FEAR OF ADDICTION: CONFRONTING A BARRIER TO CANCER PAIN RELIEF

When used correctly, analgesic drug therapy is capable of relieving pain in more than 90% of cancer patients.[1] In reality, patients worldwide continue to endure pain. One main reason: irrational fears about using opioid analgesics. Fear of addiction is fed by outdated knowledge about opioids and the unintended effects of the war on drugs. Consequently, many health care workers as well as patients believe that there is a significant risk of addiction when using opioids for cancer pain.

A fear of global proportion

Fear of addiction among physicians, nurses, and patients has been reported in many places in the world including in North America, Asia, Australia and Europe.[2-11]

Dr. Michael Zenz, a pain management expert at the University of Bochum in Germany observes: "In trying to protect patients from harm, we interfere with their pain management and many patients suffer. This is not acceptable."

"Pain patients rarely become addicted to opioids," explains Anne Merriman, who directs a hospice in Uganda, "pain counteracts the side effects of opioids." "When used to alleviate pain," adds Maria-Elena Reyes, an oncology nurse at the Mexico City National Cancer Institute, "opioids create well-being, control symptoms and can be taken for an indefinite amount of time."

The irony is that while health care professionals intend to protect patients from pain, their concerns about addiction, which are unfounded, sometimes interfere with pain management. Patients suffer the consequences.

The case of Mr. J

One highly visible case in point occurred in the US. Mr. J. was a 74-year old man with prostate cancer that had spread to his spine and leg.[12] He was admitted to a nursing home. Mr. J. was in severe pain; his doctor had prescribed morphine, but the nursing home staff thought that he would become addicted, so they substituted weaker analgesics and a placebo. They were afraid that if Mr. J. took morphine too early, it would not work when he really needed it. Mr. J. died in pain four months later.

Understanding fear of addiction

Inappropriate fear of addiction can be linked to several factors, including legitimate efforts to prevent drug abuse, which typically disregard the important medical uses of opioids, the media's preoccupation with only the risks of drug use, widespread confusion about the meaning of "addiction," and health care workers' lack of knowledge about opioid pharmacology.

Anti-drug campaigns
Throughout the world, there have been increasing efforts to combat trafficking and demand for illicit drugs, and also to reduce diversion and abuse of prescription controlled substances. Historically, these important efforts have not recognized the significant medical uses of controlled drugs for the management of pain. This lack of balance can contribute to the perception that drugs are dangerous even when used for legitimate medical purposes, including for pain management.

Confusion between addiction, physical dependence and tolerance
A serious error commonly made by health professionals and the public alike is to use "addiction" to describe physical dependence or tolerance. Addiction is defined only by psychological dependence, i.e., compulsive use of a drug for its mood-altering properties, and continued use despite harm. Physical dependence is a normal physiological consequence of chronic opioid therapy. Tolerance means decreased effects with a stable dose of a drug.

Unfortunately, some medical and nursing textbooks,[13] as well as narcotic control laws[14] have defined addiction as physical dependence, thus mistakenly associating addiction with pain management.

Lack of knowledge about opioid pharmacology
Despite significant advances in knowledge about the use of opioids for pain, many healthcare professionals prescribe, dispense, or administer opioids inadequately. There is also a misconception among patients, the public and some healthcare providers that opioids are "bad" drugs because they are often if not always associated with drug addiction and criminal activity. However, studies have shown that opioids used appropriately for pain management are effective, safe, and have an extremely low potential to produce addiction.

Consequences of fear of addiction

As in the case of Mr. J., pain patients in many countries may not receive adequate pain relief because their caregivers fear turning them into addicts. This fear can lead to prescribing ineffective doses or even discontinuing opioid therapy. "It is very important that pain be controlled," emphasizes Nessa Coyle, supportive care nurse at Memorial Sloan Kettering Cancer Center in New York City. "Unrelieved pain results in added stress to the body, is debilitating, and has an overall negative effect on quality of life and ability to live each day."

Still, patients may delay taking their medication, take less than the effective dose, or not take it at all because they fear "addiction."[4, 15] Recent research has shown that family members may also contribute to inadequate pain relief because they have unfounded fears of addiction, respiratory depression and tolerance.[5, 16] Therefore, it is important to teach patients and families about pain management and the true nature of addiction.

Patients who request more pain medications are sometimes mistakenly perceived as in danger of becoming addicted, even though they are only seeking better pain relief. It is essential for health care professionals to understand patients' behaviors associated with inadequate pain management and to recognize that true drug-seeking behavior in pain patients is rare.

Three steps to confront fear of addiction

The first step is to know the facts: addiction is very rare when treating cancer pain with opioids; opioid analgesics such as morphine and its derivatives are safe and effective when prescribed by a trained health care professional.

The second step is to insure that you and your colleagues have a good working knowledge of the mechanisms of action of opioids and their side-effects in cancer pain management.

The third step is to be prepared to tell everyone but especially patients and families the facts about pain management in relation to addiction.

Addiction is extremely rare
Research makes it very clear that addiction is a negligible occurrence among patients with no history of addiction who receive opioids for pain (see abstracts page 6-7). A retrospective review demonstrated that of 24,000 such patients, only 7 became addicted.[17] Cancer patients can stop taking opioids when the pain stops,[18] i.e., they do not crave opioids when they no longer need them for pain relief.

