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Associate Director for Policy Studies
Pain Research Group
University of Wisconsin Medical School
World Health Organization Collaborating Center
The World Health Organization has shown that pain due to cancer can be relieved using a relatively simple treatment method that involves the use of oral analgesics 4). Opioid analgesics such as codeine, fentanyl, hydromorphone, oxycodone and morphine are the cornerstones of this method.
Unfortunately, less than optimal prescribing and inadequate availability of opioid analgesics continues to be a problem in most parts of the world. This is due to a combination of factors which include the low priority of pain management, lack of education, overly restrictive drug control laws, and fear of addiction 2)5).
The fear of addiction when opioids are used to manage pain, even cancer pain, is prevalent among the public, patients health care professionals and policy-makers throughout the world 6)-11). However, this fear is not warranted and is one of the factors that can result in ineffective clinical use of opioids and reluctance on the part of policy makers to allow greater import, production and prescription of opioid analgesics 2)5).
The global consumption of morphine for medical use finally began to increase following the introduction of the WHO cancer pain relief methods 5). However, most of these increases are limited to developed countries where it is generally acknowledged that opioids are underused for the treatment of cancer pain. In Japan, the use of morphine has increased significantly, but is considerably less than in major developed countries 6). The use of pethidine, which is not recommended for chronic pain due to its toxic metabolites12), has decreased in Japan as morphine use has increased.
This paper will discuss the relation of "addiction" to the use of opioids for cancer pain and encourage health care professionals and policy markers to overcome this barrier to adequate management of pain in patients with cancer.
We have been so effective in warning the medical establishment and the public in general about the inappropriate use of opiates that we have endowed these drugs with a mysterious power to enslave that is overrated17).
In the past, official WHO definitions of drug abuse terms have equated addiction and drug dependence with physical dependence. Furthermore, despite the fact that physical dependence is common in the treatment of cancer pain, the definitions have failed to consider that physical dependence can occur independently within a therapeutic setting 14)-16)18)19).
The confusing nature of drug abuse terms, the low incidence of addiction among patients with cancer pain, and the inaccurate use of terms in both professional education and narcotic control laws has become an area of research and discussion 2)4)5)8)11)13)16)18)20)-24).
Clearly, the WHO term "drug dependence" and its predecessors "addiction" and "habituation" are intended to refer to undesirable drug-related states that are harmful to the individual and society. However, the definition and use of these terms often do not take into account the drug-related states that benefit the individual and society. The central definitional issue appears to be that physical dependence and tolerance are often perceived as synonymous with addiction or drug dependence, even though they occur within a therapeutic setting.
WHO's initial efforts to define drug abuse phenomena emphasized the power of morphine-like drugs to produce addiction in everyone:
There are some drugs, notably morphine and pharmacologically morphine-like substances, whose specific pharmacological action, under individual conditions of time and dose, will always produce compulsive craving, dependence, and addiction in any individual ... With these drugs pharmacological action is paramount, psychological make-up adjuvant. Such drugs cause individual and sociological damage and must be rigidly controlled25).
In addition, WHO strongly suggested that medical patients who are treated with opioids will become addicted:
The cycle of administration leading to addiction may begin in legitimate medical use but becomes established as a serious problem through self-administration beyond medical need 25).
There have been attempts to clarify definitions of drug abuse phenomena14)15)26)27). In 1969, the WHO Expert Committee on Drug Dependence produced a revised definition of "drug dependence" which is in effect today. In this definition, the compulsive use of a drug for its psychic effects is the only characteristic that is both necessary and sufficient to define drug dependence. Physical dependence and tolerance may be present, but are neither necessary nor sufficient by themselves to define drug dependence.
A state, psychic and sometimes also physical, resulting from the interaction between a living organism and a drug, characterized by behavioral and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present28).
This definition made psychic dependence the only necessary condition for drug dependence and deleted physical dependence as necessary or sufficient. This was a critically important change in WHO drug abuse nomenclature which received very little attention and is not well known.
Although the WHO did not state any intent to exclude physically dependent pain patients from the new definition of drug dependence, there is evidence that WHO recognized this issue:
...there are some situations in which physical dependence may occur in the absence of significant psychic dependence29).
Inadequate treatment of the [cancer] patient's pain led to behavioral changes similar to those seen with idiopathic opioid psychologic dependence (addiction). The term pseudoaddiction is introduced to describe the iatrogenic syndrome of abnormal behavior developing as a direct consequence of inadequate pain management...Treatment strategies include establishing trust between the patient and the health care team and providing appropriate and timely analgesics to control the patient's level of pains 37).
Available information suggests that some health care professionals may have, to varying degrees. a reluctance to use opiates in the treatment of their patients. There seems to be fear among health professionals (which is shared by certain patients and their families) that the use of opiates will result in iatrogenic addiction... It has been suggested that the training or education received by many health professionals does not focus sufficient attention on the treatment of pain, on the proper use of opiates, or on the treatment of chronic or acute conditions for which those drugs are required or indicated 5).
