23 Million Americans have surgery every year and nearly all of them receive opioids afterwards. Almost none become addicted. In order to get addicted to something, you have to like it. Even the rare patients who enjoy the experience rarely decide to turn their lives into a DRUG MISSION as a result. They have better things to do.

These surveys provide evidence that addiction is exceedingly rare during long-term opioid treatment and does not commonly occur among patients with no history of abuse who receive opioids for other medical indications.

Friedman DP. Perspectives on the medical use of drugs of abuse. J Pain Symptom Manage 1990; 5(1 Suppl):S2-5.

The treatment of severe pain requires the use of potent opioid analgesic medications. Many patients with opioid sensitive pain are being undermedicated. This results in increased morbidity and needless suffering. The most important reason for this undertreatment is the fear of addiction engendered by opioids, a fear that is greatly out of proportion to the real risk.

The risk of addiction is greatly overestimated in part because many people do not understand the distinctions between drug abuse and drug addiction, on the one hand, and physical dependence and tolerance, on the other. Dependence and tolerance are virtually inevitable outcomes of long-term opioid use, but they are neither sufficient to cause addiction nor the equivalent of it. Indeed, the evidence shows that only a tiny fraction of patients treated with opioids become addicted. There is little risk of addiction for those patients receiving properly administered opioids for pain.

Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med 1980; 302: 123.

The incidence of psychological dependence in 40,000 hospitalized patients was monitored in this prospective study. Among nearly 12,000 patients who received at least one opioid preparation for moderate to severe pain, there were only four reasonably well-documented cases of psychological dependence in patients who had no history of drug abuse. These data suggest that the medical use of opioid is rarely associated with the development of psychological dependence.

Medina JL, Diamond S. Drug dependency in patients with chronic headaches. Headache 1977; 17: 12-14.

This survey of patients treated at a large headache center during 11 months could only identify three problem cases (two codeine and one propoxyphene abuser) among the 2,369 patients who had access to opioid analgesics.

Kanner RM, Foley K. Patterns of narcotic drug use in a cancer pain clinic. Ann NY Acad Science 1981; 362: 161-172.

This analysis of the patterns of drug intake in cancer patients receiving chronic opioids suggests that the medical use of opioids rarely leads to drug abuse or to iatrogenic opioid addiction.

Schug SA, Zech D, Grond S, Jung H, Meuser T, Stobbe B. A long-term survey of morphine in cancer pain patients. J Pain Symptom Manage 1992;7:259-66.

This study identified one case of substance abuse among 550 cancer patients who experienced pain and were treated with morphine for a total of 22,525 treatment days. Physical dependence posed no practical problem in discontinuation of morphine treatment. Long-term opioid intake and development of tolerance did not appear to be linked; an increase in morphine dosage was most often explained by progression of the terminal disease.

Perry S, Heidrich G. Management of pain during debridement: a survey of U.S. burn units. Pain 1982; 13:267-280.

In a survey of burn facilities in the US, 181 staff members from 93 burn units were asked how many cases of actual iatrogenic addiction could be documented following the administration of narcotics for pain control in burned adults and children. Respondents with an average of 6 years of experience caring for at least 10,000 hospitalized burn patients found no case of addiction in patients treated for burn pain.

Portenoy RK, Foley KM. Chronic use of opioid analgesics in nonmalignant pain: Report of 38 cases. Pain 1986; 25: 171-186.

38 patients were maintained on opioids for severe, chronic noncancer pain; half received opioids for four or more years, and six of these were treated for more than seven years. About 60% of the 38 patients reported that their pain was eliminated or at least reduced to a tolerable level. The therapy became problematic in only two patients, who both had a history of drug abuse. The authors provide guidelines for monitoring patients requiring opioid maintenance therapy.

Zenz M, Strumpf M, Tryba M. Long-term oral opioid therapy in patients with chronic nonmalignant pain. J Pain Symptom Manage 1992; 7: 69-77.

This large survey described 100 patients with diverse pain syndromes who received dihydrocodeine, buprenorphine, or morphine for prolonged periods. More than half of these patients maintained greater than 50% analgesia for at least one month and performance status increased overall, with the largest improvement observed among those with the greatest relief of pain. No incidents were reported of serious toxicity or drug-related behaviors suggestive of addiction or abuse.

Moulin DE, et al. Randomized trial of oral morphine for chronic noncancer pain. Lancet 1996; 347: 143-147.

This study used a cross-over design to compare the opioid against a placebo (benztropine) to ensure blinding of the therapy. The study evaluated a broad range of outcomes related to subjective effects and function. The results demonstrated a significant reduction in pain during morphine therapy, without change in physical or psychological functioning, and without evidence of psychological dependence or aberrant drug-related behavior.

Brookoff D, Palomano R. Treating sickle cell pain like cancer pain. Ann Intern Med 1992; 116: 364-368.

In this survey, patients treated for sickle cell pain at a university-based clinic were prescribed opioids following the model based on the treatment of cancer pain. During a two-year follow-up period, emergency room visits declined by 67 percent and hospital admissions decreased by 44 percent. No increase in opioid abuse was reported.

Chapman CR, Hill HF. Prolonged morphine self-administration and addiction liability: evaluation of two theories in a bone marrow transplant unit. Cancer 1989; 63: 1636-1644.

Using data obtained from patients in a bone marrow transplant unit, this study examined addictive behavior in patients who self-administered intravenous morphine in comparison with patients who received the drug via routine staff-controlled continuous infusion procedures. Self-administering patients used significantly less morphine than controls and still achieved the same amount of pain control; moreover, they terminated drug use sooner than controls. The results support the assumption that self-administration of opioids in a medical setting does not put patients at risk for over-medication or addiction.

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