Can we create addicts Iatrogenically?

[Planktonmd]

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There is an announcement on top of the front page of the forum by a pharmacist SDN administrator presenting an article by a psychologist that is basically telling us that in order to make someone an addict there is many factors that need to come together to make a patient a drug addict by giving Narcotics.

here is the quote:

What is the number one thing you wish the general public understood about the problem of chronic pain?
I would like to teach people that opioids do not create addicts simply by exposure. Simply put, there is no iatrogenic addiction associated with exposure to opioids. Patients need to have a unique constellation of genetic, familial, social, psychological, and spiritual components to be vulnerable to addiction. I spend a great deal of time explaining to patients (who have no risk factors) why it is highly unlikely they will become addicts...

I have a few issues with this:
1- When someone has a certain opinion about a subject they should post it for discussion not as an announcement to "educate us" about pain.
2- I strongly disagree with the statements in the interview and based on my clinical experience and knowledge it is my opinion that we actually create drug addicts Iatrogenically every day in every pain clinic and the only individual variation is the amount and the duration needed to turn someone into an addict.
In other words: We can always make a patient a drug addict but some people require higher doses and longer treatment than others based on genetics and psycho-social factors.
Let's hear what everyone thinks about this.

 

[Bertelman]

What is the number one thing you wish the general public understood about the problem of chronic pain?
I would like to teach people that opioids do not create addicts simply by exposure. Simply put, there is no iatrogenic addiction associated with exposure to opioids. Patients need to have a unique constellation of genetic, familial, social, psychological, and spiritual components to be vulnerable to addiction. I spend a great deal of time explaining to patients (who have no risk factors) why it is highly unlikely they will become addicts...

As for the statement, I'm not sure I understand the difference between familial and genetic components. Despite what is implied, I don't think the "constellation" is very unique at all, and many become addicts with only 1-2 of the above risk factors, most importantly psychologic and genetic factors. Furthermore, the spiritual component is presumptuous, and the term itself is difficult to define. Most people would look at my life and say I possess little spirituality. Does that leave me at risk? Why?

Tell someone like Brett Favre, who by all accounts is a responsible, upstanding citizen with confidence and poise, that his addiction to Vicodin was related only to a few of the above factors, and had nothing to do with how it was prescribed.

I'm not comparing myself to Brett, but I came close to relying on hydrocodone after my wisdom teeth. By all other measures, I had no risk factors for addiction. I can consume alcohol responsibly, and have never felt I couldn't live without a drink. No psychologic issues. Closest genetic link is grandparents or uncles. Neither of my parents drink with any regularity. But those pain meds were different. Honestly, I don't know how someone familiar with opioid receptors could question the thought that many people become addicts based on prescribing habits.

 

[Intubate]

This is semantics. Dependence is iatrogenically created, not addiction.

 

[Planktonmd]

This is semantics. Dependence is iatrogenically created, not addiction.

Dependence is a step on the road to addiction.

 

[IceDoc]

Dependence is a step on the road to addiction.

It's also the exact effect of the drug on the individual. I'll never forget the former addict who had surgery, received a small amount of Dilaudid from me, and woke up saying 'it feels like I just took some heroin.'

I think I get what the pharmacist is driving at: i.e. addiction is a psychological collage of influencing factors. However, the media is full of reports of 'addicts' (especially celebrity ones) who became so only after receiving some form of narcotic after a surgical procedure. Presumably these individuals would not have become addicted had they never been exposed in the first place.

 

[SleepIsGood]

the problem is that a pharmacist and not a physician is consulted on this subject.

I see this as a new trend, even if you're reading random magazines and newspapers nowadays....Quite scary.

 

[gas87]

The examples you site of celebrities becoming addicted to their prescribed pain meds only highlights the need for more highly trained pain specialists and closer managment by these physicians of chronic pain problems. Using a multimodal approach supervised by a specialist (physical therapy, opioid sparing with non-opioid pain meds, regional procedures, massage, accupuncture, etc.) will decrease the actual and percieved "dependence" on opioids for the patient.
Also consider this scenerio: for the terminal patient with 6 months or less to live, do you care if they become an addict? do you seriously think it will negatively impact their quality of life in the time they have left?

