Addiction Is Not Dependence

Addiction Is Not Dependencepracticalpainmanagement.com – Aug 2019

In this editorial, Jennifer P. Schneider, MD, PhD, digs into a common—and frustrating—misunderstanding in pain medicine terminology.

FDA approved the buprenorphine implant, branded as Probuphine, in 2016 “for the maintenance treatment of opioid dependence.”

  • Was it approved for the treatment of what we now call Opioid Use Disorder (OUD)?
  • Or was the intent to approve it for physical dependence, a condition found in most opioid-treated chronic pain patients as well as opioid addicts?

It is not clear from the language.  

The Trouble with Time and Terminology

To understand how this confusion came about, we need to go back in time.

Since 1952, the American Psychiatric Association (APA) has published several editions of its Diagnostic and Statistical Manual of Mental Disorders (the DSM), a classification of psychiatric diagnoses.

Over the years, as the understanding of various psychological disorders has changed, the association has updated this widely accepted manual.

In the early editions, the APA referred to addictive disorders as addictions.

This is the most sensible label for a well-known mental health problem/issue. It’s perfectly clear and requires no complicated explanations or categorical exclusions.

But in 1994, the fourth edition (DSM-4) replaced the term “addiction” with “dependence,” apparently with a goal of using a less pejorative word.

Thus, an addict was considered to be dependent on a drug, so that a heroin addict was termed “opioid dependent.”

Ever since, “dependence” has remained the preferred term for professionals when describing “addiction.”

So, in the interest of not offending people with addiction, countless pain patients are labeled with the same designation of “dependence”.

I’m furious about how delicately addiction is treated, how much care is taken not to make people with addiction “feel bad”, even when it throws all pain patients under the bus.

Unfortunately, this term created a new problem for patients being treated with opioids for chronic pain.

Most patients on more than minimal doses of opioids for more than a couple of weeks will develop a specific set of withdrawal symptoms if they stop the drug suddenly.

This reaction is not addiction, but rather physical dependence, a physiological change in the body in response to ongoing use of certain drugs.

This type of change may occur not only with opioids but also with corticosteroids (which is why patients who no longer need prednisone need to be tapered rather than just stopped), with some antidepressants such as paroxetine (Paxil), and with beta-blockers in patients with heart disease.

As a result of the change in addiction terminology in 1994, not only was someone who was addicted to an opioid called “opioid dependent,” but so were most compliant opioid-treated chronic pain patients who were physically dependent.

It is known that opioids may lead to both addiction and physical dependence but being physically dependent does not mean the person is addicted.

How many times will this have to be explicitly stated, emphasized, and clarified before the public, the regulators, and far too many dim-witted doctors understand this simple difference?

Both the DSM-4 criteria, as well as the current DSM-5 version released in 2013, require three elements to diagnose substance use disorder (ie, addiction):

  1. loss of control (also termed compulsive use)
  2. continuation despite significant adverse consequences
  3. preoccupation or obsession with obtaining, using, and recovering from the effect of the substance

Addiction is a behavioral disorder, as seen from the elements above, and thus represents a different phenomenon from physical dependence and withdrawal.

the current DSM-5 guideline (see above) specifically says:

“this criterion [withdrawal] is *not* considered to be met for those individuals taking opioids solely under appropriate medical supervision.”

In other words, any withdrawal symptoms in a patient on prescribed opioids are not a tell-all sign of addiction.

What about the definition confusion?

The solution enacted by psychiatrists almost 20 years after their disruptive change in terminology, was once again to change the name of “addiction” – this time to “Substance Use Disorder,” the official term used in the DSM-5, which was published in 2013.

For opioid addiction, specifically, they introduced the term “Opioid Use Disorder (OUD)” while entirely deleting any mention of the term “dependence.”

But the term “dependence,” meaning “addiction,” was so entrenched by then that even the FDA in 2016, as shown in the language used in their approval of Probuphine, was still using the term dependence when they meant addiction.

I find this widespread ignorance among healthcare professionals frightening. If they are so oblivious to the difference between addiction and physical dependence, who knows what other important conditions they could be wrong about.

Consequences for the Patient and Public

The misunderstanding between physical dependence and addiction has had negative consequences far beyond confusion in medical records and scholarly papers.

