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In Reply: Dr Contreras raises an important point concerning the concept and term of "dependence," as it applies to patients with chronic pain who are treated with opioid analgesics. The DSM-IV diagnosis of substance dependence is based on "a maladaptive pattern of substance use," as manifested by the presence of 3 (or more) of 7 criteria.¹ One criterion is "dependence," as evidenced by the occurrence of a withdrawal syndrome when a substance is withdrawn. Another is "tolerance," the need for increased amounts of a substance to achieve a desired effect, or diminished effect with continued use of the same amount. The other 5 DSM-IV criteria include taking larger amounts of a substance than intended, unsuccessful efforts to control use, a great deal of time spent in activities to obtain a substance, the reduction of important activities, and persistent use despite known substance-related physical or psychological problems.

The DSM-IV criteria do . . . [Full Text of this Article]

Patrick G. O’Connor, MD, MPH
patrick.oconnor@yale.edu
Section of General Internal Medicine
Department of Internal Medicine
Yale University School of Medicine
New Haven, Conn

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