Distinguishing Addiction From Dependence

LAS VEGAS—Fears and misconceptions about opioid dependence and addiction can get in the way of pain management, said Cynthia F. Knorr-Mulder, MSN, BCNP, NP-C, of the Englewood Hospital and Medical Center, in Englewood, New Jersey.

“Even if you have 15 years of experience, we still struggle with the distinction between dependence and addiction,” Knorr-Mulder said. “We often use them interchangeably, but this leads to confusion among professionals and patients regarding the diagnostic implications of these terms.”

Patients sometimes resist postoperative opioid medications out of fear of developing an addiction. Some patients are even wary of acetaminophen. “The way to combat all these misconceptions is patient education,” Knorr-Mulder said.

Provider fears and misconceptions about addiction can also discourage the appropriate use of opioid therapy, Knorr-Mulder warned. “Not everybody who comes in on opioids has an addiction,” she said.

Providers' personal biases can get in the way of therapeutic relationships, she warns—such as when a patient with tattoos is assumed to have an addiction and to be drug-seeking. Provider bias is sometimes rooted in personal experience, and many providers carry around a criminal or moral model of addiction, and believe that addiction reflects a “bad or evil character,” or moral weakness.

Addiction is characterized by an inability to consistently abstain from taking a medication, cravings, difficulty recognizing the problems with one's behaviors, muted or dysfunctional emotional responses, and cycles of relapse and remission, she explained.

“We want to go to an evidence-based model that focuses on addiction as a disease and identify treatment for that disease,” Knorr-Mulder emphasized. “Without treatment or engagement in recovery, addiction is progressive and can result in disability or premature death,” she warned.

Key differences in opioid use driven by pain versus addiction include cravings and compulsive use by addicted patients, she noted. Pain-motivated patients rarely demand specific medications—a frequent behavior among those with addiction. If a patient refuses to consider alternative modalities of treatment, they may have a problem, Knorr-Mulder said.

Simple risk-assessment screening instruments like the three-item Opioid Risk Tool (ORT) do not diagnose addiction, but can identify patients whose situations require closer scrutiny.

Pseudo-addiction is a relatively new term used to describe patients whose pain is inadequately managed, and whose behaviors can mimic those seen in addiction.

“They have a pain problem and are looking for treatment,” Knorr-Mulder explained. “They may be drug seeking and they may self-escalate their dose. But don't assume the patient's addicted.” Unlike addiction, pseudo-addiction behaviors cease once pain is adequately controlled, she said.

“We need to make sure that the right patients are getting opioid prescriptions,” she said. “And we need to make sure that the wrong patients, who are just looking to come in to get medications because they have an addiction, are not receiving medications. But also that we make sure we are helping those patients.”

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