To the Editor: We agree with the call made by Charles O’Brien, M.D., Ph.D., et al. for a clarification of terminology in discussions of opioid use (1). We also agree that the DSM Committees’ choice of terminology to date is problematic. The use of the term “dependence” as a euphemism for addiction originated as a well-intentioned attempt to counter negative effects of the social stigmatization of addicted patients. Unfortunately, it has resulted in creating significant confusion in discussions of pain management by clouding the important distinction between physical dependence and uncontrolled psychological craving (addiction). Examples of this confusion are replete in the literature (2–4).
One of the most important requirements for successful pain management is a rigorous, multidimensional assessment of the patient, including a clear description and classification of the pain syndrome. Recognition of addiction, and distinguishing addiction from physical dependence, is an important part of such an assessment. The experience of cancer pain specialists around the world has confirmed this time and again. The Edmonton Classification System for Cancer Pain (5, 6) has shown that, among other factors, clear recognition and management of addiction is required for effective pain control in a subset of cancer patients. At the same time, clear distinction between physical dependence and addiction is an important tool in the prevention of “opioid-phobia” and the unwarranted fear of addiction that can impede effective pain management in any patient population.
Unfortunately, the DSM Committee has not provided such clarity to date. Fortunately, other groups have done so. The American Pain Society, The American Academy of Pain Medicine, and the American Society of Addiction Medicine, for example, have developed a consensus document with clear and useful definitions of opioid-related phenomena:
Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
Physical dependence is a state of adaptation that is manifested by a drug-class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist (7).
In the interest of patients—addicted or not—we urge that the DSM-V Committee should pursue the same degree of clarity.
1.O’Brien C, Volkow N, Li T: What’s in a word? addiction versus dependence in DSM-V. Am J Psychiatry 2006; 163:764–7652.Streltzer J, Johansen L: Prescription drug dependence and evolving beliefs about chronic pain management. Am J Psychiatry 2006; 163:594–5983.Comer S, Sullivan M, Yu E, Rothenberg J, Kleber H, Kampman K, Dackis C, O’Brien C: Injectable, sustained-release naltrexone for the treatment of opioid dependence. Arch Gen Psychiatry 2006; 63:210–2184.Johnson R, Jaffe J, Fudala P: A controlled trial of buprenorphine treatment for opioid dependence. JAMA 1992; 267: 2750–27555.Fainsinger R, Nekolaichuk C, Lawlor P, Neumann C, Hanson J, Vigano A: A multicenter study of the revised Edmonton Staging System for Classifying Cancer Pain in advanced cancer patients. JPSM 2005; 29:224–2376.Nekolaichuk C, Fainsinger R, Lawlor P: A validation study of a pain classification system for advanced cancer patients using content experts: The Edmonton classification system for cancer pain. Palliative Medicine 2005; 19:466–4767.American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine: Definitions Related to the Use of Opioids for the Treatment of Pain. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine, 2006 (www.ampainsoc.org/advocacy/opiods2.htm, accessed July 5, 2006)