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Understanding Key Terms in Pain Management

Tolerance

Tolerance is the need for an increased dosage of a drug to produce the same level of analgesia that the previously existed. Tolerance also occurs when a reduced effect is observed with a constant dose. Analgesic tolerance is not always evident during opiod treatment and is not addiction.

Pseudotolerance

Pseudotolcrance is the need to increase dosage that is not due to tolerance, but due to other factors such as: disease progression, new disease, increased physical activity, lack of compliance, change in medication, drug interaction, addiction, and deviant behavior. When a once-fixed opioid dose is no longer effective, the above conditions should be reviewed to exclude pseudotolerance.

Physical Dependence

Physical Dependence can be described as the occurrence of withdrawal syndromes after opioid use is stopped or quickly decreased without titration.  Physical dependence can also occur if an antagonist is administrated. It is not addiction. Physical Dependence “…is not a clinical problem if patients are warned to avoid abrupt discontinuation of the drug, a tapering regimen is used (if treatment cessation is indicated), and opioid antagonist drugs (including agonist – antagonist analgesics are avoided.”

Addiction

Addiction is “psychological dependence on the use of substance for their psychic effects and is characterized by compulsive use..…”  Addiction should be considered if patients no longer have control over drug use and continue to use the drugs despite harm.” The degree to which a patient is at risk for addiction cannot be predicted.

Pseudoaddiction

Pseudoaddiction  is a drug seeking behavior that seems similar to addiction, but is due to unrelieved pain. This behavior stops once that pain is relieved, often through an increase in the opioid dose. “Misunderstanding of this phenomenon may lead the clinician to inappropriately stigmatize the patient with the label “addict.”  In the setting of unrelieved pain, the request for increases in drug dose requires careful assessment, renewed efforts to manage pain and avoidance of stigmatizing labels.”

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