Balance, Pain, Palliative Care

Addiction or Dependency Syndrome? LIFE before Death Film #11

Mea culpa, mea culpa!
There I am on camera using the term “addiction.”
I will confess that I will probably continue to use the word addiction but between being interviewed for this film to its release,I participated on the committee “Ensuring Balance in National Policies on Controlled Substances, Guidance for Availability and Accessibility of Controlled Medicines.”  (available in 14 languages).  Willem Scholten, the pharmacist who leads the Access to Controlled Medications Programs, was keen that we honor the current WHO definitions.

Dependence is defined by the WHO Expert Committee on Drug Dependence as

“A cluster of physiological, behavioural and cognitive phenomena of variable intensity, in which the use of a psychoactive drug (or drugs) takes on a high priority.  The necessary descriptive characteristics are preoccupation with a desire to obtain and take the drug and persistent drug-seeking behavior. Determinants and problematic consequences of drug dependence may be biological, psychological or social, and usually interact” (6). Dependence is clearly established to be a disorder. WHO’s International classification of diseases, 10th Edition (ICD-10) (7) requires for Dependence syndrome that three or more of the following six characteristic features have been experienced or exhibited:

(a) a strong desire or sense of compulsion to take the substance;

(b) difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use;

(c) a physiological withdrawal state when substance use has ceased or been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms;

(d) evidence of tolerance, such that increased doses of the psychoactive substance are required inorder to achieve effects originally produced by lower doses;

(e) progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects;

(f) persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the harm.

The Expert Committee on Drug Dependence (ECDD) concluded that “there were no substantial inconsistencies between the definitions of dependence by the ECDD and the definition of dependence syndrome by the ICD- 10” (6).

So confused?

So despite the conclusion of the Expert Committee on Drug Dependence, as my colleagues illustrate in the film, physical dependence dependence can develop for many drugs. Jay Thomas uses the example of Beta-blockers. I use the example of steroids (as in the treatment of COPD).  Equally  Tolerance on its own does not mean some one has “dependency syndrome.”

I was pretty tough at the Guideline meeting, on asking that if we are discouraged from using the term “addiction,” that we use the term “dependency syndrome” rather than dependence.  Dependence has meaning outside of this field of medicine.

A final comment: My colleagues here were talking about the situation of “dependency syndrome” in patients with advanced cancer. It can be a major issue in other patient populations on non-cancer pain syndromes.  The area of overlap where palliative care clinicians may need to be extra alert, is the increasing numbers of people living with a cancer diagnosis (PLwCD) for whom post therapy pain is an ongoing issue.

Think this is the language police going crazy?

Write a comment.

Previous posts about LifebeforeDeath Films.

Other links.

Treat the Pain:

Pain and Policy Studies Group

Life before Death:

Union for International Cancer Control:

About Pain policy & palliative care

Improving global pain relief by achieving balanced access to opioids worldwide


3 thoughts on “Addiction or Dependency Syndrome? LIFE before Death Film #11

  1. It is true that physical dependence and addiction are not the same. But the bright line drawn between physical and psychological dependence in this video is false and misleading. Pain patients that cease long-term opioid therapy will often suffer from prolonged withdrawal symptoms that are not just physical. Insomnia, depression, irritability and anhedonia can last for months… even when the patient was just physically dependent and not addicted.

    Comparing opioid discontinuation to discontinuation of other medications that have withdrawal symptoms is also misleading and unbalanced. Stopping opioids is not at all comparable to stopping a beta blocker. Many pain patients, even when not addicted, have a terribly difficult time tapering off of opioids. Some even describe the experience as “I felt like I was going to die.” Sometimes a hospital detox admission or a rehab stay or a referral to a specialty pain program is required to get a patient off of opioids.

    Posted by Andrew Kolodny | July 29, 2011, 11:17 AM
  2. Thanks for your marvelous posting! I actually enjoyed reading it, you can be a great author.
    I will be sure to bookmark your blog and will eventually come back later in life.
    I want to encourage you continue your great posts, have a nice morning!

    Posted by Stacy | July 14, 2013, 4:09 PM

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