One concern for the patient is the possibility of addiction to the medication. There is the possibility of addiction with the use of any opioid medication, but recent medical evidence suggests that addiction may have a genetic predisposition and that the use of the medications for the intended purpose of pain management is not likely to cause addiction, even with long-term use, in the absence of a predisposition to addiction. In fact, the number of patients without a history of addiction or substance abuse who become addicted to pain killers is less than one might think. A study reported in the New England Journal of Medicine as long ago as 1980 by researchers Porter and Jick showed only four addicts of 11,882 patients treated with narcotics in an inpatient setting. A study by Perry and Heidrick in the journal Pain in 1982 showed no addicts per 10,000 patients treated in the same way. More recent studies suggest that a few percent of patients may become addicted. Of course, there never can be a guarantee that the use of an opioid medication in any one particular patient could not lead to addiction, or perhaps more correctly trigger a pre-existing addictive disease, and there can be no guarantee that any medication is completely safe.
 

PSEUDOADDICTION:
There is a condition called pseudo-addiction. This is a pattern of behavior including craving, concern about medication availability, clock watching for dosing time and small unsanctioned dose increases. This condition occurs simply because the patient is not receiving adequate pain medication. This behavior is not defined as an addiction and resolves fully with adequate analgesia by definition.


PHYSICAL DEPENDENCE:
A second concern is physical dependence. Although often confused with addiction, physical dependence is a normal phenomenon that should not lead to medication abuse. If opioid medications are suddenly stopped, the patient will experience a withdrawal syndrome with multiple physical symptoms; although generally not life threatening, withdrawal from opioids is very unpleasant. The syndrome is analogous to that of someone who uses high blood pressure medications; if the high blood pressure medication is stopped suddenly, the patient’s blood pressure will rise suddenly. This is a physiological response to the sudden cessation of the blood pressure medication; it is not addiction to the blood pressure medication.

TOLERANCE:
A third concern is narcotic tolerance. It used to be believed that the opioid medications seem to lose their power over time and that higher and higher doses of medications are required. However, new research indicates that this may not be the case. There is evidence that tolerance is a function of NMDA receptors secondary to inadequately treated pain; tolerance perhaps may not occur secondary to the use of narcotic agents themselves. In either case, it is reasonable that increased needs for pain medication are a result of increased pain from a worsening medical condition, including the effect of chronic pain itself at the NMDA receptors.

Although the above information suggests opioid addiction is unlikely, there are, in general, some findings that help suggest addiction in a random patient. Therefore patients are informed that they should avoid multiple prescribing physicians, recurrent prescription losses, constant dosage increases, and aberrant behaviors such as injecting an oral dosage form. Patients are informed that any of these behaviors may preclude future opioid prescriptions.