A recent study examined the accuracy of terminology in U. S. nursing textbooks since 1985. The criterion that was used to evaluate the accuracy of the definitions was the American Pain Society definitions in "Guidelines for Analgesic Use"38) which is analogous to the WHO definition in which neither tolerance or physical dependence by themselves are sufficient to define drug dependence, or addiction.
Only one textbook correctly stated the definition of opioid addiction and its likelihood following use of opioid analgesics for pain control. Almost all of the texts used confusing terminology, and some erroneously promoted the fear of addiction when opioids are used for pain relief 24).
a person who habitually uses a narcotic drug and who by reason of such use is dependent thereon39).
Another provision requires that such persons be reported by their physician as addicts to the state health department40). In 1987, an oncologist was investigated and finally admonished for failing to report several "addicts" that were receiving opioids for an extended period and who were actually oncology patients13).
Nevada defines "narcotic addict" in the following way:
Narcotic addict means a person of any age who has developed a compulsion to continue taking or who has developed a psychic or physical dependence on the effects of a narcotic drug41).
The State of Colorado defines the term addict in the following way: "Addict" means a person who has a
physical or psychological dependence on a controlled substance, which dependence develops following the use of the controlled substance on a periodic or continuing basis and is demonstrated by appropriate observation and tests by a person licensed to practice medicine... 42).
The drug control law of the Republic of Colombia defines "substance dependent" as:
"dependence upon substances which have been medically qualified as toxic" 43).
The above definitions do not attempt to distinguish between addicts and the important therapeutic use of opioids as does, for example, a United States regulation which states that physicians may "administer or dispense (including prescribe) narcotic drugs to persons with intractable pain in which no relief or cure is possible or none has been found after reasonable efforts" 44).
Recognizing the confusion between addiction and physical dependence on pain management, the Medical Board of California made the following statement in its new policy on "Prescribing Controlled Substances for Pain":
...addiction should be placed into proper perspective. Physical dependence and tolerance are normal physiologic consequences of extended opioid therapy and are not the same as addiction. Addiction is a behavioral syndrome characterized by psychological dependence and aberrant drug-related behaviors. Addicts compulsively use drugs for non-medical purposes despite harmful effects; a person who is addicted may also be physically dependent or tolerant. Patients with chronic pain should not be considered addicts or habitués merely because they are being treated with opioids 45).
Recently, the World Health Organization Programme on Substance Abuse was asked by the Pain Research Group at the University of Wisconsin Medical School to clarify whether a physically dependent pain patient was considered to be drug dependent (or addicted). In response, the WHO Expert Committee on Drug Dependence stated that indeed a cancer patient who is physically dependent (as indicated by a withdrawal syndrome) is not considered drug dependent:
the manifestation of withdrawal syndromes in cancer patients given opioid analgesics is not by itself sufficient evidence of dependence 46) .
Furthermore, the Expert Committee made a proactive statement on the need to improve the medical use and availability of opioid analgesics:
The Committee recommended WHO should promote the appropriate use of opioids for the relief of pain through the education of health care professionals (nurses, pharmacists, physicians), health authorities and the general public to ensure that patients with legitimate medical needs receive adequate treatment...progress has been made in increasing the appropriate use of such medications in certain countries. However, there are still many areas of the world where patients continue to suffer needless pain because of the reluctance of health care workers to provide adequate amounts of opioid analgesics46).
One of the significant barriers to cancer pain relief that must be overcome is the fear of addiction to opioids. It is unjust to confuse a patient who may benefit from the medical use of opioids with a drug abuser. Concerted efforts should be made to assure that the terminology used to describe drug abuse phenomenon in common usage, textbooks and narcotic control laws do not inappropriately affect the medical treatment of pain.
