Bottom line upfront: addiction and dependence are not the same thing, despite what popular culture would like you to believe.

I am by far not the first person in the medical community—practitioner or patient—to discuss this, nor will I be the last. But the DEA just held its Opioid Response Summit this week, and while I applaud all efforts to curb deaths by overdose, no one involved in that discussion is acknowledging the addiction/dependence conflation, much less arguing against it. This is where patients, especially pain patients, get royally screwed, a topic I addressed at length a few weeks ago. Like that twitter thread, this will not be a short post, because it’s a complicated topic.

Full disclosure: I am a chronic pain patient. I have prescriptions for narcotic painkillers. I have gone through withdrawal. But I have never, with four doctors in three states, ever been flagged as an addiction risk, and I request routine drug screens if my pain management teams do not do so automatically (most do). So mine is an unfortunately informed perspective, because when you spend years with doctors unable to diagnose you, you have no other choice but to educate yourself.

Let’s start with some definitions.  The short version is, addiction is psychological; dependence is physical.
The American Psychiatric Association (APA) defines “addiction” as follows:

Addiction is a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence. People with addiction (severe substance use disorder) have an intense focus on using a certain substance(s), such as alcohol or drugs, to the point that it takes over their life. They keep using alcohol or a drug even when they know it will causes (sic) problems.

When [pain] patients talk about dependence, however, this is what we mean:

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.

The article linked previously also begins by stating that most pain management physicians agree that prolonged opioid therapy can and frequently does result in physical dependence, but that psychological addiction is rare. If this still doesn’t make sense to you, however, take opioids of all classes out of the discussion entirely. Let’s talk about antidepressants instead. If you have ever been on an antidepressant of any class, you know that you gradually increase the dose until you and your doctor find one that works for you; if you choose to stop, you do not simply stop taking it one morning and call it good.  You have to just as gradually decrease the dose and give your body a chance to readjust to the antidepressant no longer doing the job of your neurotransmitters. Alternatively, if you’re familiar with fibromyalgia, or even the aftermath of shingles, you may be familiar with medications such as gabapentin (Neurontin) or pregabalin (Lyrica), which are frequently used to treat neuralgia, i.e. nerve pain. They are not narcotic medications, or indeed painkillers of any sort, instead affecting neurotransmitters in the brain and therefore changing your perception of pain. Like antidepressants, however, neither of these medications can be started with a sudden, large dose; and if you choose to stop taking them, you must decrease the dose slowly. Otherwise, you are at risk for serious “withdrawal” symptoms such as seizures.

Now let me ask you a question: has anyone ever, with any credibility, been accused of being addicted to antidepressants? How about Lyrica?

I’m willing to bet you that the answer to both of those questions is “no”. You can’t stop either of those medications “cold turkey” without experiencing withdrawal symptoms, because your body has become dependent on them to chemically regulate something it should but cannot do on its own. You have therefore developed a physical dependency, and stopping suddenly is accompanied by serious physical risk, but you are not addicted.

Believe it or not, the same logic can be applied to opioids (which I am defining broadly and generally here, because I don’t think you want to hear the difference between morphinans and 4-phenylpiperidines). Half the problem is, the class of drugs labelled “opioids” includes heroin; and of the most commonly listed drugs involved in the “opioid crisis”—oxycodone, hydrocodone, codeine—heroin is the only one on this list that is illegal. All others are only legally available by prescription.

There is addiction risk associated with all of these medications, and other opioids such as morphine or fentanyl. I am not denying that—I’m fairly certain no one who knows anything about medicine is trying to do so. I am very much in favour of making naloxone (Narcan) available outside of hospitals and ambulances, because it can and does prevent OD (it doesn’t cure addiction, if that is the inciting cause, but it keeps the patient alive to give them a chance to get help for addiction). I have personally witnessed and am well aware of how damaging addiction can be, both to the individual as well as to those around them; and that those in recovery know there is no “cure” and never want to see someone else go through what they did. I fully support all efforts to educate prescribers and patients, to prevent addiction, to provide treatment for addiction.

But for patients with chronic pain, and in this case I’m going to specify non-terminal-cancer pain, there is a difference. Many of us take regular doses of whatever narcotic painkiller(s) we are prescribed; but in nearly a decade of dealing with pervasive, degenerative pain, I have by extension had a chance to speak to a lot of people in the chronic pain community. I haven’t yet met one who wouldn’t give anything to not need painkillers, who doesn’t try to take less than the maximum daily dose as often as possible. Because for us, taking painkillers is not about the “high”, and it’s not about eliminating our pain, because nothing that leaves us conscious can ever do that. It’s about reducing our pain enough to let us function, to let us have something resembling quality of life—99% of prescriptions for opioids are written for nonabusers, for patients who have genuine need for them.

By “need”, I mean that it allows us to get out of bed; to eat (severe pain can induce nausea, and many of us experience this level of pain on a regular basis, myself included); to go to doctor’s appointments and run basic errands; to attend classes, for those of us who are still students—I personally finished my Master’s degree just last year, but I have been dealing with this since well before undergrad; and to work, whether we are capable of holding traditional jobs or do freelance work from home. I do not mean it allows us to go clubbing every week or go on regular social outings; I definitely don’t have the energy for that, and for most of us we have to be very selective and generally budget in a lot of recovery time afterward.

(And this is where the chronic pain community gets up in arms over House, M.D., because they had a chance to portray legitimate chronic pain and address the difference between addiction and dependence. They didn’t. Seriously, don’t get me started, I can yell about this for days on end.)

