Tolerance, Dependence, and Addiction
33. Should tolerance, dependence, and addiction to morphine be an issue in A.J.?
Tolerance and physical dependence should be anticipated and discussed openly with patients who are receiving chronic opioid analgesia. Tolerance occurs when a given dose no longer produces the same effect over time. For patients with a malignant disease, it is difficult to differentiate between tolerance and increased pain from disease progression. A.J. should be instructed to inform his clinicians when his pain regimen becomes ineffective. Escalating doses of opioid analgesics should be expected and should not deter the clinician from continuing with analgesic therapy. The need for increasing doses, however, should serve as a warning that alternative analgesic or adjunct agents need to be considered.
Physical dependence should also be anticipated. It should be explained to A.J. that this is a natural adaptation process of the body that occurs with opiates. The signs and symptoms of dependence are seen when abrupt withdrawal or a marked decrease in opioid administration occurs. Therefore, it is important that A.J. receive an adequate supply of medication to prevent exacerbating withdrawal symptoms caused by difficulties in obtaining medication or missed doses. The potential for dependency to opioid analgesics should never prevent the clinical use of opioid analgesics in malignant disease.
Addiction is a compulsive behavior relating to drug procurement and use. Addiction from clinical opioid use for the treatment of pain is rare. Misunderstanding by clinicians and caregivers regarding the difference between tolerance, dependence, and addiction is common and often results in undertreatment of painful conditions.128,129 Addiction is not an issue in patients requiring opiates for the treatment of chronic malignant pain. Tolerance and dependence should be expected and should in no way be misconstrued as evidence of addiction.
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