Concerns About Addiction: Bringing Clarity to Confusion about Addiction Terminology

Concerns About Addiction: Bringing Clarity to Confusion about Addiction Terminology

Aaron M. Gilson, MS, MSSW, PhDResearch Program Manager/Senior Scientist

Pain & Policy Studies Group

International Pain Policy Fellowship

Pain & Policy Studies Group

WHO Collaborating Center for Pain Policy & Palliative Care

University of Wisconsin Carbone Cancer Center

August 6, 2012

Evolution ofWHO Terminology and Beliefs

Evolution ofWHO Terminology and Beliefs

World Health Organization Expert Committees 1950 “Drug Addiction”* 1957 “Drug Addiction” 1964 “Drug Dependence” 1969 “Drug Dependence” 1990 “Drug Dependence” 1993 “Drug Dependence”* 1998 “Dependence Syndrome”*

International Classification of Diseases

Three elements co-occur within the preceding year:

1) Strong desire

2) Difficulties in control

3) Use occurs despite harm

4) Neglect of pleasures; increased time to obtain substance

5) Tolerance

6) Physical withdrawal

* The diagnostic requirement of essential characteristics would exclude patients who are being treated with opioids for the relief of pain.

“Dependence Syndrome”~ Current International Diagnosis ~

“Dependence Syndrome”~ Current International Diagnosis ~

World Health Organization. International Classification of Diseases (10th edition). 1992;75-76.

Maladaptive pattern of substance use, leading to clinically significant impairment or distress

Manifested by three (or more) of the following: Tolerance Withdrawal Use in larger amounts or durations than intended Use persists despite desire or efforts to control Much time spent to obtain, use, or recover from effects Decreased social, occupational, or recreational

activities Use occurs despite harm

American Psychiatric Association. Diagnostic and Statistical Manual (4th edition). 1994;181.

“Substance Dependence”~ Current U.S. Diagnosis ~“Substance Dependence”~ Current U.S. Diagnosis ~

Maladaptive pattern of substance use, leading to clinically significant impairment or distress

Manifested by one (or more) of the following: Failure to fulfill major role obligations at work,

school, or home Recurrent use in situations in which it is

physically hazardous Recurrent legal problems Persistent or recurrent social or interpersonal

problems

American Psychiatric Association. Diagnostic and Statistical Manual (4th edition). 1994;182-183.

“Substance Abuse”~ Current U.S. Diagnosis ~

“Substance Abuse”~ Current U.S. Diagnosis ~

Maladaptive pattern of substance use leading to clinically significant impairment or distress

Manifested by two (or more) of the following: Failure to fulfill major role obligations at work, school, or home Recurrent use in situations in which it is physically hazardous Persistent or recurrent social or interpersonal problems Use in larger amounts or durations than intended Use persists despite desire or efforts to control Much time spent to obtain, use, or recover from effects Decreased social, occupational, or recreational activities Continues despite knowledge of having a problem Craving or strong desire to use

American Psychiatric Association. DSM-5 Substance-Related Disorders Work Group.

“Substance Use Disorder”~ Future U.S. Diagnosis ~“Substance Use Disorder”~ Future U.S. Diagnosis ~

Additional indicatorsToleranceWithdrawal syndrome

Note: Tolerance or Withdrawal are not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications, or beta-blockers

American Psychiatric Association. DSM-5 Substance-Related Disorders Work Group.

“Substance Use Disorder”~ Future U.S. Diagnosis ~“Substance Use Disorder”~ Future U.S. Diagnosis ~

Calls for Policy ReformCalls for Policy Reform

UN International Narcotics Control Board U.S. Institute of MedicineCouncil of EuropeUN Economic and Social CouncilWorld Health Organization

International Narcotics Control Board 1989, 1996, 2005, 2007, 2010

International Narcotics Control Board 1989, 1996, 2005, 2007, 2010

Governments should examine their drug control policies for the presence of overly restrictive provisions that may impact their health care system in the delivery of pain relief, and take corrective action as needed Addiction and its terminology

International Narcotics Control Board. Reports for 1989, 1995, 2004, 2007, and 2010. New York, NY: United Nations; 1989, 1996, 2005, 2007, 2010.

World Health Organization. Achieving Balance in National Opioids Control Policy: Guidelines for Assessment. Geneva, Switzerland: WHO; 2000.

