Let's Define "Addiction"

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Specializes in PACU.
]If you wish to converse with me define your terms.
Voltaire

There is a lot of importance placed on the definition of "addiction" when discussing pain management for chronic pain.

I tend to use the definition that goes: "Physical and Psychological dependence" but there are others.

Here's an example:

Addiction is a neurobiological disease that has genetic, psychosocial, and environmental factors. It is characterized by one or more of the following behaviors:

  • Poor control over drug use
  • Compulsive drug use
  • Continued use of a drug despite physical, mental and/or social harm
  • A craving for the drug

http://www.healthcentral.com/chronic-pain/coping-279488-5.html

I

 think that in many cases the waters are muddy with respect to applying the term "addiction".

Given that patients must sign contracts with pain clinics that attempt preclude drug seeking behavior (see below) it seems that many chronic pain patients are considered to be, at least, at risk for addiction.

Many chronic pain patients fit the various definitions of addiction.

I'm one of these people who considers proper use of words to be, in many cases, vitally important. Calling something by the wrong name can lead to gross immorality for example. (Calling murderous thugs "Freedom Fighters" has caused people to support murderous causes as one example)

When dealing with important matters it's important to use words properly in order to discuss ideas clearly. Using more pleasant sounding, 'less threatening' sounding terms for "addiction" can lead people to think that a serious problem is less serious.

Overprescription of pain pills has reached epidemic proportions in this country by all accounts. I'd say that when speaking of the causes it's important to speak realistically about a very serious problem.

If anyone wants to show that I'm wrong that would be great. I encourage people to attack my assertions but I request that you don't attack me.

There is a difference between attacking an idea and attacking the person who put forth the idea.

http://www.sdcpms.com/pdf/form_sample_opiate_contract.pdf

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

thread moved for best response

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Specializes in Hospice.

Definition of Addiction From The American Society of Addiction Medicine

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

Addiction is characterized by2:

  1. Inability to consistently Abstain;
  2. Impairment in Behavioral control;
  3. Craving; or increased “hunger” for drugs or rewarding experiences;
  4. Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and
  5. A dysfunctional Emotional response.

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Specializes in PACU.

There is, of course, complete hogwash in the world of addiction in academia.

"At its core, addiction isn't just a social problem or a moral problem or a criminal problem. It's a brain problem whose behaviors manifest in all these other areas. Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It's about underlying neurology, not outward actions."

http://www.medicalnewstoday.com/articles/232841.php

In many cases outward actions are all we have to go on.......Intense brain investigation isn't practical for everyone who comes into the ER exhibiting drug seeking behavior.

We, to a very large extent, treat what we see.

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Specializes in Hospice.
There is, of course, complete hogwash in the world of addiction in academia.

http://www.medicalnewstoday.com/articles/232841.php

In many cases outward actions are all we have to go on.......Intense brain investigation isn't practical for everyone who comes into the ER exhibiting drug seeking behavior.

We, to a very large extent, treat what we see.

Of course - but it's the conflation of physical dependance - as in the development of withdrawal symptoms without the drug - with addiction that creates the problem. Addiction is primarily a behavioral degeneration that is both triggered and complicated by physical changes in the brain.

This is why pain management in the addicted patient is so difficult. It requires intense care-planning and strict consistency to work and even then it can be a nightmare. Acute care nurses just don't have that kind of resource. This is why so many posters opt to medicate rather than engage in a power struggle over it. They have decided that they are treating the pain, not the addiction.

I am curious as to what parameters might be substituted for self-reports that would change this dynamic. If it's behavior (agitation) or vital sign changes, I don't see how that would improve things. Addicts quickly learn how to change behavior to get what they want - that's what manipulation is, after all. We all learned how to simulate a fever when we didn't want to go to school, so I wouldn't be surprised if junkies had a few ideas about vital signs, too. A good temper tantrum to elevate bp and pulse spring to mind.

It seems like the model for "legitimate" pain is based on symptoms exhibited by healthy people with no chronic pain issues undergoing acute, sudden onset of severe pain. Any other presentation is invalidated ... and this is wrong and is probably the underlying concern when expert insist on validating self-reports.

Forty years ago, in caring for that 35yo sickle-cell patient, I read that it is true that addicts will lie about pain in order to get opioids. The author pointed out that invalidating a self-report will not change an addiction. It will, however, deny relief to people suffering from pain that does not present in the preferred "model". We simply have to decide which is more important.

