Compulsive drug use despite harmful consequences is a cardinal finding. Usually, the patient never takes the medication as directed. Often, they are involved in aberrant behavior patterns in order to obtain more drug. Often will seek early refills and will often report "stolen" medication. Not uncommon to also use illicit substances to use in addition to prescription abuse, or will use the prescription drug to obtain the illicit drug. These patients need to be in treatment for addiction. Some may benefit from the use of prescription medicines indicated for treatment of opioid dependence that have a strong affinity to mu receptors and can reduce cravings for heroin. The dosage range of these products is too high for effective pain management, but the patient may receive minimal benefit for their pain. It is INAPPROPRIATE to put someone on these prescriptions if they do not have addiction as they would no longer be eligible for opioid treatment. Taking thesse type of products labels the patient as having addictive behavior.

Commonly seen when short acting opioids are used alone. Occurs when a higher dose of the drug is needed to achieve the current effect. The patient has peaks and valleys when using short acting medication and when the valleys become intolerable, they will ask for more. This may not be true tolerance, as they may need a more balanced medication regime. Tolerance was seen more often before extended release medications were available. Typically, changing medication is necessary to overcome tolerance. Don't confuse tolerance with the normal waxing and waning of the chronic pain cycle and weather effects on pain.

High doses of opioids will over sensitize the CNS and at that point, giving more actually makes the pain worse, thus driving a vicious cycle of increasing doses.