 

[bubalus]

More semantics regarding dependence vs. addiction: There was a patient in the pain clinic who was on percocet, 2-3 per day. Stable and doing well, but didn't like the idea of being on percocet, but didn't see much of a way off given her conditions. The physician opined that she was dependent on percocet in a similar way to diabetics being dependent on insulin, and that if she were going to become addicted, it would have happened long before. The percocet wasn't causing problems, and she wasn't focusing her efforts on obtaining more, and she wasn't using it to get high. The percocet helped control her pain so she could function at the level she desired. In the right patient population, this is a reasonable explanation. With other patients, I wouldn't try this.

If I've got a terminal patient with 6 months to live, I say give them a bottle of roxanol and tell them to enjoy it. I once saw an ID fellow admit an end stage AIDS patient to the hospital. The guy maybe had 1-2 months left at the tops, and this could easily have been his last admission, and the fellow went on to tell this dying patient he needed to quit smoking.

 

[drusso]

I think that people are missing some very basic concepts:

1) Tolerance is a physiologic response to exposure to a substance. Most people who drink coffee become tolerant to caffeine.

2) Dependence can only be defined post-hoc by the presence of a withdrawal reaction after removal of a substance---an abstinence syndrome.

3) Addiction is a NEUROBEHAVIORAL problem characterized by craving, loss of control, and continued use of a substance despite harm to self or others.

The American Academy of Pain Medicine has an expert concensus statement on these issues with respect to management of chronicly painful syndromes. Addiction medicine and the DSM-IV does not recognize the normal physiologic signficance of tolerance and tends to overemphasize "chemical dependence" which leads to hazards in communication between addiction specialists and pain specialists.

http://www.painmed.org/pdf/definition.pdf

 

[pharmacogenomic]

I think that people are missing some very basic concepts:

1) Tolerance is a physiologic response to exposure to a substance. Most people who drink coffee become tolerant to caffeine.

2) Dependence can only be defined post-hoc by the presence of a withdrawal reaction after removal of a substance---an abstinence syndrome.

3) Addiction is a NEUROBEHAVIORAL problem characterized by craving, loss of control, and continued use of a substance despite harm to self or others.

The American Academy of Pain Medicine has an expert concensus statement on these issues with respect to management of chronicly painful syndromes. Addiction medicine and the DSM-IV does not recognize the normal physiologic signficance of tolerance and tends to overemphasize "chemical dependence" which leads to hazards in communication between addiction specialists and pain specialists.

http://www.painmed.org/pdf/definition.pdf

As a pharmacist, you've hit the nail right on the head here!

I can't find the article the OP is referring to, but most of the pharmacy forum administrators aren't even pharmacists, let alone with pain management experience! Some of the moderators & advisors are, but I don't know one who has pain management as a specialty.

There is a world of difference between patients who are treated for pain by appropriate prescribers & are monitored by those of us who dispense and those patients who seek out pain medication for reasons other than relief of pain.

Most pharmacists who have experience in pain management, whether it is in hospice or non-hospice patients work well with the prescriber to meet the agreement which the prescriber and patient have agreed upon. Our communications with the prescriber are uniformly met with welcome collaboration. I say that statement with 30+ years of experience in a hospital with a pain management center, altho I, myself, am not one of the pain management pharmacists, but do deal with hospice patients.

The drug seeker is different from the patient who is being treated for chronic pain & we can tell the difference - normally. There are always those who are really, really "good".

Personally, I think the individual who wrote the article is misleading & simplistic - I'd be curious as to the pharmacist's credentials in pain management - which is a long road to travel to know fully how patients & the prescribers within a practice area work. Pain as a medical specialty is a difficult & time intensive job - I only work to maintain sufficient communication with the primary pain specialist & all other prescribers who might be used to "supplement" the regimen or when the patient is using the medication faster than prescribed. That requires a disussion with the prescriber - not me!

 

[Planktonmd]

I think that people are missing some very basic concepts:

1) Tolerance is a physiologic response to exposure to a substance. Most people who drink coffee become tolerant to caffeine.

2) Dependence can only be defined post-hoc by the presence of a withdrawal reaction after removal of a substance---an abstinence syndrome.

3) Addiction is a NEUROBEHAVIORAL problem characterized by craving, loss of control, and continued use of a substance despite harm to self or others.