2 ) World Health Organization: Cancer pain relief and palliative care: Report of a WHO Expert Committee. Geneva, Switzerland, 1990
3 ) Angarola RT, Joranson DE: Pain and euthanasia: The need for alternatives. APS Bulletin April/May: l0, 17, 1992
4 ) World Health Organization: Cancer pain relief. Geneva, Switzerland, 1986
5 ) International Narcotics Control Board: Demand for and supply of opiates for medical and scientific needs. In Report of the International Narcotics Control Board for 1989. United Nations, 1989 [1995 report]
6 ) Joranson DE: Fear of addiction is an impediment to cancer pain relief: A proposal to the World Health Organization Programme on Substance Abuse, 1993
7 ) Gao S: International workshop on cancer pain relief and research. Beijing, China, 1992
8 ) Jage J: Opioids and the fear of addiction in Germany. Cancer Pain Release 5(2): 1, 1991
9 ) WHO Collaborating Center: Annual Report 1990. Japan: Saitama Cancer Center, 1990
10 ) National Health and Medical Research Council: Management of severe pain: Report of the working party on management of severe pain. Canberra, Australia, 1989
11) Zenz M, Sorge J: Is the therapeutic use or opioids adversely affected by prejudice and law ? Recent Results in Cancer Research 121 : 43-50, 1991
12) Agency for Health Care Policy and Research: Acute pain management: Operative or medical procedures and trauma. Rockville, MD: U.S. Department of Health and Human Services, 1992
13) Joranson DE: Federal and state regulation of opioids. Journal of Pain and Symptom Management 5: S12-S23, 1990
14) Jaffe JH: Misinformation: Euphoria and addiction. In Advances in Pain Research and Therapy, Volume 11, ed by Hill CS Jr, Fields WS. New York, Raven Press, Ltd., 163-174, 1989
15) Houde RW: Misinformation: Side effects and drug interactions. In Advances in Pain Recearch and Therapy, Volume 11, ed by Hill CS Jr, Fields WS. New York, Raven Press, Ltd., 145-162, 1989
16) Foley KM: The "decriminalization' of cancer pain. In Advances in Pain Research and Therapy, Volume 11, ed by Hill CS Jr, Fields WS.New York, Raven Press, Ltd., 5-18, 1989
17) Schuster CR: Does treatment of cancer pain with narcotics produce junkies? In Advances in Pain Research and Therapy, Volume 11, ed by Hill CS Jr., Fields WS. New York, Raven Press, Ltd., 1-3, 1989
18) Morgan JP: American opiophobia: Customary underutilization of opioid analgesics. Advances in Alcohol and Substance Abuse 5: 163-173, 1986
19) Kleber HD: The nosology of abuse and dependence. Journal of Psychiatric Residency 24 (suppl 2) 57-64, 1990
20) Angarola RT, Wray SD: Legal impediments to cancer pain treatment. In Advances in Pain Reseach and Therapy, Volume 11, ed by Hill CS Jr., Fields WS. New York, Raven Press, 213-231, 1989
21) Hill CS: The negative effect of regulatory agencies on adequate pain control. Primary Care and Cancer November: 47-53, 1989
22) Portenoy RK: Chronic opioid therapy in nonmalignant pain. Journal of Pain and Symptom Management 5(1): S46-S62, 1990
23) Fishbain DA, Rosomoff HL, Rosomoff RS: Drug abuse, dependence, and addiction in chronic pain patients. The Clinical Journal of Pain 8: 77-85, 1992
24) Ferrell BR, McCaffery M, Rhiner M: Pain and addiction: An urgent need for change in nursing education. Journal of Pain and Symptom Management 7(2): 117-124, 1992
25) World Health Organization: WHO Expert Committee on drugs liable to produce addiction: Third report. Geneva, Switzerland, 1952
26) World Health Organization: WHO Expert Committee on addiction-producing drugs: Seventh report. Geneva, Switzerland, 1957
27) Rinaldi RC, Steindler EM, Wilford BB, Goodwin D: Clarification and standardization of substance abuse terminology. JAMA 259(4): 555-557, 1988
28) World Health Organization: WHO Expert Committee on drug dependence: Sixteenth report. Geneva, Switzerland, 1969
29) World Health Organization: WHO Expert Committee on drug dependence: Nineteenth report. Geneva, Switzerland, 1973
30) Porter J, Jick H: Addiction rare in patients treated with narcotics. New England Journal of Medicine 302: 123, 1980
31) Senay E (Quoted in Marks EM, Sachar EJ): Undertreatment of medical inpatients with narcotic analgesics. Annals of Internal Medicine 78: 173-181, 1973
32) Taub A: Opioid analgesics in the treatment of chronic intractable pain of nonneoplastic origin. In Narcotic analgesics in anesthesiology, ed by Kitahata LM, Collins D. Baltimore, Williams and Wilkens, l99-208, 1982
33) Tennant FS, Rawson RA: Outpatient treatment of prescription opioid dependence. Archives of Internal Medicine 142: 1845-1847, 1982
34) Tennant FS, Uelman OF: Narcotic maintenance for chronic pain: Medical and legal guidelines. Postgraduate Medicine 73: 8194, 1983
35) Portenoy RK, Foley KM: Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases. Pain 25: 171-186, 1986
36) Zene M, Strumpf M, Tryba M: Long-term oral opioid therapy in patients with chronic nonmalignant pain. Journal of Pain and Symptom Management 7(2): 69-77, 1992
37) Weissman DE, Haddock JD: Opioid pseudoaddiction an iatrogenic syndrome. Pain 36: 363-366, 1939
38) American Pain Sociaty: Principles of analgesic use in the treatment of acute pain and cancer pain (Third Ed.). Skokie, Illinois, 1992
39) New York State Controlled Substances Act, Section 3302. 1.
40) New York State Controlled Substances Act, Section 3372.
41) Nevada Uniform Controlled Substances A., Section 453. 098.
42) Colorado Controlled Substances Act, Section 12-22-303.
43) National Drug Statute, Article 2, January 30, 1986
44) Code of Federal Regulations. Title 21 Part 1306.07(c), 1988
45) Medical Board of California: Prescribing controlled substances for pain. May 6, 1994. Sacramento, California, 1994
46) World Health Organization: WHO Expert Committee on drug dependence: Twenty-eighth report. Series 836. Geneva, Switzerland, 1993