What is Addiction?

Definition:
While tolerance and physical dependence are physical changes in the body, addiction is defined by aberrant changes in behavior. Addiction is compulsive use of drugs for nonmedical reasons; it is characterized by a craving for mood altering drug effects, not pain relief.[8] Addiction means dysfunctional behavior, in sharp contrast to the improved function and quality of life that result from pain relief. Aberrant behaviors which indicate addiction may include: denial of drug use; lying; forgery of prescriptions; theft of drugs from other patients or family members; selling and buying drugs on the street; using prescribed drugs to get “high.”[8]

Clinical relevance:
Addiction is extremely rare in cancer patients who use opioids for pain (see abstracts). Biochemical, social and psychological factors are more important in the development of addiction. Opioids should not be withheld for fear that a patient will become addicted. If a pain patient requests a strong analgesic, it is likely that the patient has inadequate pain control.

What is Dependence?

Definition:
Physical dependence is the physiological adaptation of the body to the presence of an opioid. It is defined by the development of withdrawal symptoms when opioids are discontinued, when the dose is reduced abruptly or when an antagonist (e.g., naloxone) or an agonist-antagonist (e.g., pentazocine) is administered.[6]

Clinical relevance
Physical dependence is a normal and expected response to continuous opioid therapy. Physical dependence may occur within a few days of dosing with opioids, although it varies among patients. Physical dependence (indicated by withdrawal symptoms) does not mean that the patient is addicted.[6]

Health care workers should advise patients to take their pain medication as directed, and that withdrawal symptoms may occur if they reduce their dose or stop taking the medication.[7] Symptoms of withdrawal may include agitation, insomnia, diarrhea, sweating, and rapid heart beat. If the source of pain is successfully treated or removed, physical dependence is easily treated by gradually decreasing the opioid dose, e.g., reducing the daily dose by 10 to 25 percent every 2 days. When a daily dose of 10-15 mg of parenteral morphine (or its equivalent) is reached, maintain that dose for 2 days, then discontinue.

Psychological dependence occurs when a person feels he or she needs the drug to function or feel comfortable (e.g., needing to drink alcohol to feel relaxed in social situations, or needing to be high to enjoy sex). Some people come to feel they need a substance just to be able to cope with daily life.

Physical  dependence occurs when a person’s body has adapted to the presence of a drug. Tolerance has developed, which means that the person needs to use more of the drug to get the same effect. When drug use stops, symptoms of withdrawal occurs.

People often think that psychological dependence is not as serious as physical dependence. This is not necessarily true. Cocaine, for example, does not cause physical dependence—but it is considered one of the easiest drugs to get hooked on and one of the hardest to give up

Why do people keep using?

Substance use can be hard to change. One thing that makes change so difficult is that the immediate effects of substance use tend to be positive. People may feel good, have more confidence and forget about problems. In contrast, the problems from use might not be obvious for some time.   People may come to rely on the effects of substances to bring short-term relief from difficult or painful feelings. The effects of substances can make problems seem less important, or make it seem easier to talk and to be with others. People may come to believe that they cannot function or make it through the day without drugs. When people use substances to escape or change the way they feel, using can become a habit, which can be hard to break.   Continued substance use, especially heavy use, can cause changes in the body and brain. If people develop physical dependence and then stop using, they may experience distressing symptoms of withdrawal. Changes to the brain may be lasting. These changes may be why people continue to crave substances and slip back into substance use long after they have stopped using.   When people who are addicted stop their substance use, they often compare the experience to leaving a relationship that was very important to them.

Alex began using heroin more than 10 years ago. Getting money to buy drugs was always a problem. He grew tired of the stress of always needing to score, and of knowing that if he got arrested again, he’d go to jail. Still, deciding to leave heroin and try methadone treatment was hard. Once the treatment became routine, he felt bored and didn’t know what to do with his time. He wished he could go back to using, but was afraid of what would happen if he did. His counsellor helped Alex to think about what he wanted from life. Alex enrolled in school and got a part-time job. Soon after, he started a new relationship with someone he trusted. Some days are still a struggle, but with time, and keeping busy, it gets easier.

Alex found it hard to stop using heroin and to continue with his treatment, especially at first. But just as substance use problems don’t start overnight, they don’t get better right away either. By staying in treatment and continuing to get support, Alex began to get his life back on track.

How common is addiction?

Addiction affects many people. Those who have not experienced a substance use problem first-hand are likely to have a family member, friend or colleague who has. Although addiction affects men and women of all ages, rates are:

•   two to three times higher in men than women

•   highest among people aged 15 to 24 (Statistics Canada, 2003).

