Drug Dependency Complicating Therapy for Chronic Pain
By, Dr Michael McDonough, Drug Dependency Unit, Western Hospital, Melbourne, Victoria
An estimated 5% to 10% of the general population will acquire some form of drug dependence in their lifetime hence doctors treating common conditions such as pain are likely to have to confront the management of this challenging co-morbidity. While most pain patients appear to “depend” on their analgesic medication to some extent, the majority will not meet DSM IV criteria for a Dependence Syndrome. Patients who use opioid analgesics daily usually develop Neuroadaptation (i.e. physiological dependence) which may eventually lead to tolerance problems but not necessarily a Dependence Syndrome or Addiction. The risk factors for developing Drug Dependence/Addiction include a background history of substance abuse, family history of same, childhood emotional trauma and cigarette smoking. Any aberrant (ie. involving the actual/potential risk of harm) drug-related behaviours should alert the treating doctor to the potential risk of that patient having/developing Drug Dependence and/or sustaining some form of drug related harm. Some patients without a Drug Dependence Syndrome may still manifest drug-related problems while other patients who have a Drug Dependence Syndrome do not always manifest the same degree of drug-related problems ( by analogy, a similar situation exists for Alcohol use in the community). Some research has shown few differences between opioid-taking chronic pain patients and chronic pain patients who have co-morbid Drug Dependence. The management of the states of Neuroadaptation, Aberrant Drug Related Behaviours and Drug Dependence will be discussed. Generally, Aberrant Drug Related Behaviours require the implementation of specific Risk Management Strategies while Drug Dependence also requires specific treatment for the maintenance of abstinence from drugs of dependence (thus requiring “alternative” approaches to pain management) or medically managed, maintenance pharmacotherapy eg. may be provided within the context of a specialist Methadone/Buprenorphine Program. Knowledge of and compliance with State drug regulations is essential for all prescribers of Drugs of Dependence. When managing acute and/or chronic pain in patients with established Drug Dependence, it is always recommended to liaise with an Addiction Medicine service.
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