Furthermore, the WHO has recognized that "the medical use of opioids is rarely associated with the development of psychological dependence."[19] The American Pain Society also acknowledges that "although most patients who take opioids several times daily for more than one month develop some degree of tolerance and physical dependence, the available data suggest that the risk of iatrogenic addiction is very small."[18]

Opioids are safe
The safety of opioids' long-term use has been well documented.[20] Opioids are remarkably safe compared to many other medications. The most prevalent and potentially serious side effect of long-term opioid use is constipation. On the other hand, chronic use of nonopioid analgesics can cause stomach, kidney and liver damage. "Patients fearing addiction must be reassured that opioids are safe," explains Professor Ventafridda, of the European School of Oncology, Milan, Italy. "Opioids are in fact less toxic than chemotherapeutic agents."

Use correct terminology
Health care professionals should use correct terms with both colleagues and patients. For example, the term 'dependence' by itself is imprecise. The term 'physically dependent' should be used when explaining withdrawal. It is also best to avoid terms like 'addict' or 'hooked' which can stigmatize a patient if used haphazardly. Before assuming that a patient is an addict, one should check if the patient has been properly assessed. Even so, the presence of addictive disease should not disqualify a person from pain relief.

Recognize addiction
Identifying addiction means recognizing the presence of certain drug-taking behaviors. Experts agree that addiction is loss of control over drug use, compulsive use of drugs for their mood-altering effects and continued use despite harm. Figure 1 presents examples of behaviors which are more predictive and less predictive of addiction.

Know the pharmacology of opioids
Effective opioid therapy requires knowledge of opioid pharmacology described in consensus guidelines.[18, 20-23] These recommendations emphasize the need to individualize therapy following a pain assessment and dose adjustments. The "standard" therapy is to increase the opioid dose until satisfactory analgesia occurs, or until intolerable or unmanageable side effects occur. Long-term opioid therapy in cancer pain will provide pain relief in 70 to 90% of patients, as well as improved quality of life.[22]

Dr. Rajagopal, an anesthesiologist who provides pain management for thousands of patients in Calicut (India) explains: "Opioids must be used only in opioid-responsive pain. Therefore, a proper assessment of the type of pain must precede the prescription. The dose of the opioid must be titrated to the degree of pain. The proper dose of morphine to treat a morphine-responsive pain is guaranteed not to cause addiction."

Get to know patients and provide correct information
Pain patients should be given the facts about the use of opioids and the incidence of addiction. Confident, consistent and repeated explanations about addiction, tolerance and physical dependence can go a long way to reassure patients and their families. Margo McCaffery, an expert in the nursing care of pain patients, recommends talking with patients about opioids and their side effects. Providing written information helps reinforce explanations about the method of opioid delivery, dosing schedules that patients need to remember, as well as the nature and incidence of addiction (see Figure 2).

Conclusion

Improving relief of cancer pain in the world will depend in part on eliminating irrational fears of addiction to opioid analgesics. Health professionals should be the first to overcome their fears, so they can educate patients and families, as well as regulators and policy makers. Information about opioids and the true nature of addiction should become part of health professional education to undo the confusion and misinformation which have made fear of addiction the number one impediment to the medical use of opioids, according to a recent survey of governments.[24]

--Sophie M. Colleau, PhD and David E. Joranson, MSSW

We would like to thank Dr. June Dahl, Professor of Pharmacology, University of Wisconsin Medical School, for her thoughtful comments on this issue.

References

1. World Health Organization. Cancer pain relief. Geneva: WHO, 1986.

2. Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Inter Med 1973; 78: 173-181.

3. McCaffery M, Ferrell BR. Nurses' knowledge of pain assessment and management: how much progress have we made? J Pain Symptom Manage 1997; 14: 175-188.

4. Ward SE, et al. Patient-related barriers to management of cancer pain. Pain 1993; 52: 319-324.

5. Ward SE, Berry PE, Misiewicz H. Concerns about analgesics among patients and family caregivers in a hospice setting. Res Nurs Health 1997; 19: 205-211.

6. Expert Advisory Committee on the Management of Severe Chronic Pain in Cancer Patients. Cancer Pain. Canada: Minister of Supply and Services, 1984.

7. Morgan JP, Plect DL. Opiophobia in the United States. The undertreatment of severe pain in society and medication: Conflicting signals for prescribing of patients. Lexington, MA: Lexington Books, 1983: 313-326.

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9. National Health and Medical Research Council. Management of severe pain. Canberra, Australia:1989.

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14. Joranson DE. Current thoughts on opioid analgesics and addiction. Symptom Control in Cancer Patients [Japanese] 1995; 6: 105-110.

15. Cleeland CS. Barriers to the management of cancer pain. Oncology 1987; 1: 19-26.

16. Ferrell BR, Grant M, Chan J, Ahn C, Ferrell BA. The impact of cancer pain education on family caregivers of elderly patients. Oncol Nurs Forum 1995: 22(8):1211-1218.

17. Friedman DP. Perspectives on the medical use of drugs of abuse. J Pain Symptom Manage 1990; 5: S2-S5.

18. American Pain Society. Principles of analgesic use in the treatment of cancer pain. 3rd edition. Skokie, IL: American Pain Society, 1992.

19. World Health Organization. Cancer pain relief and palliative care. Technical Report Series 804. Geneva: WHO, 1990.

20. Portenoy RK. Pharmacologic management of cancer pain. Sem Oncol 1995; 22: 112-120.

21. World Health Organization. Cancer pain relief. Second edition. Geneva: WHO, 1996

22. Jacox A, Carr DB, Payne R, et al. Management of cancer pain. Clinical practice guideline No. 9. AHCPR Publication No. 94-0592. Rockville, MD. 1994.

23. ANDEM. Recommandations pour la prise en charge de la douleur du cancer chez l'adulte en médecine ambulatoire. Paris, France 1995.

24. International Narcotics Control Board. Availability of Opiates for Medical Needs. New York: UN, 1996.