The American Academy of Pain Medicine has an expert concensus statement on these issues with respect to management of chronicly painful syndromes. Addiction medicine and the DSM-IV does not recognize the normal physiologic signficance of tolerance and tends to overemphasize "chemical dependence" which leads to hazards in communication between addiction specialists and pain specialists.

http://www.painmed.org/pdf/definition.pdf

No,
We are not missing these basic concepts!
Everyone knows this classification but what people tend to forget is that these different stages are not really separate entities and they often overlap and coexist.
In other words: addiction is not an all or none situation, it's not black or white but rather a spectrum of many shades of gray.
And I am talking about addiction not dependence or tolerance.
I think that in order to properly treat chronic pain patients we have to admit that we are capable of creating addicts even in people who seem not to have obvious "risk factors".
If iatrogenic addiction was not possible as was suggested in that interview:
http://studentdoctor.net/blog/2007/11/10/20-questions-for-a-clinical-psychologist-kenneth-kirsh-phd/
Then why do we even worry about controlling and regulating the prescribing patterns to chronic pain patients?

 

[drusso]

No,
We are not missing these basic concepts!
Everyone knows this classification but what people tend to forget is that these different stages are not really separate entities and they often overlap and coexist.
In other words: addiction is not an all or none situation, it's not black or white but rather a spectrum of many shades of gray.
And I am talking about addiction not dependence or tolerance.
I think that in order to properly treat chronic pain patients we have to admit that we are capable of creating addicts even in people who seem not to have obvious "risk factors".
If iatrogenic addiction was not possible as was suggested in that interview:
http://studentdoctor.net/blog/2007/11/10/20-questions-for-a-clinical-psychologist-kenneth-kirsh-phd/
Then why do we even worry about controlling and regulating the prescribing patterns to chronic pain patients?

Yes, you are missing the basic concept. There is no such thing as "a little addiction." The disease of addiction is a categorically different from the normal physiologic development of tolerance or the development of an abstinence syndrome typified by withdrawal symptoms. Addiction is a neurobehavioral problem *BECAUSE* of a substance.

Plenty of people become tolerant and physically dependent on substances yet never loose control, develop craving, or harm themselves or others because of the substance. Some people are "social" drinkers: They drink, maybe even binge on the weekends, but then their friend gets in a car accident and they stop cold turkey--no abstinence syndrome, no withdrawal. Some people are "situational smokers;" they only smoke when they play pool or hang out with their college friends. Some become "habitual smokers or drinkers." They may experience withdrawal (headaches from smoking or agitation from drinking) when they stop, but they nonetheless do it relatively easily. Again, no craving, no loss of control, no harm to self or others.

Iatrogenic addiction is a concept difficult for me to visualize, but would certainly be unethical practice of medicine. I suppose if you were knowing prescribing opioids to someone with an active heroin addiction you would be exacerbating an iatrogenic addiction. Anyone who practices pain medicine needs to carefully assess and refer for treatment anyone who displays neurobehavioral signs and symptoms of addiction.

 

[Planktonmd]

Yes, you are missing the basic concept. There is no such thing as "a little addiction." The disease of addiction is a categorically different from the normal physiologic development of tolerance or the development of an abstinence syndrome typified by withdrawal symptoms. Addiction is a neurobehavioral problem *BECAUSE* of a substance.

Plenty of people become tolerant and physically dependent on substances yet never loose control, develop craving, or harm themselves or others because of the substance. Some people are "social" drinkers: They drink, maybe even binge on the weekends, but then their friend gets in a car accident and they stop cold turkey--no abstinence syndrome, no withdrawal. Some people are "situational smokers;" they only smoke when they play pool or hang out with their college friends. Some become "habitual smokers or drinkers." They may experience withdrawal (headaches from smoking or agitation from drinking) when they stop, but they nonetheless do it relatively easily. Again, no craving, no loss of control, no harm to self or others.

Iatrogenic addiction is a concept difficult for me to visualize, but would certainly be unethical practice of medicine. I suppose if you were knowing prescribing opioids to someone with an active heroin addiction you would be exacerbating an iatrogenic addiction. Anyone who practices pain medicine needs to carefully assess and refer for treatment anyone who displays neurobehavioral signs and symptoms of addiction.

