Addiction (also referred to as dependence syndrome, drug dependence, psychological dependence, or substance dependence) refers to a maladaptive pattern of behaviors and compulsive use of drugs despite harm. Addiction is distinct from analgesic tolerance or physical dependence, although the phenomena may co-occur (e.g., in heroin addicts). Neither analgesic tolerance nor physical dependence is sufficient to characterize addiction. Addiction is a biopsychosocial condition and evidence shows that it is not more common in patients with chronic pain from cancer than in the general population. Addiction is not a side effect, or an expected consequence, of opioid use.
Analgesic Tolerance refers to the diminishing analgesic effect of an opioid because of physiological adaptation to the opioid. Analgesic tolerance is not inevitable, but it does occur. The dose of an opioid such as morphine typically can be increased to overcome any tolerance that may develop, as long as side effects are tolerated. Analgesic tolerance should not be confused with the need to increase dose because of an increase in pain.
Balance (also referred to as the Principle of Balance) refers to the dual obligation of governments to establish a system of control to prevent abuse, trafficking, and diversion of narcotic drugs while, at the same time, ensuring their medical availability. Although opioid analgesics are controlled drugs, they also are essential drugs and are indispensable for the relief of pain. Opioids, including those in the therapeutic group of morphine, should be accessible to all patients who need them for relief of pain. Governments must take steps to ensure the adequate availability of opioids for medical and scientific purposes.
Commission On Narcotic Drugs (CND) refers to the the central policy-making body within the United Nations system for dealing with all drug-related matters, including those pertaining to the aims of the Single Convention on Narcotic Drugs, 1961, as amended by the Protocol Amending the Single Convention on Narcotic Drugs.(1) The members of CND are representatives of governments. The CND is responsible for drug scheduling under the Single Convention.
Consumption refers to the amounts of opioid analgesics distributed legally in a country for medical purposes to those institutions and programs that are licensed to dispense to patients, such as hospitals, nursing homes, pharmacies, hospices and palliative care programs. In international drug control terminology, consumption does not refer to the amounts dispensed to or used by patients, but rather amounts distributed to the retail level. (See also Statistical returns system)
Diversion refers to the intentional illegal movement of controlled medications from the licit distribution system into the illicit market. Diversion may occur at any level of the distribution system and is caused by the illegal acts of individuals. Diversion prevention and control is to be addressed by implementing the provisions of the Single Convention.
Drug Distribution System refers to the entire system of medication acquisition and disbursement. In any country, opioid medications must be approved and then obtained by importation from a manufacturer or exporter in another country, and/or finished products are manufactured domestically from narcotic raw materials. A system of government-regulated distributors or wholesalers then distribute to pharmacies, hospitals, clinics, nursing homes, hospices, and palliative care programs, where duly authorized health care professionals prescribe, dispense, or administer them to patients.
Drug Requirements refer to the amount of opioid analgesics that are estimated to be necessary to satisfy actual medical and scientific needs in a year. In many countries, this amount often is not adequate to meet the needs for all patients. (See Estimate of Annual Requirement for Narcotic Drugs)
Essential Medicines as defined by the World Health Organization, refers to those medicines that, “… satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness. Essential medicines are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford. The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility.”
Estimate of Annual Requirement For Narcotic Drugs refers to the report that a National Competent Authority must submit to the International Narcotics Control Board for the anticipated amount of opioid analgesics that will be used in the following year. The International Narcotics Control Board must confirm this estimate before the country is allowed to import and/or manufacture this amount. (See Drug requirements)
Export is to legitimately transfer a good or commodity (such as a medication) from one country to another. (See Import)
Guideline refers to an official policy statement, which does not have the force of law. Guidelines may be issued by a professional association or a government agency to express the group's attitude about a particular matter. While guidelines themselves do not have binding legal force, they define the parameters of conduct for professionals which are consistent with accepted standards of practice.
State medical boards have issued guidelines regarding the medical use of opioids which define the conduct which the board considers to be within the legitimate practice of medicine. Guidelines may also be called a position statement or policy statement; and these may appear in a position paper, report, areticle, letter or news letter.
Import is to legitimately bring into one country from another country a good or commodity (such as a medication). (See Export)
International Narcotics Control Board (INCB) refers to a quasi-judicial monitoring body established in 1968 to implement United Nations international drug control conventions.
Law is a broad term that refers to the rules of conduct with binding legal force, adopted by governments at the international, federal, state or local levels. Laws can be found in treaties, constitutional provisions, decisions of the court, statutes and regulations. A number of laws have been adopted by states concerning pain management.
Narcotic Drug is a legal term encompassing those substances covered by the Single Convention on Narcotic Drugs, 1961, and the 1972 Protocol Amending that Convention, including opiates, opioids, as well as cocaine and marihuana. (2)
National Competent Authority refers to the principal national authority for ensuring that opioid analgesics are adequately available for medical and scientific purposes and for submitting the required documents to the International Narcotics Control Board. This office, designated by each government that is Party to the Single Convention on Narcotic Drugs, 1961, is responsible for carrying out the functions required by the international drug control treaties. This office may be located in a country’s pharmaceutical department within the Ministry of Health, or in the national drug control agency.
National Policy should be interpreted broadly. “There are different levels of ‘national policy,’ including law (sometimes referred to as codes or statutes), regulations (issued by governmental agencies to interpret or implement laws), and other policy (governmental directives, budgets or policy documents). There are also different types of national policies that may be relevant…For example, some of the relevant provisions and administrative practices may be found in governmental policies on public health, drugs, drug abuse and cancer control. ‘National policy’ also refers to the government policies of states, provinces, territories, and other governmental subdivisions….” ( 2 )
Nonmedical use refers to the use of any drug for non-therapeutic purposes.