WHO Ensuring Balance Guideline, 2011WHO Ensuring Balance Guideline, 2011

Guideline 10: Terminology in national drug control legislation and policies should be clear and unambiguous in order not to confuse the use of controlled medicines for medical and scientific purposes with misuse “dependence” vs. “dependence syndrome” avoid use of stigmatizing terms like “addiction” in

legislation

Occurrence of Addiction in Medical Treatment with Rx Opioids

Occurrence of Addiction in Medical Treatment with Rx Opioids

Webster L, Webster R. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Medicine. 2005;6:432-442.Webster L, Webster R. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Medicine. 2005;6:432-442.

TheoreticalPrevalenceTheoreticalPrevalence

Total Pain PopulationTotal Pain Population

AberrantBehaviors 40%

AberrantBehaviors 40%

Abuse 20%Abuse 20%

Addiction 2-5%Addiction 2-5%

Occurrence of Addiction in Medical Treatment with Rx Opioids

Occurrence of Addiction in Medical Treatment with Rx Opioids

Fleming et al. 3.1% UW outpatients with chronic

non-cancer pain DSM “substance dependence”

Fishbain et al. 3.3% Meta-analysis of studies of

patients with chronic non-cancer pain addiction (typically undefined)

StatisticalPrevalenceStatisticalPrevalence

Fishbain et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Medicine. 2008;9:444-459.

Fishbain et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Medicine. 2008;9:444-459.

Fleming et al. Substance use disorders in a primary care sample receiving daily opioid therapy. Journal of Pain. 2007;8:573-582.Fleming et al. Substance use disorders in a primary care sample receiving daily opioid therapy. Journal of Pain. 2007;8:573-582.

Occurrence of Addiction in Medical Treatment with Rx Opioids

Occurrence of Addiction in Medical Treatment with Rx Opioids

Boscarino et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction. 2010;105:1776-1782.Boscarino et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction. 2010;105:1776-1782.

2.33

< 65 years

3.59

< 65 years +Pain impairment

4.63

< 65 years +Pain impairment +

Depression Hx

8.01

14.8

56.36

< 65 years +Pain impairment +Depression Hx +

Psychotropic meds

< 65 years +Pain impairment +Depression Hx +

Psychotropic meds +Severe Rx opioid dpnd Hx

< 65 years +Pain impairment +Depression Hx +

Psychotropic meds +Severe Rx opioid dpnd Hx +

Rx opioid abuse Hx

Current Rx opioid dependence (DSM-IV)(n=705; 25.8%)

Odds Ratio

Need to Consider the Spectrum ofNon-Medical Use of Rx Opioids

Need to Consider the Spectrum ofNon-Medical Use of Rx Opioids

Misuse(unintentional)

e.g.,- sharing with others

- unknowingly taking largeramounts than directed- inadvertent poisoning

DependenceSyndrome

(“Addiction”)

Abuse

Misuse(intentional)

e.g.,- recreational use for psychic effects

- decide to increase dose for pain control- suicidal gesture or attempt

Use involving aberrant behaviorse.g.,

- forging/altering prescriptions- going to multiple doctors

- stealing drugs

Concurrent use of illicit drugsor

undisclosed Rx medication use

ConclusionsConclusions

Evolution in concept and terminology New medical and scientific understanding

Research evidence about prevalence

Fear of addiction limits access to pain relief

Influences content of laws and other policies Definitions in laws of many countries have not changed

Ample expert guidance and tools exists To evaluate national drug control and healthcare policies To correct the definitions

Changes have legal and clinical implications

Action Steps:Communicating to Others

Action Steps:Communicating to Others

Do not assume that the other person understands what is meant by the term “addiction” find out about his or her beliefs and offer to clarify if necessary

Clarify how available terminology relates to currently-accepted standards (WHO concept of “dependence syndrome”)

Ensure that “addiction” does not characterize only the development of withdrawal syndrome or tolerance

Clarify that “addiction” cannot always be identified by behaviors alone motivations for such behaviors are important

Clarify that available U.S. research suggests that iatrogenic addiction is more prevalent when patients have existing co-morbidities (e.g., substance abuse history) practitioners need to assess for co-morbidities, and then monitor

for the development of addiction throughout treatment

Determine if data are available in your country to document the prevalence or incidence of “addiction”

Determine the sources of opioid analgesics used by people with the disease of addiction

Determine how perceptions about addiction are influencing the treatment of people with chronic pain

Action Steps:Communicating to Others

Action Steps:Communicating to Others