Opioids: Addiction or Physical Dependence?

Understanding the difference between addiction and physical dependence, as well as their risks and implications, is crucial for anyone managing chronic pain with prescribed opioids.

When taking prescribed opioids for chronic pain management, it is not uncommon to ask about addiction and physical dependence. Both patients and professionals can confuse the two, and there are several reasons for that described below. But first, a little history...

Before 2013, the medical label for an addiction to opioids was “opiate dependence.” Since 2013, the term used for addiction to opioids has been called “opioid use disorder,” or OUD. These terminology changes, and the former use of the word “dependence” – which conflicted with the actual prospect of being physically dependent on opioids (defined below), continue to contribute to common misunderstandings around addiction and physical dependence.

 

Addiction versus Physical Dependence

There is a common perception that to be “addicted” to a substance means one gets physically sick or agitated when one doesn’t use the substance. This, however, is not necessarily the case. Physical dependence reflects just two out of the 11 current criteria used in the United States to officially diagnose an OUD.

Addiction is defined by the American Society of Addiction Medicine as a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Hence, OUD, as with other substance use disorders, is a chronic relapsing disease. Repeated opioid use, as with other substances of abuse, can hijack our learning and ability to remember. It appears that for some, opioids may also create irreversible physical changes at cellular levels in the brain. This transformation contrasts with most other substance use disorders, where changes to the brain are largely believed to be reversible with time and abstinence.

Physical dependence means, in part, that an individual experiences symptoms and signs of withdrawal when abruptly lowering his or her dose of a medication. People can also become physically dependent on antidepressants, blood pressure medications, and so forth, but this does not mean they have a substance use disorder or are “addicted” to these substances, at least from a formal medical understanding.

Tolerance can also be a sign of physical dependence. Tolerance occurs when a medication no longer seems to have the same effect on the person’s symptoms, and as a result, higher doses are required to achieve similar benefits.

Physical dependence—which, as noted, involves withdrawal and tolerance—is commonly associated with substance use disorders and is prominent in OUD. Nonetheless, someone can have an OUD and be entirely free of signs or symptoms of physical dependence. Conversely, one can be highly physically dependent on opioids and not have an OUD.

 

Surrounded by Stigma

Another potential reason for the confusion around opioid addiction and physical dependence is the cultural stigma that surrounds the idea of addiction and being an addict. Such perceptions compromise straightforward discussions between patients, physicians, caregivers, and all interested parties.

Stigmas often prevent those involved from realizing or accepting that OUD is a formal medical diagnosis with confirmed genetic and common risk factors. The truth is, substance use disorders have a clear pathophysiology (that is, the process of how a medical condition develops and progresses) compared to most diseases. Furthermore, there are validated effective medical treatments for opioid use disorder.

 

Proper Evaluation Can Ensure Proper Treatment

According to recent US Centers for Disease Control (CDC), as many as one in four adults will develop an opioid use disorder as a result of taking prescribed opioids for chronic pain (CDC Guideline for Prescribing Opioids for Chronic Pain). This estimate is in comparison to the commonly cited (among clinicians) 98% of adults who may develop physical dependence during long-term use of opioids.

Understanding the distinct differences between having an OUD and being physically dependent on opioids is important not only in terms of discussions held between a patient and his/her doctor, but also paves the way for receiving proper care when using or tapering prescribed opioids.

Tapering

Tapering is a specific process prescribed by a doctor to slowly decrease, over time, a patient’s use of prescribed opioids until he/she is no longer taking them. Tapers, which help to reduce withdrawal symptoms, may be conducted for a variety of reasons, including addiction and physical dependence, as well as undesired side effects, a pending surgical procedure, or the medication’s effect on secondary medical conditions, such as anxiety or depression. In some cases, tapers involve taking another, weaker opioid medication.

Age-Related Issues

One often hears of an elderly person who has terminal illness and is in a lot of pain but who refuses opioids out of fear of becoming “addicted.” As an addiction specialist, I attempt to reassure patients that the chances of someone over age 60 becoming addicted to opioids, especially a patient who has never had another substance use disorder, is highly unlikely. One could compare it to the likelihood of someone over age 60 learning and fluently speaking a new language. In contrast, an elderly patient can readily develop some physical dependence on opioids even after just a few days or weeks of regular use.