Opiate refers to drugs whose origin is the opium poppy, including codeine and morphine.
Opioid Accessibility refers to the extent that patients can obtain the opioid pain medications they need for pain relief. Clearly, patient access is not possible unless opioids are available on the market. Therefore opioids may be legally available within a country or even a health care facility, but patients may not be able to access them for a variety of reasons.
Opioid Analgesic (also Opioid) is a scientific term that refers to both natural (codeine, morphine) and synthetic (methadone, fentanyl) drugs, and whose pharmacological effects are mediated by specific receptors in the nervous system.(2)
Opioid Availability refers to whether a country has stocks of opioid pain medications either at the manufacturer or retail level of the drug distribution system. The term may be used in referring to the presence of opioids within a country, or at any point throughout the drug distribution system, including in the health care facilities that provide medical care for patients.
Opiophobia refers to a phenomenon in which exaggerated concern about the risks associated with opioids prevent appropriate medical use of opioid analgesics. Anyone involved in the drug distribution system, as well as patients, family members, and members of the public, can have these exaggerated concerns. (3,4)
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. (5)
Pain & Policy Studies Group (PPSG) refers to a World Health Organization Collaborating Center at the University of Wisconsin Paul P. Carbone Cancer Center in Madison, Wisconson, USA. This group coordinates a program of international policy studies to identify and address barriers to opioid availability in national policy and national health care systems. PPSG provides technical assistance and monitors progress to improve the availability of opioid analgesics for pain management and palliative care.
Palliative care as defined by the World Health Organization, refers to, “…an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” (p. 84) ( 6 )
Physical Dependence describes the physical adaptation of the body to the presence of an opioid; it is characterized by signs of withdrawal when use of an opioid is stopped abruptly, or when an opioid antagonist is administered to an individual who has been on chronic opioid therapy.
Pseudoaddiction refers to an iatrogenic syndrome resulting from practitioners misinterpretating patients’ pain relief seeking behaviors as drug-seeking behaviors common to addiction. For example, a patient with unrelieved pain may attempt to obtain medications from multiple practitioners or multiple pharmacies. The pain relief seeking behaviors resolve upon institution of effective analgesic therapy.
Psychological Dependence is a behavioral pattern characterized by a compulsion to obtain a drug for mood altering effects.
Controlled substances are drugs which have a potential for abuse. They are classified by the U.S. Controlled Substances Act of 1970 and the individual state laws into five schedules according to three basic considerations:
the degree of potential for abuse;
whether the substance has currently accepted medical use; and
whether the use under medical circumstances is considered safe(7). The schedules are known as schedule I, II, III, IV, V, schedule I being the most restrictive and V the least restrictive. Schedule I substances have no accepted medical uses and are illegal (heroin, LSD, marijuana); schedules II, III, IV, and V have accepted medical uses and generally have Food and Drug Administration (FDA) approval for medical use. Schedule II substances can be narcotic or non-narcotic. Schedule II narcotics include morphine, methadone, hydromorphone, and oxycodone.(8)
Single Convention on Narcotic Drugs, 1961, as amended by the 1972 Protocol Amending the Single Convention on Narcotic Drugs (Single Convention) refers to an international drug control treaty, which obligates national governments to control narcotic drugs to prevent non-medical use and diversion while ensuring their availability for medical uses including the relief of pain.
Statistical Returns System refers to the information that countries must report to the International Narcotics Control Board on an annual basis, and includes the production, manufacture, retail distribution, and stocks of opioid analgesics for the previous year. The retail distribution reports are the consumption statistics (see Consumption).
Tolerance refers to the physical adaptation of the body to an opioid, resulting in the need to increase the dose to achieve the same effect, as in "analgesic tolerance", or as in the reduction in a response (such as sedation) with repeated administration of a drug.
ECOSOC serves as the central forum for discussing international economic and social issues, and for formulating policy recommendations addressed to Member States and the United Nations system. “ECOSOC is also the electoral organ of the INCB and may provide a forum for the discussion by parties and the Board of the application of certain provisions of the Convention.” (1) The members of ECOSOC are representatives of national governments.
UNODC refers to the global leader in the fight against illicit drugs and international crime. The executive director of the UNODC represents the United Nations secretary-general, who is the depositary of the Single Convention and its Protocol and also provides both the Commission on Narcotic Drugs and the International Narcotics Control Board with secretariat services.
Withdrawal Syndrome (also referred to as physical dependence) refers to the consequences of repeated administration of certain drugs, whose abstinence can increase the intensity of drug-seeking behavior because of the need to avoid or relieve withdrawal discomfort and/or produce physiological changes of sufficient severity to require medical treatment.(2) Patients who use opioids for pain relief on a long-term basis will likely develop a withdrawal syndrome when therapy is stopped abruptly, the dose is reduced sharply or an antagonist is administered. However, this can be avoided if opioids are tapered gradually over a period of time.
World Health Assembly is the supreme decision-making body for the WHO. Its main function is to determine the policies of the World Health Organization. It also appoints the Director-General and supervises the financial policies of the World Health Organization. The members of World Health Assembly are representatives of national governments.
World Health Organization Expert Committee on Drug dependence (ECDD) refers to the body of experts responsible for conducting the medical and scientific evaluation of dependence-producing substances and makes recommendations to the Commission on Narcotic Drugs …concerning the level of international control to be applied to them ... No psychoactive substance can be controlled internationally without first being evaluated by WHO. (9)
World Health Organization (WHO) refers to the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.