The definition of addiction, now called substance use disorder, has varied greatly over time. The first edition of the Diagnostic and Statistical Manual, from 1952, didn’t include specific diagnostic criteria for this condition. Over the next sixty years, the DSM went through six revisions, with a slow evolution of the terms “substance abuse” and “dependence.” The first was limited to substance use causing social and occupational problems, while the last was reserved for compulsive use and physiological symptoms. This distinction is very important, as many states have outlawed the use of controlled medications to treat “chemical dependence.” This latter phrase was considered synonymous with addiction in the minds of most doctors, but it could be confused by others, including some medical board members and especially law enforcement, as being synonymous with physical dependence.
And then we come to the fifth edition of the DSM, published in 2013, which brought about a substantial reimagining of substance-related disorders. It moved away from the terms “substance abuse” and “substance dependence,” which were criticized for not adequately capturing the complexity of the problem. Instead, the DSM-5 introduced the unified term “substance use disorder” and a criteria-based approach for diagnosis.
This criteria-based framework for diagnosing substance use disorder included eleven criteria:
- Impaired control
- Social impairment
- Risky use
- Pharmacological indicators
- Time spent acquiring
- Giving up activities
- Physical and psychological problems
- Attempts to cut down
- Desire and effort to control use
- Time spent recovering
- Reduced social, occupational, and recreational activities.
You have just perfectly described almost every patient with chronic pain. When someone is in agony, they have a very hard time controlling their use of pain medication. That is not because they are chasing the sensation of euphoria; it’s because they are suffering horribly. Now they meet the first criterion. These people also go through profound personality changes because of their pain, so number 2 comes up – social impairment. People in severe pain become cranky and upset. They often feel that life has been unfair to them, and it has. No one deserves what has happened to them, and even if they did something stupid, we all do stupid things, and we don’t all end up in severe chronic pain. They start to withdraw socially. Check number 2. Now the person can be diagnosed with mild substance use disorder, and, according to the testimony of many “experts” used in the prosecution of physicians, treatment must be stopped.
But hardly any chronic pain patient will have only those two. Number 3 – risky use. This is defined as continuing to use despite knowing that the use causes or exacerbates a physical or psychological problem, and/or using substances despite being aware of their contribution to a social or interpersonal problem. So when a chronic pain patient keeps using their medication despite developing constipation, they meet the physical problem definition. If they disagree with their family over how much medication they should use because the family blames the psychological changes on the medications, then we can check number 3 twice.
Tolerance and withdrawal. Every chronic pain patient who takes opiate medications for more than a few days starts to develop some degree of tolerance, as the body fights against the effects of the medication. If the medication is stopped abruptly, the patient will get sick and can even die. Despite what you might have heard, people do die from the effects of opiate withdrawal. Just look up “opiate withdrawal induced cardiomyopathy” if you don’t believe me. Now, these two are supposed to be excluded for patients on opiate therapy, but there is a caveat we will get to soon.
The amount of time that must be dedicated to acquiring pain medications has done nothing but skyrocket with the DEA restricting distribution in large areas of the country. This leaves pharmacies without medications to dispense, and it leaves patients traveling all over trying to find a pharmacy that has medication and will dispense it.
Giving up activities. A chronic pain patient’s quality of life and activity level depend on the little relief they get from their medications. They will give up activities because they can no longer enjoy the activities – they are too painful – or it’s simply physically not possible for them any longer.
The development of physical and psychological problems for chronic pain patients is a well-documented progression. Social isolation, loss of gainful productivity, estrangement from spouses and loved ones – these are all consequences of the stress that chronic pain causes. But as the patients’ problems usually start at the same time as their pain medication, it can become impossible to prove that these changes are not from the pain medicine.
Trying to cut down. I tell every patient on chronic pain medications to try to cut down. I want them to always try. That doesn’t mean it is always possible to do so. One note in my chart that I was going to try to reduce medication was used against me in court when the patient was not able to tolerate the change. “But you said you were going to reduce the medications! And you didn’t!” That’s true. I would rather the patient take an extra pill and have some relief and quality of life. On the other hand, no one prosecutes you if you cut them off and they shoot themselves.
A persistent desire or unsuccessful effort to control substance use. This means something totally different for chronic pain patients, most of whom would love to not need any medications at all. And not being able to tolerate an increasing level of pain is not the same as uncontrolled use to generate euphoria.
Recovering from the effects of substance use can mean family members testifying about how groggy the medications make them. Not realizing that chronic pain completely disrupts the sleep cycle, and even a modicum of pain relief can trigger a strong desire to sleep. Poor sleep is, in fact, one of the worst side effects of chronic pain.
Reducing or giving up social, occupational, or recreational activities because of substance use. Chronic pain patients suffer from elevated stress hormones, which causes them to lose their desire to socialize. They automatically lose their jobs usually. And they cannot tolerate the recreational activities that they used to. Can you prove by some test that this is due to the pain and not the medications? You cannot.
There is not a chronic pain patient on the planet who won’t qualify for at least two of these, and usually five or six. That puts them at a mild or moderate substance abuse level. Now, I know that tolerance and dependence are qualified as not applying to persons “taking opiates solely under medical supervision.” The problem is that every other criterion can be applied. Therefore, making your treatment seem inappropriate. Then they get to add back 4 and 5. So, to be safe, you can only treat chronic pain patients who are not wanting to reduce or quit their medications, who get along great with everyone, don’t spend time trying to get their medications, haven’t had to give up any activities, don’t have any other associated physical or psychological issues, never attempt and fail to cut back, never take a nap after a pain pill, and have maintained their job, dancing skills, and water skiing abilities. That should really lighten up your schedule. To correct this deficiency, the next DSM must be corrected to say, “These criteria do not apply to patients on controlled medication therapy.”
L. Joseph Parker is a research physician.