Evaluation regarding OUD

If you have an OUD that goes unrecognized and do not obtain proper care for the disorder, the prognosis for treatment is widely accepted as poor. (See Chapters 2 and 3 of Opidemic – A Public Health Epidemic for further details.) Indeed, it behooves any person who has been taking opioids for more than a month to be professionally evaluated. A prescribing doctor may ask a series of questions to determine whether there are risk factors for developing an OUD (eg, family history, substance use history, exposure to addictive substances from an early age up to age 25, adverse childhood experiences, post-traumatic stress disorder or extreme anxiety.) and/or determine whether one may have already developed an OUD, or physical dependence. There are simple questionnaires that help to make these determinations: one is the Current Opioid Misuse Measure (COMM)screen and another is the Rapid Opioid Use Disorder Screen (RODS).

If your doctor determines that you may have an OUD or another substance use disorder (SUD) he/she may refer you to an addiction specialist for professional confirmation and treatment. Alcohol use disorders are quite common in the population at large and perhaps even more so in patients with complex pain issues. For those patients at high risk, ongoing monitoring will likely be folded into the treatment plan.

How often a doctor conducts formal evaluation checks for an opioid use disorder will be based on the patient’s specific clinical contextual factors. For example, if an individual is not able to adhere to standard agreements related to opioid use, or findings on urine drug screens become problematic, the physician may request a re-evaluation sooner than later. On the other hand, if an individual has a terminal illness, other objectives in the treatment plan are likely to take precedence.

 

My Doctor Says I May Have an OUD, Now What?

Individuals who are taking prescribed opioids to manage chronic pain (that is, pain that lasts more than 3 months) are said to be on “chronic opioid agonist therapy,” or COAT for short. Agonist medications by definition create an action, causing the medication to bind to the receptors in your brain in a similar manner to the natural opioid-like substances that every brain produces. These substances can help limit pain and anxiety. When higher intermittent doses of opioids are used, patients can experience euphoria and are more likely to develop an OUD. Nonetheless, even without a “high” and without misuse, a good percentage of COAT patients may develop an OUD.

(Antagonist therapy, on the other hand, can be used to block the brain’s opioid receptors and interfere with the effects of opioids).

If one is diagnosed with an OUD, there is commonly experienced disbelief or fear. While the diagnosis should be taken seriously, there are safe and effective treatments that promote positive outcomes. Standard first-line care includes medication-assisted treatment (MAT), which is particularly helpful for those living with chronic pain conditions. There is a lot of overlap between the brain circuits that manage addictions, sleep, mood, pain, and even anxiety. If one does not effectively manage the OUD, therefore, chronic pain management and the care of other underlying conditions may be compromised.

The basics and nature of MAT can be explored online. SAMSHA, the US Substance Abuse and Mental Health Services Administration, is a reliable source for pertinent patient information:

 

My Doctor Says I Do Not Have an Opioid Use Disorder, but I Am Physically Dependent, Now What?

In this case, the decision to taper off of opioids will likely be the prescribed path. Tapering, as described above, is a complex medical decision and is often individualized for the specific patient’s situation based on his or her medical history, any secondary or underlying conditions, the reason for the taper, and more. The most important issue is for you and your doctor to establish the goal of therapy together – most often, this is to improve quality and duration of life.

Effective interventions, including alternative therapies and even surgical options, may be presented to help manage your chronic pain while reducing or discontinuing opioids. Be sure to ask your doctor for a clear plan, including timeframes, benefits, and risks. It is essential that contingencies be made available if the taper is not successful or consistent with common goals.

Summary

Patients who are on chronic opioid agonist therapy (COAT) for pain management need to be monitored and occasionally screened for possibly having an opioid use disorder, even when there are no overt symptoms or signs. It is wise to speak to your doctor if you are concerned about being physically dependent on your medication. Skilled physicians can taper opioids safely and often the results are quite good. If opioids are to be continued, regular evaluations and discussions with your doctor can limit unnecessary complications.

If a physician makes the recommendation for screening or monitoring services, one can hopefully avoid feeling resentful based on societal stigmas associated with having a substance use disorder. Regular evaluations, as in all areas of medicine, provide measures to better assure that each and every patient receives the safest and most effective care.

In the book, Opioids in Chronic Pain – A Guide for Patients, Dr. Rotchford explores in greater depth when opioids are likely to be part of a solution in chronic pain management, and when they may be part of a problem, as well as the grey areas in between.

 

 

Updated on: 05/01/18
Continue Reading:
The Smart Patient's Guide to Chronic Pain Management
SHOW MAIN MENU
SHOW SUB MENU