In these situations, dependence can have two separate meanings, and they are not mutually exclusive. 1) the patient is dependent on painkillers to be able to go out and get required errands done; if they run out, they are in pain and miserable because of said pain, but not “craving” more of the drug. 2) the patient is chemically dependent because their body is used to a certain dose; if they run out, they deal with symptoms frequently associated with “withdrawal”—sweating, muscle tremors, nausea, etc. These symptoms can be experienced without addiction. Most commonly, it occurs with narcotics which are available in patch form, and many of them are considered a lower addiction risk: it is a 24/7 dispersal of medication, but because the dose is so regular, it is dispensed in micrograms per hour. You as a patient might take 5 milligrams of oxycodone per dose; but you can take 5 milligrams of buprenorphine per week. That is significantly lower than the as-needed individual doses, even accounting for different potencies; and the frequency of breakthrough pain—sharp increases in pain beyond the baseline levels one feels on a regular basis—that requires as-needed oral painkillers decreases in turn. For example, you might be taking 5mg of oxycodone twice a day, every day; but with a buprenorphine patch, you only find yourself needing to treat severe breakthrough pain a couple times a week. The downside is, your body becomes dependent on that constant dose. That still does not mean that you are addicted.

If you don’t believe this is possible, I am speaking from personal experience; let me tell you a quick story. Several years ago, my pain management team and I decided to try a radiofrequency ablation, which basically means radiofrequency waves are used to sever the connection between nerves at the central point of pain from the rest of the body. Its effects are usually not permanent, and like any surgical procedure it has a risk of failure. On me, it really failed. I was on a 5mg/week buprenorphine patch before the procedure, and the ideal result was that I wouldn’t need it at all or be able to go back to as-needed doses of Vicodin after a week or two of recovery. The opposite happened: my pain levels skyrocketed, and my pain management doctor ended up pushing me all the way up to the 25mg/week buprenorphine patch, which helped but didn’t eliminate the pain by any means. Then, after a few months on that dose, I took a holiday and went home to visit my parents. Only problem was, I brought all of my medications except the buprenorphine. We had wanted to start decreasing the dose, but we’d have done it incrementally—25 to 20 to 15 to 10 to 5 to none. I went from 25 to 0—and at that point, I had a doctor who would not prescribe as-needed oral painkillers with patch-form narcotics, so I literally had nothing to help my body adjust. It was a miserable experience physically: insomnia, severe pain, cold sweats, muscle tremors, nausea, the list goes on. But there was no psychological craving: I was furious with myself because I had put myself through this needless exercise for no other reason than forgetfulness; and sure, I’d have liked to not deal with that, but all of my attention was not focussed on obtaining more of the drug. I wasn’t particularly active, because I couldn’t be, but I lived my life while I waited out the withdrawal symptoms. QED: my family had planned a camping trip. My parents thought we should cancel it, and I said the hell with that, let’s go. The absence of the drug did not overtake my life, my every thought and wish. Once the symptoms were gone, the whole thing was over, and when I went back to work I told my doctor we were returning instead to oral, as-needed pain medication. I also refused to go back on any sort of 24/7 patch-form medications, because forgetting your oral meds means pain; forgetting the patches means a whole other level of hell. When my pain degenerated severely last fall, I finally agreed to try the lowest dose of buprenorphine again, because it was the most effective painkiller I’d ever been on, but I now impose a limit that has nothing to do with my doctors: I flat out tell them I will not even go to 10mg/week.

This is not addiction. This is pain management. This is self-awareness and using painkillers to reduce pain enough so that said pain is not the only thing on your mind, severe enough that you cannot move or even breathe without hurting. Sometimes breathing still hurts even with the painkillers, but you are at least awake and talking and capable of coherent thought.

And this is the group of patients most adversely affected by the regulations put in place for this “opioid epidemic”. Because these bureaucratic panels frequently do not include so much as a public health official, never mind a doctor, they subsequently do not see this difference. They see “narcotic” and automatically see “addiction”. If you want to see the detailed impact, I’ll direct you to the twitter thread linked at the top of this post (it will display the whole thread).

But that is not what this post is about. This post is intended to highlight the fact that a chronic pain patient who may be dependent on opioids to be able to move, or who gets through the workday on NSAIDs and acetaminophen but comes home and takes a dose of a narcotic painkiller, is not in the same situation as the heroin addict who will do anything to get their next fix.

And yet, the reaction to the opioid epidemics treats them the same way.

Again, yes, there is addiction risk with narcotics. A patient can be dependent. A patient can be addicted. A patient can be dependent and addicted. This is why chronic pain patients have doctors who specialise in pain management. This is why they are required to see those doctors regularly, to maintain an objective monitor to try to prevent addiction, or intervene if it occurs. The system is certainly not perfect, but no system is.

So the next time you talk about the “opioid epidemic”; the next time someone—especially a friend—tells you that they’re on an opioid to manage a long-term pain condition; please, please remember that there is a difference between addiction and dependence. Remember that very few long-term pain patients abuse their prescriptions (again, 1% out of 14,000 prescriptions written, as linked above). Remember that, if a long-term pain patient is on a narcotic painkiller, that is because they and their doctors have determined the benefits outweigh the risks, and that what they need from you is not a lecture on addiction risk.

Trust me: we already know.

Thank you for reading this far. I hope this provokes thought; I hope it helps provide context; I hope it helps, period.

If you have questions, you are welcome to comment here or on twitter or both; but please be courteous. Trolling and abuse will be blocked, deleted, or dismissed as appropriate to the platform. I am happy to have a discussion with you about different points of view, but I won’t tolerate sheer vitriol because you think I am wrong, lying, or deluded, and you are unwilling to listen to a perspective that is different from your own.