Concerns About Addiction: Bringing Clarity to Confusion about Addiction Terminology Aaron M. Gilson, MS, MSSW, PhD Research Program Manager/Senior Scientist Pain & Policy Studies Group International Pain Policy Fellowship Pain & Policy Studies Group WHO Collaborating Center for Pain Policy & Palliative Care University of Wisconsin Carbone Cancer Center August 6, 2012

Evolution of WHO Terminology and Beliefs  World Health Organization Expert Committees  1950 “Drug Addiction”*  1957 “Drug Addiction”  1964 “Drug Dependence”  1969 “Drug Dependence”  1990 “Drug Dependence”  1993 “Drug Dependence”*  1998 “Dependence Syndrome”*  International Classification of Diseases

 Three elements co-occur within the preceding year: 1)Strong desire 2)Difficulties in control 3)Use occurs despite harm 4)Neglect of pleasures; increased time to obtain substance 5)Tolerance 6)Physical withdrawal * The diagnostic requirement of essential characteristics would exclude patients who are being treated with opioids for the relief of pain. “Dependence Syndrome” ~ Current International Diagnosis ~ World Health Organization. International Classification of Diseases (10 th edition). 1992;75-76.

 Maladaptive pattern of substance use, leading to clinically significant impairment or distress  Manifested by three (or more) of the following:  Tolerance  Withdrawal  Use in larger amounts or durations than intended  Use persists despite desire or efforts to control  Much time spent to obtain, use, or recover from effects  Decreased social, occupational, or recreational activities  Use occurs despite harm American Psychiatric Association. Diagnostic and Statistical Manual (4 th edition). 1994;181. “Substance Dependence” ~ Current U.S. Diagnosis ~

 Maladaptive pattern of substance use, leading to clinically significant impairment or distress  Manifested by one (or more) of the following:  Failure to fulfill major role obligations at work, school, or home  Recurrent use in situations in which it is physically hazardous  Recurrent legal problems  Persistent or recurrent social or interpersonal problems American Psychiatric Association. Diagnostic and Statistical Manual (4 th edition). 1994; “Substance Abuse” ~ Current U.S. Diagnosis ~

 Maladaptive pattern of substance use leading to clinically significant impairment or distress  Manifested by two (or more) of the following:  Failure to fulfill major role obligations at work, school, or home  Recurrent use in situations in which it is physically hazardous  Persistent or recurrent social or interpersonal problems  Use in larger amounts or durations than intended  Use persists despite desire or efforts to control  Much time spent to obtain, use, or recover from effects  Decreased social, occupational, or recreational activities  Continues despite knowledge of having a problem  Craving or strong desire to use American Psychiatric Association. DSM-5 Substance-Related Disorders Work Group. “Substance Use Disorder” ~ Future U.S. Diagnosis ~

Additional indicators  Tolerance  Withdrawal syndrome Note: Tolerance or Withdrawal are not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications, or beta-blockers American Psychiatric Association. DSM-5 Substance-Related Disorders Work Group. “Substance Use Disorder” ~ Future U.S. Diagnosis ~

Calls for Policy Reform  UN International Narcotics Control Board  U.S. Institute of Medicine  Council of Europe  UN Economic and Social Council  World Health Organization

International Narcotics Control Board 1989, 1996, 2005, 2007, 2010  Governments should examine their drug control policies for the presence of overly restrictive provisions that may impact their health care system in the delivery of pain relief, and take corrective action as needed  Addiction and its terminology International Narcotics Control Board. Reports for 1989, 1995, 2004, 2007, and New York, NY: United Nations; 1989, 1996, 2005, 2007, 2010.

World Health Organization. Achieving Balance in National Opioids Control Policy: Guidelines for Assessment. Geneva, Switzerland: WHO; WHO Ensuring Balance Guideline, 2011  Guideline 10: Terminology in national drug control legislation and policies should be clear and unambiguous in order not to confuse the use of controlled medicines for medical and scientific purposes with misuse  “dependence” vs. “dependence syndrome”  avoid use of stigmatizing terms like “addiction” in legislation

Occurrence of Addiction in Medical Treatment with Rx Opioids Webster L, Webster R. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Medicine. 2005;6: Theoretical Prevalence Theoretical Prevalence Total Pain Population Aberrant Behaviors 40% Abuse 20% Addiction 2-5%

Occurrence of Addiction in Medical Treatment with Rx Opioids  Fleming et al.3.1%  UW outpatients with chronic non-cancer pain  DSM “substance dependence”  Fishbain et al.3.3%  Meta-analysis of studies of patients with chronic non-cancer pain  addiction (typically undefined) Statistical Prevalence Statistical Prevalence Fishbain et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Medicine. 2008;9: Fleming et al. Substance use disorders in a primary care sample receiving daily opioid therapy. Journal of Pain. 2007;8:

Occurrence of Addiction in Medical Treatment with Rx Opioids Boscarino et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health- care system. Addiction. 2010;105: < 65 years 3.59 < 65 years + Pain impairment 4.63 < 65 years + Pain impairment + Depression Hx < 65 years + Pain impairment + Depression Hx + Psychotropic meds < 65 years + Pain impairment + Depression Hx + Psychotropic meds + Severe Rx opioid dpnd Hx < 65 years + Pain impairment + Depression Hx + Psychotropic meds + Severe Rx opioid dpnd Hx + Rx opioid abuse Hx Current Rx opioid dependence (DSM-IV) (n=705; 25.8%) Odds Ratio

Need to Consider the Spectrum of Non-Medical Use of Rx Opioids Misuse (unintentional) e.g., - sharing with others - unknowingly taking larger amounts than directed - inadvertent poisoning Dependence Syndrome (“Addiction”) Abuse Misuse (intentional) e.g., - recreational use for psychic effects - decide to increase dose for pain control - suicidal gesture or attempt Use involving aberrant behaviors e.g., - forging/altering prescriptions - going to multiple doctors - stealing drugs Concurrent use of illicit drugs or undisclosed Rx medication use

Conclusions  Evolution in concept and terminology  New medical and scientific understanding  Research evidence about prevalence  Fear of addiction limits access to pain relief  Influences content of laws and other policies  Definitions in laws of many countries have not changed  Ample expert guidance and tools exists  To evaluate national drug control and healthcare policies  To correct the definitions  Changes have legal and clinical implications

Action Steps: Communicating to Others  Do not assume that the other person understands what is meant by the term “addiction”  find out about his or her beliefs and offer to clarify if necessary  Clarify how available terminology relates to currently- accepted standards (WHO concept of “dependence syndrome”)  Ensure that “addiction” does not characterize only the development of withdrawal syndrome or tolerance  Clarify that “addiction” cannot always be identified by behaviors alone  motivations for such behaviors are important

 Clarify that available U.S. research suggests that iatrogenic addiction is more prevalent when patients have existing co-morbidities (e.g., substance abuse history)  practitioners need to assess for co-morbidities, and then monitor for the development of addiction throughout treatment  Determine if data are available in your country to document the prevalence or incidence of “addiction”  Determine the sources of opioid analgesics used by people with the disease of addiction  Determine how perceptions about addiction are influencing the treatment of people with chronic pain Action Steps: Communicating to Others