A 2002 study of the rates of addiction found that 2.6 per cent of Canadians were dependent on alcohol and that fewer than one per cent were dependent on illegal drugs (Statistics Canada, 2003). These numbers, however, do not reflect the full impact of substance use problems in Canada. Substance use problems can occur even with low levels of alcohol or other drug use, and in people who are not dependent. For example, estimates suggest that more than 25 per cent of men and nearly 9 per cent of women who drink alcohol are “high-risk” drinkers. These are people whose drinking can be said to be hazardous and harmful to themselves or others, even though these people may not be substance dependent (Adlaf et al., 2004).   Methadone is useful to prevent withdrawal because it has a long duration of action. For most people a single dose prevents withdrawal for 24 hours. By slowly decreasing the dose over months patients can become opiate free without having to go through withdrawal. Patients that are compliant with their treatment contract are never forced to go off MMT – some stay on indefinitely.   Most people get some side effects. Most common are constipation (typical of all opiates), sweating and weight gain (due to better health and appetite), and libido changes (increased or decreased).   Taken as directed, methadone is very safe and does not cause long-term damage to organs, even after several years. However, it is a powerful drug and a typical dose for an addict can be fatal to someone that has not developed tolerance.

The stigma of addiction

Stigma is another reason why the rates of substance use problems may be higher than studies suggest. Stigma marks substance use problems as shameful and makes people want to hide their addiction.   Stigma also affects the families of people with addiction. It makes them hide the problem or pretend it isn’t there at a time when families need support.   What can we do about stigma? One simple way you can help is to choose to talk about “people with substance use problems” rather than about “addicts,” “alcoholics,” “junkies” or “stoners.” Try this approach whether you are talking about another person or about yourself. When you do this, you put the person ahead of the problem. This helps to show that you know there is more to a person than a problem. You are also giving the person with an addiction the support and understanding it takes to recover.​   People use alcohol and other drugs for many reasons. Some use these substances to help them to relax, to feel more lively, to feel less inhibited or to feel pleasure. Some find the effects of substances make it seem easier to cope with problems. Some use substances for religious reasons or to fit in with the crowd. Others may be curious about the effects of a specific drug.   No one plans to become addicted. People may think that they can handle their substance use and that they only use when they want to. But when they want to change the way they use, they may find it’s not that simple.

References

1. Portenoy RK. Opioid tolerance and responsiveness: Research findings and clinical observations. In: Gebhart GF, Hammond DL, Jensen TS (eds) Proceedings of the 7th world congress on pain. Seattle: IASP Press, 1994: 595-619.

2. Brescia FJ, Portenoy RK, Ryan M, et al. Pain, opioid use, and survival in hospitalized patients with advanced cancer. J Clin Oncol 1992; 10: 149.

3. Schug SA, et al. A long-term survey of morphine in cancer pain patients. J Pain Symptom Manage 1992; 7: 259-266.

4. Von Roenn JH et al. Physician attitudes and practice in cancer pain management: A survey from the Eastern Cooperative Oncology Group.Ann Intern Med 1993; 119: 121-126.

5. Waller A, Caroline NL. Handbook of palliative care in cancer. Butterworth-Heinemann: Boston, 1996.

6. O’Brien CP. Drug addiction and drug abuse. In: Goodman and Gilman’s The pharmacological basis of therapeutics. 9th edition. New York: McGraw Hill, 1996: 557-569.

7. Weissman DE, Dahl JL, Dinndorf PA. Handbook of cancer pain management. 5th edition. Madison, WI: WCPI, 1996.

8. American Pain Society. Principles of analgesic use in the treatment of acute pain and cancer pain. Glenview, IL: APS, 1992.

9. Weissman DE, Haddox JD. Opioid pseudo-addiction – an iatrogenic syndrome. Pain 1989; 36: 363-366.

Opioid dependence can affect everyone differently. That’s why knowing the signs and symptoms of opioid dependence and how they may relate to you is an important first step in recognizing your own individual risk.

The following is a list of some general warning signs and symptoms that could indicate you may be at risk of opioid dependence.

It is not a complete list, so please talk to your doctor if you feel you are experiencing any of these symptoms and to decide on your next step.

Opioid dependence may be more common than you thought. And although you may feel alone, you’re not. Opioid dependence can affect men and women of all ages, races, ethnic groups, and educational levels. So, it can happen to anyone – a friend, a neighbor, a coworker, a spouse, a brother, a sister, or parent.

Did you know?

Why Are Some People More Likely to Become Opioid-Dependent?

Exactly why some people, and not others, become dependent on opioids (or any addictive substance) is not totally understood. Most people who take opioids do not become opioid-dependent. However, certain factors appear to increase the likelihood of dependence, including:

No one sets out to become dependent, but why do some people become dependent on opioids while others don’t?

