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Dependence Is Not Addiction and “Tolerance” Declares Addiction

Dependence Is Not Addiction and “Tolerance” Declares Addiction Ballantyne et al1 accurately reported opioid dependence reflecting non –life-threatening withdrawal symptoms but fundamentally mischaracterized associations between dependence, tolerance, and addiction. Abrupt termination of opioid use simply precipitates withdrawal nausea. As such, dependence on continued opioid consumption does not necessitate any treatment. However, if opioid access is terminated, then dependence requires gradual taper to avoid nausea in addition to acceptance that previously suppressed pain will return with consequential increased effort to continue functional full-time work. In contrast, providing opioids to addicts harms them. Addicts seek euphoria, not pain relief. Consequently, addicts robustly declare illicit intent by soliciting interminably escalating opioid dosing via fabricating “tolerance” to feed unquenchable counterproductive euphoric journeys. Addicts functionally decompensate, behaviorally ruminating on narcotic acquisition, often culminating in unemployment. As such, unemployment is reported to predict opioid abuse.2 Objective unemployment despite subjectively asserting opioid symptomatic pain relief and narcotic solicitation must be viewed analogous to Ballantyne and colleagues' appropriately reported indication of addiction of doctor shopping.1 If pain impairment is treated, work disability should remit unless another compelling occult impairment distinct from pain is exposed, that of comorbid addiction. Conversely, euphoria is not desired by legitimate chronic pain patients. Furthermore, legitimate chronic pain patients dependent on opioids functionally soar vocationally. The authors1 assert that tolerance is valid in clinical experience, suggesting physiologic necessity of incessant dose escalation to effect identical levels of pain relief. However, postmarketing surveillance of innumerable pharmacologic agents reveals that in vitro interpretation of laboratory animal behavior often is not paralleled by clinical in vivo human physiologic experience. Similarly, numerous studies3 of stable opioid dosing declares “tolerance” a myth when prescribed to legitimate chronic pain patients because they appreciate satisfactory analgesia with “stable (non escalating) [low] dose of opioids with a minimal risk of addiction.”4(p1944) By contrast, “addiction can be masked when physicians comply with the patient's unreasonable demands for opioids.”4(p1950-1951) Illegitimate tolerance assertions must be recognized as alerting, unveiling a pathologic condition of abuse, contrasting legitimate chronic pain patients seeking sensible dosing, appropriately fearing “iatrogenic addiction.”1 Chronic pain patients view pain as the opioid medication–responsive symptom, which impedes ability to optimally assume the dignified objective primary role of family provider/worker. Finally, inappropriately melding dependence with addiction terminology erroneously suggests that opioids are toxic to chronic pain patients, but only 6 deaths were reported per 9940 legitimate patients.5 Withholding safe, symptom-relieving, and work-facilitating opioids from legitimate chronic pain patients is a disservice to optimal patient care. Back to top Article Information Correspondence: Dr Geller, Nashua Pain Management Corp, 154 Broad St, Nashua, NH 03063 (GELLERTreatment@hotmail.com). Conflict of Interest Disclosures: None reported. References 1. Ballantyne JC, Sullivan MD, Kolodny A. Opioid dependence vs addiction: a distinction without a difference. Arch Intern Med. 2012;172(17):1342-134322892799PubMedGoogle Scholar 2. White KT, Dillingham TR, González-Fernández M, Rothfield L. Opiates for chronic nonmalignant pain syndromes: can appropriate candidates be identified for outpatient clinic management? Am J Phys Med Rehabil. 2009;88(12):995-100119789432PubMedGoogle ScholarCrossref 3. Jensen MK, Thomsen AB, Højsted J. 10-year follow-up of chronic non-malignant pain patients: opioid use, health related quality of life and health care utilization. Eur J Pain. 2006;10(5):423-43316054407PubMedGoogle ScholarCrossref 4. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003;349(20):1943-195314614170PubMedGoogle ScholarCrossref 5. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-9220083827PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Dependence Is Not Addiction and “Tolerance” Declares Addiction

Geller, Aaron S.
JAMA Internal Medicine , Volume 173 (7) – Apr 8, 2013
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References (6)

Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/jamainternmed.2013.3045
Publisher site
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Abstract

Ballantyne et al1 accurately reported opioid dependence reflecting non –life-threatening withdrawal symptoms but fundamentally mischaracterized associations between dependence, tolerance, and addiction. Abrupt termination of opioid use simply precipitates withdrawal nausea. As such, dependence on continued opioid consumption does not necessitate any treatment. However, if opioid access is terminated, then dependence requires gradual taper to avoid nausea in addition to acceptance that previously suppressed pain will return with consequential increased effort to continue functional full-time work. In contrast, providing opioids to addicts harms them. Addicts seek euphoria, not pain relief. Consequently, addicts robustly declare illicit intent by soliciting interminably escalating opioid dosing via fabricating “tolerance” to feed unquenchable counterproductive euphoric journeys. Addicts functionally decompensate, behaviorally ruminating on narcotic acquisition, often culminating in unemployment. As such, unemployment is reported to predict opioid abuse.2 Objective unemployment despite subjectively asserting opioid symptomatic pain relief and narcotic solicitation must be viewed analogous to Ballantyne and colleagues' appropriately reported indication of addiction of doctor shopping.1 If pain impairment is treated, work disability should remit unless another compelling occult impairment distinct from pain is exposed, that of comorbid addiction. Conversely, euphoria is not desired by legitimate chronic pain patients. Furthermore, legitimate chronic pain patients dependent on opioids functionally soar vocationally. The authors1 assert that tolerance is valid in clinical experience, suggesting physiologic necessity of incessant dose escalation to effect identical levels of pain relief. However, postmarketing surveillance of innumerable pharmacologic agents reveals that in vitro interpretation of laboratory animal behavior often is not paralleled by clinical in vivo human physiologic experience. Similarly, numerous studies3 of stable opioid dosing declares “tolerance” a myth when prescribed to legitimate chronic pain patients because they appreciate satisfactory analgesia with “stable (non escalating) [low] dose of opioids with a minimal risk of addiction.”4(p1944) By contrast, “addiction can be masked when physicians comply with the patient's unreasonable demands for opioids.”4(p1950-1951) Illegitimate tolerance assertions must be recognized as alerting, unveiling a pathologic condition of abuse, contrasting legitimate chronic pain patients seeking sensible dosing, appropriately fearing “iatrogenic addiction.”1 Chronic pain patients view pain as the opioid medication–responsive symptom, which impedes ability to optimally assume the dignified objective primary role of family provider/worker. Finally, inappropriately melding dependence with addiction terminology erroneously suggests that opioids are toxic to chronic pain patients, but only 6 deaths were reported per 9940 legitimate patients.5 Withholding safe, symptom-relieving, and work-facilitating opioids from legitimate chronic pain patients is a disservice to optimal patient care. Back to top Article Information Correspondence: Dr Geller, Nashua Pain Management Corp, 154 Broad St, Nashua, NH 03063 (GELLERTreatment@hotmail.com). Conflict of Interest Disclosures: None reported. References 1. Ballantyne JC, Sullivan MD, Kolodny A. Opioid dependence vs addiction: a distinction without a difference. Arch Intern Med. 2012;172(17):1342-134322892799PubMedGoogle Scholar 2. White KT, Dillingham TR, González-Fernández M, Rothfield L. Opiates for chronic nonmalignant pain syndromes: can appropriate candidates be identified for outpatient clinic management? Am J Phys Med Rehabil. 2009;88(12):995-100119789432PubMedGoogle ScholarCrossref 3. Jensen MK, Thomsen AB, Højsted J. 10-year follow-up of chronic non-malignant pain patients: opioid use, health related quality of life and health care utilization. Eur J Pain. 2006;10(5):423-43316054407PubMedGoogle ScholarCrossref 4. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003;349(20):1943-195314614170PubMedGoogle ScholarCrossref 5. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-9220083827PubMedGoogle Scholar

Journal

JAMA Internal Medicine – American Medical Association

Published: Apr 8, 2013

Keywords: addictive behavior,opioids

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