This is precisely where I am disagreeing with you.
Is it that complicated?
I am saying that the disease process for addiction is actually the same one for tolerance and dependence, just one step further.
I am not missing the basic concept I am actually saying it is invalid.
I am saying that I can take a chronic pain patient who does not show any of the "risk factors" for addiction, blast him with narcotics, and after a certain amount of time he becomes an addict who will fit your definition of addiction, he will start seeking the drug, manipulate the system to get more, and his social functioning will be identical to that of a typical addict who started taking the drug for recreation.
This happens everyday and we ignore it because we are being taught that there is no such a thing as iatrogenic addiction.

 

[All4MyDaughter]

There is an announcement on top of the front page of the forum by a pharmacist SDN administrator presenting an article by a psychologist that is basically telling us that in order to make someone an addict there is many factors that need to come together to make a patient a drug addict by giving Narcotics.

I'm the administrator that posted the announcement.
I'm also the staff writer who wrote the article, although "wrote" is a misleading verb to use because it was a question and answer email interview and Dr. Kirsh's answers were included verbatim with no editing by me.

I'm a pharmacy student, not a pharmacist.

I have a few issues with this:
1- When someone has a certain opinion about a subject they should post it for discussion not as an announcement to "educate us" about pain.
2- I strongly disagree with the statements in the interview...

The purpose of the announcement was to get you to go to the front page and read the entire article. Did you?

The announcements are often used as advertising for SDN features.
You should read the article if you haven't - there is a place for you to leave comments there as well, if you wish.

Remember, it is a Q & A interview. The answers are the opinion of the professional being interviewed. You are free to agree or disagree. 🙂

I'm not sure I understand the difference between familial and genetic components.

Familial components include who you live with and what their habits are. You might have a genetic predisposition to addiction but if you live in a home where no one drinks, smokes or takes drugs that may provide some protection. Likewise, you might not have any genetic predisposition but if you live with a people (they do not even need to be related to you) who are addicts and engaged in frequent drug-use, that would be considered a "familial" risk factor.

the problem is that a pharmacist and not a physician is consulted on this subject.
I see this as a new trend, even if you're reading random magazines and newspapers nowadays....Quite scary.

Read the article. No pharmacist involved. A medical psychologist who is employed in the field of pain management and working in a multi-disciplinary pain treatment center is the subject of the interview. A pharmacy student (moi) conducted the interview.

I can't find the article the OP is referring to, but most of the pharmacy forum administrators aren't even pharmacists, let alone with pain management experience! Some of the moderators & advisors are, but I don't know one who has pain management as a specialty.
*snip*
Personally, I think the individual who wrote the article is misleading & simplistic - I'd be curious as to the pharmacist's credentials in pain management...

There are several members of the SDN staff who have pain management credentials. Some of us have other training in addiction and drug abuse issues, (probably not 30 years' worth though 😉). In my former career as a non-profit executive I was certified as a drug abuse prevention professional. But I really didn't need to use that training to conduct the interview that makes up this article.

You admit to having not read the article you find "misleading and simplistic." That's ironic. Had you read it, you'd know that there is no pharmacist quoted and that the subject of the interview is a medical psychologist.

If any of you would like to read the article, it is still available here: Ken Kirsh, PhD. I encourage you to read the entire article and leave your comments.

 

[Planktonmd]

The purpose of the announcement was to get you to go to the front page and read the entire article. Did you?

.

What makes you assume I did not read the article?

 

[Planktonmd]

Familial components include who you live with and what their habits are. You might have a genetic predisposition to addiction but if you live in a home where no one drinks, smokes or takes drugs that may provide some protection. Likewise, you might not have any genetic predisposition but if you live with a people (they do not even need to be related to you) who are addicts and engaged in frequent drug-use, that would be considered a "familial" risk factor.



.

For your information:
People you live with but not related to you = Environmental risk.
Familial risk = Genetic risk.

 

[All4MyDaughter]

What makes you assume I did not read the article?

Thank you for using the large black type. That really does help make your point. 🙂 You'll notice that I asked if you read the article. There were a couple of things that caused me to wonder if you had, but this was the main one:

When someone has a certain opinion about a subject they should post it for discussion not as an announcement to "educate us" about pain.

