Should a person who uses opioids (opioid analgesics) daily for pain management be automatically classified with an opioid use disorder diagnosis?

Daily Opioid Use for Pain Management Does Not Automatically Indicate Opioid Use Disorder

Daily use of opioids for legitimate pain management should not automatically be classified as an opioid use disorder diagnosis, as physical dependence and tolerance are expected physiological responses to chronic opioid therapy and do not alone constitute addiction.

Understanding Key Terminology and Distinctions

The distinction between physical dependence and addiction is critical when evaluating patients on long-term opioid therapy:

• Physical dependence and tolerance: These are normal, expected physiological consequences of repeated opioid exposure that develop rapidly in most patients, regardless of the type of opioid or patient characteristics 1.

• Opioid use disorder/addiction: This is characterized by specific maladaptive behaviors including impaired control over drug use, compulsive use, continued use despite harm, and craving 1. Addiction develops much more slowly than physical dependence, usually after months of exposure, and occurs far less frequently 1.

Diagnostic Considerations

When evaluating patients on daily opioid therapy for pain, consider:

1. Behavioral indicators: True addiction involves behaviors that indicate loss of control, such as:

   • Using more medication than prescribed
   • Obtaining opioids from multiple providers ("doctor shopping")
   • Prescription forgery
   • Diversion of medications
   • Using opioids despite harm 1

2. Pseudo-addiction vs. addiction: Some behaviors that may appear to indicate addiction (requesting early refills, increased doses) may actually represent "pseudo-addiction" - behaviors resulting from undertreated pain that resolve when pain is adequately managed 1.

3. Therapeutic dependence: Patients with good pain relief may exhibit drug-seeking behaviors due to fear of pain recurrence or withdrawal symptoms, rather than addiction 1.

Risk Assessment and Monitoring

For patients requiring daily opioid therapy:

• Conduct routine screening for unhealthy substance use before initiating chronic opioid therapy 1
• Assess risk factors for opioid misuse, including:
  • Prior history of substance use disorders
  • Younger age
  • Family history of substance use disorders
  • Personal/family psychiatric history
  • Childhood trauma 1
• Implement appropriate monitoring strategies:
  • Urine drug testing
  • Prescription monitoring program checks
  • Regular reassessment of pain, function, and opioid-related risks 1

Common Pitfalls to Avoid

1. Misinterpreting physical dependence as addiction: The FDA label for buprenorphine clearly states: "Physical dependence may not occur to a clinically significant degree until after several days to weeks of continued use. Buprenorphine hydrochloride should not be abruptly discontinued in a physically-dependent patient" 2. This principle applies to all opioids.

2. Stigmatizing necessary pain treatment: Labeling patients with an addiction diagnosis solely based on daily use can lead to stigmatization and undertreatment of pain 1.

3. Overlooking true addiction: Failing to recognize signs of actual opioid use disorder can lead to continued harm. Studies suggest carefully diagnosed addiction occurs in <8% of patients prescribed opioids for chronic pain 1.

4. Confusing classification systems: Different diagnostic systems (ICD-10, ICD-11, DSM-IV, DSM-5) may classify problematic opioid use differently, with varying levels of agreement between systems 3.

Clinical Implications

The appropriate approach to patients on daily opioid therapy includes:

• Maintaining uninterrupted therapy to address baseline opioid requirements
• Recognizing that abrupt discontinuation can lead to withdrawal and worsened pain
• Understanding that patients with legitimate pain may require ongoing opioid therapy
• Regularly reassessing the benefits and risks of continued therapy
• Monitoring for signs of true addiction versus expected physical dependence

By understanding the distinction between physical dependence and addiction, clinicians can provide appropriate care without unnecessarily stigmatizing patients who require daily opioid therapy for pain management.