While everyone is unique, some known factors can increase the chances that a person will become dependent. These may include:

Mary’s Story

Mary loves going out after work with her friends. Her job is stressful, and having a few drinks with her friends helps her to unwind and relax. Lately, Mary’s regular “after-work drink” has turned into a whole evening of drinking. She often misses dinner and doesn’t get home until late. A couple of times Mary hasn’t remembered how she got home the night before, and she’s been late for work. Her manager has commented that she seems tired and distracted, and wonders if anything is wrong.

This example shows how substance use problems can develop slowly, and how it can be easy to overlook some early warning signs that a person’s substance use is becoming a problem.

What are opioids and why are they prescribed?

Opioids can include heroin, opium, and certain prescription painkillers. Also referred to as prescription narcotics, some opioids are drugs that can be prescribed for the management of pain. Some are made directly from opium (for example, morphine and codeine), while others are man-made but similar chemically to opium (for example, the painkillers oxycodone, hydrocodone, and fentanyl, better known by such brand names as OxyContin^®, Vicodin^®, Percocet^®, and Actiq^®). Heroin is also an opioid.

For people with severe pain, opioids are very effective medicines, and most patients treated for pain with opioids do not become dependent on them. For some people, however, opioid dependence is an unexpected side effect of proper pain treatment. The challenge comes when someone is unable to stop using the drug after the pain passes.

What are some examples of opioid prescription painkillers?

* Tylenol #1,2,3
* Duragesic (fentanyl)
* Dilaudid (hydromorphone)
* Demerol (pethidine)
* Vicodin, Lorcet, Lortab (hydrocodone)
* Percocet, Percodan, OxyContin (oxycodone)

What are triggers and what do they have to do with opioid dependence or drug addiction?

For people dealing with opioid dependence or drug addiction – including those in recovery – a trigger is a situation, a person, a memory, or a feeling that triggers the urge to use drugs (often referred to as cravings). Stressful situations are a common trigger, but each person has his or her own factors that trigger substance abuse behaviors

Is addiction to opioid prescription painkillers a disease?

Addiction or dependence on opioids – prescription pain medications and heroin – has been defined as a chronic (long-term) brain disease by the World Health Organization and the National Institute on Drug Abuse.

What this means is…the brain is the organ in the body that has been affected by the disease, and the brain requires treatment to heal. Similar to other chronic diseases like diabetes, asthma, and heart disease, opioid dependence can be successfully managed, but not cured. Chronic disease usually requires ongoing, long-term treatment that includes medication and/or behavior change.

Can someone who is addicted to opioids or heroin simply stop taking them or “quit cold turkey”?

Some people do succeed in stopping cold turkey – that is, quit on their own without treatment or help. But many more try to stop on their own and find that they end up returning to use because of the intense withdrawal symptoms, despite their best intentions and willpower to stay away from using drugs. According to NIDA, the National Institute on Drug Abuse, nearly all opioid-dependent people believe at first that they can stop using drugs on their own.

People are often relieved to discover that there are effective treatments available that are private and discreet, and that can help suppress withdrawal symptoms while helping to manage cravings. Learn more about available treatment options for you.

Strong Evidence Said to Support Opioid-Addiction Treatment With Methadone, Buprenorphine
Strong evidence confirms that two forms of medication maintenance therapy show benefits in treating opioid use disorders, according to literature reviews published in the new issue of Psychiatric Services. Buprenorphine treatment or a combination of buprenorphine and naloxone “indicated a high level of evidence for its positive impact on treatment retention and illicit opioid use,” said Cindy Thomas, Ph.D., an associate research professor at the Heller School for Social Policy and Management at Brandeis University, and colleagues.

Buprenorphine may be safer than methadone for pregnant women and their newborns, they noted. The treatment may also work as well for patients with prescription opioid dependence as for those dependent on heroin, said the authors. Access may be better, too, since buprenorphine can be prescribed in doctors’ offices rather than only in specialized treatment centers, as is the case with methadone.

Methadone treatment also had significant value in reducing illicit opioid use and in retaining patients in treatment, said Catherine Fullerton, M.D., M.P.H., of Truven Health Analytics in Cambridge, Mass., and colleagues. Evidence for methadone treatment’s effects on mortality, drug-related HIV risk behaviors, and criminal activity were less robust but still positive. However, methadone may also present risks for adverse events, including respiratory depression and cardiac arrhythmias.

Neither form of treatment appeared to be improved by the incorporation of psychosocial therapies, the authors noted. After reviewing the data, the authors of the studies, which are part of the journal’s SAMHSA-sponsored “Assessing the Evidence Base” series, concluded that health officials and policymakers should expand insurance coverage of methadone and buprenorphine maintenance treatments.