Dependence, Addiction and Pseudo-Addiction

[Jaybay]

Hi Dr. Junig.  I see so many people are confusing what actually happens to their bodies with opiate therapy.  Some patients mistake physical dependence with addiction and hysterically discontinue their medication.  When withdrawal symptoms kick in, they're convinced their doctor made them "addicts" with the end result being their pain isn't treated - and the poor doctor gets bad-mouthed in the community.  Many patients won't go near an opiate because of the bad press.  Family members and friends read opiate patients the riot act about addiction because they aren't educated.  

Can you give us all a quick opinion on your interpretation of the differences between dependence and tolerance; addiction; and pseudo-addiction as it relates to opiate therapy?  Any examples of what you've seen in your own practice?  Many thanks!  :-)

[J T Junig, MD PhD]

Thank you for pointing out something that is often confused. I will do my best to summarize the differences—I encourage people to do some reading on their own, using the comments by Jay and myself as a starting point.

‘Addiction’ is not a name for a condition listed in the ‘DSM’, the book that psychiatrists use to identify and characterize mental illness.  The condition most people would likely see as most similar would be drug dependence, which is distinguished from drug abuse by physical dependence and other things that are associated with heavier use, and by a pattern of negative consequences related to using.  

I think I have already confused everyone.

Addiction is not formally defined by psychiatrists, but when I talk about addiction I am usually referring to the relationship that a person has with a substance or other object of addiction.  If a person wants to stop drinking, but can’t bring himself to throw out the beer he just poured himself… and instead leaves the beer in the glass on the counter all day… he is in a relationship with alcohol.  Opiate addicts think about using constantly—they are enjoying the last dose for only a few minutes before trying to feel if it is still there, or if it is starting to go away… and then if it is going away, how much longer do I have?  What is left?  Do I have any money?  Where can I get some?  Who is holding?  Where can I find him?  Uh oh—is that sweat?  I’m sweating, not good.  Is that my belly making noise?  Better get moving…

You get the idea—life becomes all about using, and not even about the ‘joy’ of using (as if!) but about the need to find the next one, and the one after that.  Addiction takes a great deal of mental energy.  Opiate dependence, or alcohol dependence, or cocaine dependence, are the official terms for ‘addiction’ in the DSM.  If you google DSM criteria for drug dependence you will find the formal criteria that must be met to qualify for the condition.  Drug dependence, or addiction, usually include physical dependence… but not always.  For cocaine for example, the addiction or ‘cocaine dependence’ can be quite severe with very little ‘physical dependence’.  The same is true for alcohol.

Physical dependence is when the body becomes more and more ‘used to’ the substance, so that ‘tolerance’ occurs—meaning larger and larger doses are required to get the same effects.  Tolerance is usually associated with ‘withdrawal’.  Physical dependence is NOT identical to ‘drug dependence’ or to addiction.  You can become physically dependent on non-addictive substances, such as blood pressure medication;  suddenly stopping a beta-blocker will result in ‘rebound hypertension’, which is a form of withdrawal.

‘Pseudo-addiction’ is a more complicated concept, but is probably the most commonly occurring of all of these conditions.  The term refers to a person being prescribed a dose of pain medication that is not sufficient to treat the pain, and in response the patient takes amounts of medication beyond what has been prescribed.  The patient feels guilty for doing so, and exhibits many of the signs of addiction, including feeling ashamed, covering up the use, being less than truthful about the use, and perhaps doctor shopping.  The patient’s doctor learns of this behavior, and responds by reducing the medication, ‘since the patient is addicted’.  This, of course, just makes the patient go to greater extremes to find relief from the pain.

There are so many problems with how narcotics are prescribed; doctors often fear getting in trouble, even when there is no real risk of that happening.  On the other hand, there have been some extreme cases where good doctors have been prosecuted or disciplined for care that turned out to be appropriate, but that attracted the attention of the licensing board for some reason.  I see one pattern over and over… the patient complains of pain, and the doctor writes a script, without spending any time discussing the limitations of the medication and the problems that occur from tolerance.  The patient returns and asks for more, or maybe even runs out early;  the doctor scolds the patient as he/she writes for a higher dose.  As time goes on, the patient gets higher and higher doses, each time suffering a new round of scolding so that he feels as if he is doing something wrong.  At some point the doctor is suddenly angry.  He has been getting more and more nervous inside;  many doctors don’t like confrontation, and so they don’t want to talk openly about what is happening…so they pretend everything is fine.  But when the dose gets to a certain point— or perhaps a pharmacist calls the doc and asks ‘are you sure you want to write for THAT many?’—the doc blows his top!  The patient, meanwhile, doesn’t know what has happened, and what he did wrong.  Suddenly the nurses and other office people are giving the patient funny looks, and the doc ‘isn’t available’ to talk anymore.  Sound familiar?

If I had any ‘pull’, I would have medical schools teach a formal course in prescribing narcotics.  I even think that narcotic prescribing could warrant a new medical specialty.  At one point I had a separate ‘division’ to my practice that I called the ‘Wisconsin Opiate Management Center’, and my goal was to prescribe narcotics the ‘right’ way, using adequate education, treatment contracts, meetings with pharmacists in the case of abuse concerns, etc.  I thought it was a great idea… and I still do.  But most doctors want to run the show themselves, or so it seems, anyway.  

Thank you again, Jay, for the suggestion.  

[Jaybay]

jollyman - you'll probably want to post your question in a new topic in case it gets missed in this particular thread.  Hope you're having a realatively pain-free evening.  :-)

[jollyman069]

Hi , i have been in chronic pain for about 15 years now, 4 years ago my dr sent me to a pain specialist, ihave 4 herntaed disc in my back , have had 1 srgery and pain was wporst, anyways i have been seeing my pain dr now and when i first started to see him he started me on percs 10/325, up to 5 times a day.. after about 3 years or so i wasnt getting the releif that iwas getting, so he added avinza30mg 1 per day and still gave me the percs but cut them to 4 aday for breakthrough pain. Is my body getting a tolerence built up or is my back condition getting worst?

[Jaybay]

WOW!  Thank you so very much for your insightful and detailed response.  Be assured I'll be sending the link to a whole lot of people.  :-)