A Word about Words

A Word about Words: Substance Abuse Terminology

Words are important and sometimes what we call things makes a big difference in how our patients perceive their situations. In fact, in many cases a “diagnosis” is really just applying a term to a set of symptoms, thereby naming what is going on with a patient.

Some key terms in managing commonly abused prescription medications include:

  • Addiction: Neurobehavioral syndrome with genetic and environmental influences that result in psychological dependence for psychic effects. Chronic, Craving, Compulsive and Continuous despite harm
  • Dependence: Neuro-adaptation characterized by withdrawal syndrome if substance is stopped or lowered abruptly
  • Tolerance: Physiologic state resulting from regular use of drug in which the dose must be increased to achieve the same clinical response
  • Diversion: Illegal acquisition and sale of prescription medications (most often stimulants, sedatives, and opioids)
  • Illegitimate use of legitimate Rx, illegitimate Rx and or stolen from pharmacy or manufacturer.
  • Substance abuse
  • Maladaptive use of substances (tobacco, alcohol, licit and illicit drugs) over time that does not meet criteria for addiction
  • Pseudoaddiction: Behavior of a patient who is prescribed pain relieving medication but who exhibits opioid drug-seeking patterns in response to inadequate pain relief through the prescribed treatment
  • Aberrancy: Refers to a range of anomalous events involving prescribed narcotic medications suggestive of patient opioid misuse and possibly a substance use disorder

Aberrant Medication Behaviors
A spectrum of behaviors that may reflect misuse: aberrant drug behaviors are common, with nearly four out of five subjects reporting one or more aberrant drug behaviors. Most patients may exhibit some aberrant drug behaviors.Some warnings are RED FLAGS. If these are indicated, even once, they strongly suggest a problem and merit action. Other warnings are YELLOW FLAGS, and suggest further exploration and monitoring.

Aberrant Medication-Taking Behavior More Likely to be Suggestive of Addiction – RED FLAGS

  • Deterioration in functioning at work or socially
  • Illegal activities – selling, forging, buying from nonmedical sources
  • Injection or snorting medication
  • Multiple episodes of “lost” or “stolen” scripts
  • Resistance to change therapy despite adverse effects
  • Refusal to comply with random drug screens
  • Concurrent abuse of alcohol or illicit drugs
  • Use of multiple physicians and pharmacies
Aberrant Medication-Taking Behavior Less Likely to be Suggestive of Addiction – YELLOW FLAGS

  • Complaints about need for more medication
  • Drug hoarding
  • Requesting specific pain medications
  • Openly acquiring similar medications from other providers
  • Occasional unsanctioned dose escalation
  • Nonadherence to other recommendations for pain therapyWith Yellow Flags, it is the pattern and consistency of a warning, not a single warning itself, that is primarily suggestive of a problem.
  • 2 to 3 minor aberrant behaviors over an 24 month period would not likely represent a type of aberrancy that is worrisome e.g. addiction/diversion
  • Use these opportunities to educate the patient so you can lower the risk of facilitating the development of more aberrant behavior or addiction and increase the chances for improved and safer outcomes. When calm exchanges occur you & the patient gain understandings & appreciations that will more safely allow continued care with or without opiates.
  • Decisions are best made in context, taking account of the patient’s risk of narcotic abuse (current life-stressors, Past Medical History, measures and metrics, and the seriousness of the aberrant behavior(s).
  • 2-3 minor “issues” over a 6-week period is more concerning and would require more immediate action.