Although the DSM-IV criteria are widely used and have proved beneficial, they also have been criticized by the American Academy of Pain Medicine (AAPM), the American Pain Society (APS), and the American Society of Addiction Medicine (ASAM) for not distinguishing between dependence and addiction. These groups argue that the term addiction is widely used but poorly defined, and thus confused with physical dependence. As a consequence, patients who are physically dependent but not addicted sometimes fail to receive the medications they need because doctors may think physical dependence is addiction. AAPM, APS, and ASAM feel that this issue could be addressed in part by adequately addressing the distinction between physical dependence and addiction. To that end, they offer the following discussion and definitions:
“Clear terminology is necessary for effective communication regarding medical issues. Scientists, clinicians, regulators, and the lay public use disparate definitions of terms related to addiction. These disparities contribute to a misunderstanding of the nature of addiction and the risk of addiction, especially in situations in which opioids are used, or are being considered for use, to manage pain. Confusion regarding the treatment of pain results in unnecessary suffering, economic burdens to society, and inappropriate adverse actions against patients and professionals.
Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
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 is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug´s effects over time.”
AAPM, APS, and ASAM also argue that physical dependence on and tolerance to prescribed drugs does not constitute sufficient evidence of psychoactive substance use disorder or addiction. Instead, these are considered normal responses that often occur with the persistent use of certain medications.
Finally, AAPM, APS, and ASAM offer an additional term, pseudoaddiction, which has been used to describe patient behaviors that may occur when pain is under-treated. Patients with unrelieved pain may become focused on obtaining medications, may "clock watch," and may otherwise seem inappropriately "drug seeking." Even such behaviors as illicit drug use and deception can occur in the patient´s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.