I believe that what we do in the acute settings described by the OP has little to no effect on the rate of addiction in this country. Strategies made possible by EMRs and linked pharmacy and er records can be very helpful in curbing abuses of the system. Good support from admin. can go a long way towards curbing misbehavior in the clinical setting. But making sure a junkie doesn't get high on your watch will do nothing but frustrate you and escalate the junkie.

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It seems like the model for "legitimate" pain is based on symptoms exhibited by healthy people with no chronic pain issues undergoing acute, sudden onset of severe pain. Any other presentation is invalidated ... and this is wrong and is probably the underlying concern when expert insist on validating self-reports.

Forty years ago, in caring for that 35yo sickle-cell patient, I read that it is true that addicts will lie about pain in order to get opioids. The author pointed out that invalidating a self-report will not change an addiction. It will, however, deny relief to people suffering from pain that does not present in the preferred "model". We simply have to decide which is more important.

I do agree with your entire post. The part I chose to quote echo my sentiments exactly, you have managed to put words to my thoughts on the subject in a way that I haven't been able to.

:up:

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Specializes in PACU.
Of course - but it's the conflation of physical dependance - as in the development of withdrawal symptoms without the drug - with addiction that creates the problem. Addiction is primarily a behavioral degeneration that is both triggered and complicated by physical changes in the brain.

I agree. Addiction has different dynamics in different people. Some people are 'wired' to be addicts.....As soon as they swallow their first Percocet they are addicted.....This is profoundly sad.

Others slip into addiction over the course of years. They take pills to escape psychological pain and, over time, become addicted.

This is why pain management in the addicted patient is so difficult. It requires intense care-planning and strict consistency to work and even then it can be a nightmare. Acute care nurses just don't have that kind of resource. This is why so many posters opt to medicate rather than engage in a power struggle over it. They have decided that they are treating the pain, not the addiction..

I couldn't agree more...Nicely put!

But making sure a junkie doesn't get high on your watch will do nothing but frustrate you and escalate the junkie.

I strongly agree with you about that too.

I remember well how extreme the pain of Sickle Cell can be......I've seen a few patients in crisis and the pain is extreme and very real......They are the prototype of patients in a pain emergency who need to be treated aggressively.

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Specializes in Hospice.

I remember well how extreme the pain of Sickle Cell can be......I've seen a few patients in crisis and the pain is extreme and very real......They are the prototype of patients in a pain emergency who need to be treated aggressively.

This woman was 35 years old in 1973, when most sickle-cell patients died in their teens. Can you imagine the organ damage ... and the chronic pain that was barely managed on dilaudid 8mgs Q4hr? The intern in her infinite wisdom and overwhelming concern over potential addiction put her on demerol 50mgs im q4h during a crisis! You could hear the screams on other floors. There's a special place in hades ...

We resorted to looking the other way when her husband smuggled in her home supply of dilaudid, since nothing could change the intern's mind and pain control was a non-issue, back then.

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Specializes in PACU.
The intern in her infinite wisdom and overwhelming concern over potential addiction put her on demerol 50mgs im q4h during a crisis! You could hear the screams on other floors. There's a special place in hades ...

That's horrible! I used to work at a hospital where we had three siblings coming in frequently for Sickle Cell. Sometimes all three would be in the hospital at the same time but not usually. They were in their 20s and they were really nice.......You know how you become fond of some patients?.....I really liked those three.

Dilaudid is the drug for a Sickle Cell crisis......There is no question about that.

You and I disagree on some aspects of pain management but I think you know that, in no way shape or form, am I advocating not treating severe pain aggressively. A pain emergency is a pain emergency.....It gets top priority.

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Specializes in Hospice.

What I disagree with is the kind of sloppy, prejudiced and ignorant thinking on the part of the intern that her escalating home doses of dilaudid and her behavior when in pain = a drug addict. This is why she refused to reconsider the pain orders.

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Specializes in PACU.
What I disagree with is the kind of sloppy, prejudiced and ignorant thinking on the part of the intern that her escalating home doses of dilaudid and her behavior when in pain = a drug addict. This is why she refused to reconsider the pain orders.

That's "thinking" with blinders on. You expect more from medical people but you don't always get more. The vast majority of medical folks I've worked with have more sense than that.

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