Reviewed February 2014
Words can be powerful, and sometimes their meaning may be misinterpreted based on how they are used. One person may think that words are being used inaccurately and as a form of ‘labeling’, while another person may believe that they are being used correctly and without bias. In medicine it is especially important to use words correctly to convey as much objectivity as possible; think of the difference between the words ‘rash’ and ‘petechiae’ – what is documented in the medical record will be what people think of when they read it. Consider the difference between being “dependent” and being “addicted”; describing a patient as being dependent might lead that person to think that they are addicted.
Certain prescription pain medications that the U.S. Drug Enforcement Administration (DEA) has labeled as controlled substances may be referred to at times as “narcotics” by some people and “opioids” by others. The DEA uses both of these terms and many agree that they convey the same message, just with two different names. However, some people believe that in a clinical context the term opioid is most appropriate, and when law enforcement is involved the word narcotic fits best.
Words that describe aberrant drug-related behaviors may also sound the same to people, but can actually mean very different things; in certain instances this can lead to them being used or interpreted incorrectly. Incorrect use may lead to false assumptions that affect treatment plan development and even, in some cases, poor clinical decisions.
In this article, we will describe some traditional definitions of terms related to aberrant drug-related behaviors, starting with aberrant drug-related behavior itself. Our intention is to lay the groundwork for improved communication by clarifying commonly accepted definitions, although we know that some may use other definitions than those presented here. We also will present some new definitions. It is important to keep in mind that definitions and even names may be dynamic, and their use may be changed over time with the intention of improving understanding or classification by consensus. An example of changing a name to improve understanding is the renaming of Causalgia to Reflex Sympathetic Dystrophy to Complex Regional Pain Syndrome.
Traditional definitions of aberrant drug-related behavior have been accepted by the American Pain Society and the American Academy of Pain Medicine and were summarized by Webster and others in a recent article in The Journal of Opioid Management1.
Aberrant drug-related behavior
This term describes behaviors broadly ranging from mildly problematic (such as hoarding medications to have extra doses during times of more severe pain), to felonious acts (such as selling medications). Simply, these are any medication-related behaviors that depart from strict adherence to the prescribed therapeutic plan of care. Aberrant drug-related behavior covers a great deal of territory. If your patient requests early prescription pain medication refills, it is important to consider what this behavior may signify. Considerations might include the following:
- – Has the patient developed tolerance requiring a higher dose to maintain the same level of pain control?
- – Has the patient developed physical dependence and is experiencing early withdrawal symptoms?
- – Has the patient become addicted to the medication?
- – Is the patient selling some of the medication to pay for the increased cost of heating oil?
- – Have the patient’s children or grandchildren been pilfering from bottles stored in the medicine cabinet?
The traditional definition of abuse is the use of an illicit drug or the intentional self-administration of a prescription (or over-the counter) medication for any nonmedical purpose, such as altering one’s state of consciousness, e.g., “getting high.” However, there is sometimes disagreement about this definition. William White, MA and John Kelly, PhD, wrote a commentary about abuse in 2010 in the Alcoholism Treatment Quarterly Journal titled, “Alcohol/Drug/Substance ‘Abuse’: The History and (Hopeful) Demise of a Pernicious Label2.” The authors argue that the term ‘abuse’ applied to substance use disorders is technically inaccurate, and reflects morality-based language to depict what may actually be a medical condition.
Misuse is defined as the use of a medication (with therapeutic intent) other than as directed or indicated, whether willful or unintentional, and whether it results in harm or not. Increasing a medication dose without clinician approval is misuse whether the reason is dependence, tolerance, desire to achieve greater therapeutic effect, or forgetfulness.
Traditionally defined, addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is often characterized by behaviors that include one or more of the following:
- – Impaired control over use
- – Compulsive use
- – Continued use despite harm
- – Craving
In August, 2011, the American Society of Addiction Medicine released a new definition, Public Policy Statement: Definition of Addiction3. Its ‘short” revised definition of addiction is:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations.
This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. This revised definition of addiction is characterized by:
- – Inability to consistently abstain
- – Impairment in behavioral control
- – Craving
- – Diminished recognition of significant problems with one’s behaviors and interpersonal relationships
- – A dysfunctional emotional response
Like other chronic diseases addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities addiction is often considered progressive and can result in significant disability, or depending on the circumstances, even premature death.
Diversion is defined as the intentional removal of a medication from legitimate distribution and dispensing channels. Diversion also involves the sharing or purchasing of prescription medication between family members and friends or individual theft from family and friends.
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.
Tolerance, like physical dependence is also an adaptive state where there is a decrease or loss of therapeutic effect of a pharmacological agent over a prolonged period of use, or the need to escalate the dose of the agent in order to maintain the same pharmacological effect. Patients can develop tolerance to an opioid just like they develop tolerance to alcohol and many other substances as enzymes in the liver increase to achieve metabolic efficiency.
In summary, it is important to consider all possible behaviors, and how they are labeled when it comes to the multitude of reasons that patients may not take their medications as they are prescribed. Understanding the specific reason for each unexpected behavior, rather than sending the behavior to a bucket with a label too quickly, can help the clinician not only take the correct next step, but make decisions that help minimize risk, improve safety, and most of all benefit the patient.
- 1. Webster L, St. Marie B, McCarberg, B, et.al: Current status and evolving role of abuse-deterrent opioids in managing patients with chronic pain. J Opioid Manag. 2011. May-June;7(3):235-45.
- 2. White WL, Kelly JF: Alcohol/drug/substance “abuse”: The history and (hopeful) demise of a pernicious label. Alcoholism Treatment Quarterly. 2011; 29 (3):317-321.
- 3. American Society of Addiction Medicine. Public Policy Statement: Definition of Addiction. 2011. http://www.asam.org/DefinitionofAddiction-LongVersion.html