To me, that shows confusion about the purpose of the announcement (advertisement vs. educational) and the purpose of the article in general, which was to present an overview of the career of one professional working in the medical field (the purpose of all our 20 Questions articles) vs. to be an oratory piece on pain management. That's why I asked if you'd read it.

RE: your other point (familial, environmental, genetic) about classification of risk factors - I pulled that pretty much verbatim from my medical psych textbook. It presents one system of classification - the one that the author of the textbook likes. No doubt there are many variations that are equally valid. It isn't as if that's an exact science.

Thanks for your feedback. 🙂

 

[Planktonmd]

Thank you for using the large black type. That really does help make your point. 🙂

I was just trying to highlight a portion of the text, no insult intended.
Sorry.

 

[Tenesma]

go to youtube --- type in oxycodone, oxycontin or any other opioid name - there are literally thousands of videos by young kids (late teens to early twenties) who describe that they became addicted to opioids after being treated for pain....

so we can argue about the semantics - we can argue about genetic, neurobehavioral, environmental issues -

what we can't argue about is the issue that yes pain meds are a conduit to potential addiction - and that is why risk assessment and careful monitoring is crucial

 

[drusso]

This is precisely where I am disagreeing with you.

Is it that complicated?

--SNIP--

I am saying that I can take a chronic pain patient who does not show any of the "risk factors" for addiction, blast him with narcotics, and after a certain amount of time he becomes an addict who will fit your definition of addiction, he will start seeking the drug, manipulate the system to get more, and his social functioning will be identical to that of a typical addict who started taking the drug for recreation. This happens everyday and we ignore it because we are being taught that there is no such a thing as iatrogenic addiction.

It is that complicated or else we wouldn't be having this discussion and there wouldn't be at least 3 medical specialties grappling with these issues head-on.

A substance is NECESSARY but not SUFFICIENT for the development of addiction. The feds realize this and thats why we have the scheduling system.

You can't take **ANY** chronic pain patient and blast them with opioids and make them an addict. I am routinely asked by patients with chronic pain, who have been mis-managed by their physician, to come off pain medication (because it's expensive or because of side-effects) and try other treatment modalities---spinal cord stimulators, etc. They're not out of control (in fact they're highly functional human beings), they're not craving it (they want off), and there not harmful. They're just sick and tired of using a substance to manage their symptoms. It's no different than patients on steroids for vasculitis or RA.

There's no doubt that SOME patients are not good candidates for time-contingent opioid treatment, but this is why PAIN SPECIALISTS with the appropriate training and access to addiction treatment services should make these assessments...it's harder than you think.

 

[Tenesma]

actually planktonmd is kind of right in the sense that mu opioid receptors in the nucleus accumbens upon repeated exposure will entice further use due to the reward system that develops

so if you were to instill opioids intra-ventricularly you would likely get behaviors similar or identical to addiction

and drrusso is right in that most people don't like the side-effects and that can be enough to negate the nucleus accumbens/reward system

but overall opioids are EVIL and should ONLY be used with clear patient selection criteria, stringent risk assessment and constant monitoring
--- if the patients pass those criteria then the opioids become GOOD

but if you speak to any addictionologist they will usually tell you the same old story that the addicts tell them: "my problem started when my doc prescribed vicodin for my back pain"... hard to ignore that fact.

 

[Planktonmd]

It is that complicated or else we wouldn't be having this discussion and there wouldn't be at least 3 medical specialties grappling with these issues head-on.

A substance is NECESSARY but not SUFFICIENT for the development of addiction. The feds realize this and thats why we have the scheduling system.

You can't take **ANY** chronic pain patient and blast them with opioids and make them an addict. I am routinely asked by patients with chronic pain, who have been mis-managed by their physician, to come off pain medication (because it's expensive or because of side-effects) and try other treatment modalities---spinal cord stimulators, etc. They're not out of control (in fact they're highly functional human beings), they're not craving it (they want off), and there not harmful. They're just sick and tired of using a substance to manage their symptoms. It's no different than patients on steroids for vasculitis or RA.

There's no doubt that SOME patients are not good candidates for time-contingent opioid treatment, but this is why PAIN SPECIALISTS with the appropriate training and access to addiction treatment services should make these assessments...it's harder than you think.

