“Opium! Dread agent of unimaginable pleasure and pain!” – Thomas de Quincey, Confessions of an English Opium Eater (1820)
Opioid addiction seems to be in the news every day. But what’s the difference between an opioid user and an opioid addict?
First, let’s define our terms. Opioids are drugs derived from the opium poppy, including heroin and morphine. The class also includes synthetic opium-derived prescription painkillers including oxycontin and fentanyl, as well as drugs used to treat opioid addiction, such as methadone and buprenorphine. Since the 1990s, increasing amounts of painkillers have been prescribed by physicians, and both prescription and illicit opioid use, and related mortality, have increased substantially in recent years. Last year, Medical Care published an article calling the current crisis “arguably the greatest iatrogenic epidemic in the history of America.”
The National Survey on Drug Use and Health, fielded by the Substance Abuse and Mental Health Services Administration (SAMHSA), adopted a revised definition of prescription drug misuse [PDF] in 2015. It defines misuse as use that is in any way not directed by a doctor, including:
- use without a prescription of one’s own;
- use in greater amounts, more often, or longer than told to take a drug; or
- use in any other way not directed by a doctor.
That definition is a bit different from the typical definition of addiction—or, in current terminology, opioid use disorder—a much more serious condition that is characterized by the 4 Cs: impaired control over drug use, compulsive use, continued use despite harm, and craving. Misuse, as defined above, can be either intentional or unintentional (such as an older person forgetting whether they have taken a dose and taking one too many), just as addiction can be seen as both voluntary and involuntary.
Experts in addiction medicine have further described addiction as characterized by:
- Inability to consistently abstain
- Impairment in behavior control
- Craving
- Diminished recognition of significant problems with one’s behaviors and interpersonal relationships
- A dysfunctional emotional response
How does the number of misusers of pain relievers compare to the number of people who use pain relievers as directed? According to the 2015 NSDUH report, in the past year 97.5 million people over age 12 used prescription pain relievers, and an estimated 12.5 million of them misused pain relievers. Within that group, about 2.5 million people were estimated to have an opioid use disorder.
So, the vast majority of people (87%) report using their medications as directed by a doctor. Now whether those prescriptions were warranted — or whether the backlash against prescribing opioids for non-cancer, chronic pain is deserved — is a question for another post. Obviously, non-opioid (including behavioral) treatments for pain are preferred, and chronic opioid use can lead to serious adverse effects. In my view, the trick is to follow evidence-based practice and clinical guidelines while treating each person individually, as a whole person.
Adequate pain control is a fundamental human right, and inadequate pain management has serious detrimental effects on physical and mental function. Yet undertreatment remains a substantial problem, especially for women and racial/ethnic minorities. (As I have previously written, I have a family member living with chronic pain.)
A consensus statement from 21 health organizations and the Drug Enforcement Agency concluded that:
“Effective pain management is an integral and important aspect of quality medical care, and pain should be treated aggressively… Preventing drug abuse is an important societal goal, but it should not hinder patients’ ability to receive the care they need and deserve.”
Here at The Medical Care Blog, we have written about many opioid-related studies published in Medical Care, including research on trends in opioid use and mortality and opioid prescribing and opioid treatment. We have also written about the economic impact of the opioid epidemic. In these discussions, it is important to keep in mind that while opioid addiction is a serious and growing problem, we should not over-react to the point of returning to the bad old days of widespread undertreatment for pain. Let’s not paint every opioid user as an addict – that is neither helpful nor accurate.
Lisa M. Lines