result of treatment.

Research regarding the chronic pain population suggests that for the majority of cases, addiction or dependence is the result of prescription medication use, not the cause of it.  Consider the following:

1. “The prevalence of lifetime substance use disorders ranged from 36% to 56%, and the estimates of the prevalence of current substance use disorders were as high as 43%. Aberrant medication-taking behaviors ranged from 5% to 24%.”  (The “Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction (Annals of Internal Medicine, January 16, 2007 vol. 146 no. 2 116-127)
2. Fishbain, et. al, in their article, “Comorbidity Between Psychiatric Disorders and Chronic Pain,” estimated that perhaps up to 18.9% of chronic pain patients have issues with abuse, addiction or dependence, but stated that recent studies showed current problems with dependence in up to 34% of chronic pain patients.  Up to 12.5 percent were found to use illicit drugs.
3. In my informal discussion with colleagues who run comprehensive pain programs, it was felt that of the patients presenting to their program with problematic prescription drug use, perhaps 20-30% had a primary addiction problem, separate of pain issues.

The chronic pain population includes a wide variety of people who can be vulnerable to addiction to prescription medications.  Some have addictive habits, such as smoking, over-eating and alcohol, while others have a past history of addictions.  Conversely, others had no prior vulnerability to addiction.  One of the most common traits in pain patients with problematic opiate use is maladaptive coping abilities.  The Fishbain article noted that 71% of chronic pain patients have adjustment disorders.

It is vital that clinicians recognize pain as a biopsychosocial condition.  That means most patients not only have biological factors causing pain, but also significant psychosocial aspects prolonging disability and delaying recovery.  This makes treatment a more complicated endeavor than standard drug and alcohol detoxification or rehabilitation.

Return next week to learn how to identify the appropriate resources for treating iatrogenic addiction.