In stark contrast, patients taking opioids to relieve pain usually become more functional, able to rejoin the lives of their families and community and return to work. They're less depressed, less anxious and often view the change as "life-saving". Thus, the Florida Board of Medicine instructs physicians that "tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction." This advice hasn't penetrated deeply even into the medical community. The general public and majority of the media still equate physical dependence and addiction; even those patients who have not been well counseled by their doctors may wrongly believe they are addicted.
Even some patients now currently taking opioids as a component of their pain management plan, haven't been taught that when properly prescribed and taken as prescribed, opioids are very effective for the treatment of moderate to severe pain. They've only been exposed to the media, which tends to hype the dangers (without mentioning that the problems almost always occur only when the drugs are misused or abused) and causes a hideous stigma to be attached to those who take opioids, legally or illegally. Out of prejudice, patients who take opioids are assumed to be addicts. The label "addict" is highly stigmatizing. Society is inordinately concerned with drug abuse, rightly so. However, when the stigma spills over to affect the availability of proper pain management to those who need it to function better, it becomes a serious wrong. Pain patients have lost their jobs simply on the strength of employer awareness that they take opioids.
To further cloud the differences between addiction and dependence, there is a third issue that must not be overlooked. Pseudo-addiction or pseudo-addictive behavior is a reaction to the harsh reality of the opioid prescribing climate: doctors are afraid to prescribe opioids to therapeutic levels for chronic pain patients. Across the U.S., doctors have been arrested and jailed when patients lie to them about drug use/abuse or intentions, and someone dies of an overdose. The law-enforcement mind-set works to the great detriment of patients. Physicians aren't ignorant. Rather than risk professional licenses or personal freedom, they routinely refuse to prescribe opioids to patients they know would benefit from them. Those who do prescribe opioids frequently self-impose a dose limitation that falls short of therapeutic levels for the individual. These choices are ethically and clinically wrong, but the chances may be good that a doctor who puts his patient first may be putting himself legally or professionally in danger. Legislative and Medical Board actions accepting and encouraging opioid use for chronic pain seem worthless in a context of punitive and ill-informed law enforcement. Physicians are well aware of instances where colleagues are being "punished" by the law-enforcement community since those instances are usually overly-well publicized by the media. Physicians are meant to be healers, but fear their patients' misdeeds, and now must fear criminal prosecution.
Many patients who are victims of doctor's fears will try to persevere. Others feel driven to the pseudo-addictive behavior of doctor-shopping to get a self-adjudicated therapeutic level of pain relief. This is harmful since he/she is then deceiving their doctors and committing a crime. He/she also foregoes the fully-informed medical management of any side-effects. Though a crime, doctor shopping for pain relief is above all a victimless one, committed by a patient who is a victim of a climate of fear. Many who have untreated or under-treated pain will set out to find adequate pain relief. What they feel forced to do is then labeled "drug seeking behavior" - including "doctor shopping" and purchasing on the illegal market (in the same way that both real addicts and the criminal drug diverters do). One obviously cannot condone this but can well understand why it occurs. The difference is that unlike addicts, for pseudo-addicted patients, when they can find a way to adequately treat their pain, their ability to function and the quality of their life improves dramatically.
There is only one solution, public education. It
must be done on a large scale through the media just as the highly
stigmatizing campaign against addiction/dependence was promoted. It
must include distinctions between dependence and addiction and highlight the
fundamental causes of pseudo-addictive behaviors. In addition, proper and
reasonable pain management parameters must be shared with governmental
administration and law enforcement community to dispel fears about pain
medications and teach that all opioid use is not bad. Education could further
help to remove the stigma associated with addiction by pointing to the fact that
though it doesn't reduce responsibility, addictive or compulsive behaviors may
well be genetics rather than choice.
