American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tolerance, dependence and addiction

From the December ACP Observer, copyright © 2004 by the American College of Physicians.

When treating patients for pain, watch for the development of tolerance, dependence and addiction in patients, and treat appropriately.

Experts define tolerance as the need for an increased amount of drug to achieve the same analgesic effect. This is a common and expected occurrence in individuals who chronically take opioids.

The first sign of tolerance may be a decrease in the duration of effective pain relief with the patient's usual opioid dose. To treat tolerance, you may have to increase the current opioid dose by between 10% and 15%.

Physical dependence is a physiological state marked by the development of withdrawal symptoms when medications are discontinued abruptly. Signs of withdrawal include anxiety, irritability, excessive salivation, tearing, runny nose, sweating, nausea, vomiting and insomnia. You can prevent opioid withdrawal by slowly tapering chronically-used opioids doses, and by avoiding opioid antagonists and mixed agonists-antagonists in patients on chronic opioid therapy.

Addiction is an abnormal behavioral condition in which a person develops an overwhelming involvement in acquiring and using a drug despite adverse social, psychological or physical consequences. Tolerance and physical dependence are not equivalent to addiction. Addiction is relatively rare and occurs in a small percentage of patients taking opioids as prescribed to control pain.

Be aware that under-treatment of chronic pain can result in behaviors—termed "pseudoaddiction"—that resemble addiction. These behaviors resolve once a patient's pain is adequately treated.

In prescribing long-term opioids, many physicians find it helpful to have patients sign a written agreement that details the conditions of their continuing pain treatment. According to a sample pain management agreement posted by the American Academy of Pain Management, for instance, a patient being managed for pain would agree to several conditions including not to try to obtain controlled substances from another physician; to have refills made only at the time of an office visit or during office hours; and to submit to a blood or urine test at the physician's request.

Psychosocial and psychiatric aspects of chronic pain

Patients with chronic pain commonly suffer from psychiatric disorders and psychological distress. They frequently exhibit depressive symptoms and often present with overt clinical syndromes, including major depression and dysthymic disorder.

Anxiety disorders are also common, and patients often present with both anxiety and depressive symptoms. In addition, patients treated with opioid analgesics may develop delirium.

Any assessment of depression in pain patients must include past psychiatric history, past and current suicidal behavior, and an assessment of the severity of current depressive symptoms. Rating systems like the Beck Anxiety Inventory or the Zung Scale can be useful. (See "Assessment tools and patient information.")

Patients assessed as acutely suicidal need an urgent, specific disposition to maintain their safety, as well as acute treatment for the depressive syndrome.

Delirium is a complication of chronic pain. Its pharmacotherapy is seen most often in high-risk patients, which include the elderly; individuals with preexisting neurocognitive disorders such as dementia; patients with cancer or AIDS; and patients who are debilitated and/or taking multiple psychoactive medications.

Because delirium in medical patients is associated with high morbidity and mortality, physicians must promptly recognize this neuropsychiatric syndrome and identify specific etiologies.

Treatment may include constant observation, pharmacotherapy with antipsychotics and modifications to the opioid regimen. Modifications can include stopping, reducing and/or changing the drug.

Team building for chronic pain management

Successfully managing the complicated chronic pain patient almost always involves a team approach. This may include consultation and ongoing care from psychiatrists, psychologists, social workers, clergy and nurses, as well as family and community resources.

For patients with severe depression or who have not responded to one or two trials of an antidepressant, psychiatric consultation is indicated. Psychologists with specific training in cognitive therapy or health psychology can also play a key role in the extended team.

Nurses, especially those trained in hospice care, are essential for managing pain in patients at the end of life. Nurses can help titrate opioids and manage side effects, provide emotional support, assess for depression and anxiety, and monitor serial mental status exams to detect delirium or early neurocognitive toxicity.

Social workers can help with issues related to home care, insurance and prescriptions that may not be covered by a patient's insurance. Along with other team members, social workers also help support and educate the patient's family. Clergy address spiritual issues especially at the end of life, regardless of religious affiliation.

Documentation is key

According to policy issued earlier this year by the Federation of State Medical Boards (FSMB), treating pain appropriately is the standard of care—and documentation is key to establishing that a patient received appropriate treatment. "The Board will judge the validity of the physician's treatment of the patient," the FSMB wrote, "based on available documentation, rather than solely on the quantity and duration of medication administration."

The FSMB guidance directs physicians to document the following when treating patients for pain:

  • history and exam results;

  • diagnostic, therapeutic and lab results;

  • consultations and evaluation;

  • treatment objectives;

  • discussions of treatment risks and benefits;

  • informed consent;

  • medications, including date, type, dosage and prescribed quantities, and treatments;

  • patient agreements and instructions; and

  • periodic assessment and reviews.

Experts also advise that you document alternative treatments you considered and rejected, and your reasons for doing so. When you are documenting pain treatment, your records need to be current and accessible, according to the FSMB.

The FSMB's guidance, "Model Policy for the Use of Controlled Substances for the Treatment of Pain," is online. State policies on treating pain, including documentation requirements, are online.

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Inappropriate drug use

You need to periodically monitor patients on long-term opioid therapy for inappropriate or dangerous drug-use patterns. Look for signs that include the following:

  • Current or past history of drug abuse.

  • Adverse life consequences related to medication, such as loss of a job or relationship, or legal or medical problems related to drugs.

  • Drug-seeking behaviors, including obtaining prescriptions from several physicians, filling prescriptions at several pharmacies, losing medications or prescriptions, and calling after hours or making multiple emergency department visits for refills.

  • Abuse of other drugs including alcohol, cocaine, benzodiazepines and heroin.

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