Opioids: Addiction or Physical Dependence?

Opioids: Addiction or Physical Dependence?  – By J. Kimber Rotchford, MD, MPH  – Updated on: 05/01/18

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.

• 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.

I have yet to find any scientific proof of this though. I’ve seen brain images from people who live with great pain and those definitely show brain changes (see PAIN-DAMAGE), but I’ve not seen images from people who stopped abusing opioids and have been without them for years.

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.

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.

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.”

I have to wonder how severe a person’s pain is if they are turning down opioids (especially when they only have a short time left to live).

After days, weeks, and months  (years, decades) of unrelenting and incurable (intractable) pain, anyone would gratefully use anything they could find to ease it – especially when they weren’t going to live long enough to suffer the consequences.

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.

My mom, at 89, is having her opioids severely restricted to the point she only gets 2 Vicodin, providing only 8 total hours of pain relief per day. The rest of the day she’s miserable and can’t do much.

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.

Prognosis for treatment may be poor, but that doesn’t account for so many people that simply stop on their own.

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.

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 are our endorphins, opioid compounds that are manufactured by our own bodies.

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.

See my previous post, Opioids, Endorphins, and Euphoria, which explains why opioid abusers experience euphoria while pain patients very rarely do.

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

Why is there an assumption that I’d have to taper off opioids when I don’t have an OUD and they’ve been working well?

Effective interventions, including alternative therapies and even surgical options, may be presented to help manage your chronic pain while reducing or discontinuing opioids

I find it outrageous that they are recommending “alternative” therapies without any solid evidence of effectiveness or drastic procedures like surgery, which rarely works and often leaves patients in even worse pain.

There’s even a separate diagnostic code for the results of these surgeries, Failed Back Surgery Syndrome (FBSS).

Of course, as soon as it’s diagnosed and given a  diagnostic code, it becomes the patient’s problem/diagnosis, while the doctor only goes on to suggest it to the next patients.

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.

In the case of opioid tapers, there is no contingency: opioids are usually the last resort after all other “contingencies” have already been tried.

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.

This specific process is subverted by rules and standards that doctors are forced to enact on ALL patients.

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.