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

370 IV. SPECIAL POPULATIONSThere continues to be confusion about the differences between physicaldependence and addiction. Physical dependence, like tolerance, has been suggestedto be a component of addiction (American Psychiatic Association,2000); specifically, the desire to avoid withdrawal has been postulated to createbehavioral contingencies that reinforce drug-seeking behavior (Wikler, 1980).Although this phenomenon may be important in the subpopulation of individualspredisposed to addiction, it has no relevance for the vast majority ofpatients who receive opioid therapy for the treatment of acute or chronic pain.Physical dependence does not preclude the uncomplicated discontinuationof opioids during multidisciplinary pain management of nonmalignant pain(Halpern & Robinson, 1985), and opioid therapy is routinely stopped withoutdifficulty in the cancer patients whose pain disappears following effectiveantineoplastic therapy.In the clinical setting, therefore, the capacity to experience abstinenceshould never be labeled “addiction.” Unless abstinence is intentionally or unintentionallyinduced by discontinuation of therapy or administration of anantagonist (including a partial agonist like buprenorphine or an agonist–antagonist opioid), the phenomenon of physical dependence is subclinical andnot an issue in practice.Abuse and AddictionThe definitions of abuse and addiction are complex when potentially abusabledrugs are prescribed for specific medical indications (Kirsh, Whitcomb,Donaghy, & Passik, 2002). In the nomenclature of the American PsychiatricAssociation (2000), substance abuse refers to a maladaptive pattern of drug useassociated with some manifest harm to the user or others. A less restrictive definitioncharacterizes drug abuse as any use outside of socially accepted norms(Rinaldi, Steindler, Wilford, & Goodwin, 1998). Although the latter definitionraises concerns about cultural sensitivity in labeling abuse, it can be appliedmore easily to misuse of prescribed analgesics and therefore has greater utility inthe clinical setting. For the clinician, the use of any illicit drug, the maladaptiveuse of alcohol, and the use of prescribed drugs in a manner not intended bythe clinician all may be perceived as abuse. If a prescribed regimen is inappropriatelyused in a manner that is not persistent or extreme, however, the term“misuse” is sometimes applied.The American Psychiatric Association (2000) uses the term “substancedependence” to refer to addiction and defines this disorder as a maladaptivepattern of drug use associated with harm and, most importantly, characterizedby compulsive drug use. Although this definition can be applied broadly to painpatients, it has been criticized because of specific criteria that include toleranceand physical dependence. Other definitions of addiction developed by specialistsin addiction medicine (American Psychiatric Association, 2000; Rinaldi et