Opioid use in the treatment of chronic pain: assessment of addiction.

Addiction medicine specialists, besieged with the adverse consequences of opioids, not unreasonably develop reservations about their use. Opioid prohibition may be appropriate when working with addicts, but drug abstinence is not always the most appropriate nor optimal treatment of pain patients. Consultation concerning the management of chronic pain patients may require an attitude adjustment of challenging proportions for the addiction medicine specialist; it is a role substantially different from that usually assumed in treating alcohol- and drug-dependent patients. Rather than relentlessly pursuing psychotropic drug abstinence as the treatment goal, restoration of function should be the primary treatment goal for the chronic pain patient. Unlike the chemically dependent patient whose level of function is impaired by substance use, the chronic pain patient's level of function may improve with adequate, judicious use of medications, which may include opioids. Evaluating for addiction in a patient who is prescribed long-term opioids for pain control is often problematic. While the concept of addiction may include the symptoms of physical dependence and tolerance, physical dependence and/or tolerance alone does not equate with addiction. In the chronic pain patient taking long-term opioids, physical dependence and tolerance should be expected, but the maladaptive behavior changes associated with addiction are not expected. Thus, it is the presence of these behaviors in the chronic pain patient that is far more important in diagnosing addiction.