Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

368 IV. SPECIAL POPULATIONSThe expanding role of opioid therapy in the treatment of chronic painlends particular urgency to the need for an accurate and dispassionate appraisalof the benefits and risks associated with pain control and chemical dependence.Medical perceptions surrounding opioid therapy have cycled dramatically duringthe past century (Musto, 1999; Rock, 1977). A more liberal approach toprescribing began during the latter part of the 20th century with worldwideendorsement of opioid therapy for cancer pain. This spurred a more gradualacceptance of the view that opioid therapy may be appropriate for larger numbersof patients with chronic pain. During the past 10 years, this acceptance hasadvanced throughout the community of pain specialists, driven by favorableexperiences with these drugs, incontrovertible evidence of widespread undertreatmentof pain, and the reduced stigmatization of opioid drugs. From thisperspective, opioid use was encouraged, with relatively little focus on thepotential risks associated with abuse, addiction, and diversion. Indeed, for somepractitioners, the myth of inevitable addiction was replaced by another myth,based on the misapprehension that chronic pain patients are somehow “immune”to the problems of misuse, abuse, addiction, or diversion (Friedman,1990).Pain specialists now have begun to realize that the issues related to chemicaldependence are central to the safe and effective use of opioids as analgesicsfor chronic pain. The emphasis is now on a balanced perspective, in whichpotential therapeutic benefits are weighed against this risk. With a balancedperspective, the divide between professionals in addiction medicine and painmedicine is narrowing, and a new level of discourse may enhance the ability ofeach discipline to comprehend clinical phenomena and formulate questions forresearch.DEFINITIONS AND PHENOMENOLOGYRedefining Abuse and AddictionBoth clinical practice and research depend on a valid nomenclature for thephenomena associated with drug abuse and addiction. Unfortunately, this terminologyhas been problematic historically, and clarification is a necessary firststep in advancing the understanding of the relationship between pain andchemical dependence.ToleranceTolerance is a pharmacological property defined by the need for increasingdoses of a drug to maintain effects (Dole, 1972; Martin & Jasinski, 1969). Itimplies that exposure to the drug itself is the “driving force” for the physiologi-