I think I have to repeat myself:
Iatrogenic addiction is a reality, and very common.
If you deny it's existence it won't go away!
This is why every pain practice must monitor patient compliance closely and do contracts and random urine tests.
Addictive personality is very common in the general public and this is why there are so many smokers, alcoholics and obese people, You do agree that these are addictions don't you?
So these people are out there and all they need is a substance and we supply it to them.
I am not saying stop prescribing Narcotics, I am just saying let's just admit that we are part of the problem so we can address it correctly.
I also appreciate your attempt to educate me on what real " PAIN SPECIALISTS" do but sometimes it helps to stop educating and just listen.

 

[phillyfornia]

It is that complicated or else we wouldn't be having this discussion and there wouldn't be at least 3 medical specialties grappling with these issues head-on.

A substance is NECESSARY but not SUFFICIENT for the development of addiction. The feds realize this and thats why we have the scheduling system.

You can't take **ANY** chronic pain patient and blast them with opioids and make them an addict. I am routinely asked by patients with chronic pain, who have been mis-managed by their physician, to come off pain medication (because it's expensive or because of side-effects) and try other treatment modalities---spinal cord stimulators, etc. They're not out of control (in fact
they're highly functional human beings), they're not craving it (they want off), and there not harmful. They're just sick and tired of using a substance to manage their symptoms. It's no different than patients on steroids for vasculitis or RA.

There's no doubt that SOME patients are not good candidates for time-contingent opioid treatment, but this is why PAIN SPECIALISTS with the appropriate training and access to addiction treatment services should make these assessments...it's harder than you think.

i'm curious as to what a person would have to do in order for you to consider him/her an addict. i ask b/c the patients you describe above could be considered addicts, couldn't they? although they would like to get off the meds, something is compelling them to continue taking them. couldn't that be considered a craving or loss of control. these meds are also adversely affecting their lives (b/c of side effects or their financial cost), couldn't that be considered harm to self? i think that the very fact that these people want to get off these drugs but are not able to suggests that these people might be addicted to these medications.

i think that you are getting too caught up in semantics. you are correct in saying that addiction and dependence are separated by the fact that one is a neurobehavioral disease and the other is a physiological process. however, the mind and body are linked in such a way that what happens in one affects the other. so while dependence and addiction are separate concepts, they are very closely related and often occur simultaneously.

i think that you may be missing the main point which is that we, as physicians, are capable of creating addicts if we are not responsible with how we prescribe narcotics.

 

[lobelsteve]

This thread is a disgusting obliteration of the current definitions for addiction, dependence, and tolerance. There are several who misunderstand the terminology and argur points to no end.

Yes, iatrogenic addiction exists and is a real problem.
Yes, addiction will not develop without the right genetic and social background to kindle the fire.

So you are all partially right, but stop bashing each other like little children.
You are all also missing the big point.

Please insert $5 for the big point.

Steve

 

[Planktonmd]

This thread is a disgusting obliteration of the current definitions for addiction, dependence, and tolerance. There are several who misunderstand the terminology and argur points to no end.

Yes, iatrogenic addiction exists and is a real problem.
Yes, addiction will not develop without the right genetic and social background to kindle the fire.

So you are all partially right, but stop bashing each other like little children.
You are all also missing the big point.

Please insert $5 for the big point.

Steve

😕
If you have something to add you might want to consider adding it!

 

[All4MyDaughter]

😕
If you have something to add you might want to consider adding it!

Well, THAT we can agree on, doc! 🙂

 

[Planktonmd]

Well, THAT we can agree on, doc! 🙂

I am glad we do 😉

 

[lobelsteve]

From Pain Medicine, Nov/Dec 2007: Edlund et al

Conclusions. Users of prescribed opioids had higher rates of opioid and nonopioid abuse problems compared with nonusers of prescribed opioids, but these higher rates appear to be partially mediated by depressive and anxiety disorders. It is not possible to assign causal priority based on our cross-sectional data, but our findings are more compatible with mental disorders leading to substance abuse among prescription opioid users than prescription opioids themselves prompting substance abuse iatrogenically. In patients receiving prescribed opioids, clinicians need to be alert to drug abuse problems and potentially mediating mental health disorders.