A major consequence is that the majority of prescribers, the lay public, the media, and government officials still believe that a majority of patients on chronic opioids become addicted.

For example, a 2018 study of almost 400 prescribers found that, when asked their belief about this statement, “I anticipate that my patient will become addicted to the opioid that I am prescribing for him/her for chronic pain,”

  • 60% said “always,”
  • 23% said “sometimes,” and
  • 40% said “rarely or never.”

This is a shocking level of incompetence and ignorance, inexcusable in a medical professional (and I use the term loosely).

The reality is that several studies have shown that the likelihood of addiction to opioids from prescribed opioid therapy is closer to 2 to 5%.

Nora D. Volkow, MD, director of the National Institute on Drug Abuse, part of NIH, wrote,

“Although published estimates of iatrogenic addiction vary substantially from less than 1% to more than 26% of cases, part of this variability is due to confusion in the definition.

Rates of carefully diagnosed addiction have averaged less than 8% in published studies.”

She stated in the same paper,

“Addiction occurs in only a small percentage of persons who are exposed to opioids — even among those with pre-existing vulnerabilities.”

A Brief History of Opioid Addiction Terminology

Based on the Diagnostic and Statistical Manual of Mental Disorders (DSM), of the American Psychiatric Association (APA)

1952 – 1993: The DSM I, II, and III, termed addictive substance disorders, including opioid addiction, as “addiction.”

1994: The DSM-4relabeled substance “addiction” as “dependence” meaning a heroin addict would be called “opioid dependent.”

2013: The DSM-5 introduced the term “Opioid Use Disorder (OUD)” to describe “opioid addiction.” “Addiction” overall was replaced by “Substance Use Disorder.”

The term “dependence” was dropped from the manual altogether; neither “opioid dependence” nor “drug dependence” can be found in its extensive index.

Given that the main characteristic of physical dependence is the presentation of withdrawal symptoms upon stopping the substance, the DSM-5 does note that “withdrawal” is one of the 11 criteria for diagnosing OUD, stating:

“This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.”

In other words, the APA is noting that physical dependence is not a criterion for addiction in patients being prescribed opioids.

For more on this topic, see PPM’s 2019 literature review on addiction medicine and relapse prevention.

6 thoughts on “Addiction Is Not Dependence

  1. Kathy C

    Marketers found that conflating these terms was more profitable. The APA failed to clarify the terms, by design. It certainly was convenient, and profitable. This is what happens when certain industries direct and fund the research. For psychologists blurring and conflating the terms led them to extend their services, and put them on a level with physicians in pain care, and addiction. It is really clear not one ever thought about the ramifications or unintended consequences.

    The confusion they created deliberately was profitable. The insurance industry, large health providers and pharma all benefited and profited from this deliberate confusion. Psychology is considered benign, so they do not have to look at the negative outcomes in any of their research. The “science” the mass media and marketers used to peddle their pain cures, and quack treatments,was all, qualitative not quantitative.

    NPR is at it again, a few factoids, introduced as if there is not a long history of denial, lies and deliberate misinterpretation. https://www.npr.org/sections/health-shots/2019/08/26/741926952/women-may-be-more-adept-than-men-at-discerning-pain

    Liked by 2 people

    Reply
  2. GZB

    After the C.D.C. Guidelines first came out I remember facing a very nervous P.A. at my Pain Specialist. I questioned what in the world the C.D.C. was doing getting involved in pain treatment? After all, they are specifically the centers for disease control. I’m not sure how to describe the look on the P.A.’s face, but the response was an emphatic ‘opioid use disorder!’ So, there you have it, I was labeled right there and then. Of course this has nothing to do with facts,but everything to do with fear and ignorance. I didn’t understand at the time just how detrimental this label could be. Every time I think it’s been sorted out clinically and scientifically, it isn’t.
    Oh, N.P.R.! What ever happened to the fact driven journalism that I remember? That article contradicts itself many times and there are no footnotes or links provided to validate a single thing that they say. But, this is a psychologists viewpoint. They use simple stimulus and think that is anything close to the pain that is endured by someone (especially women!!) with intractable disease or injury? Another case of simple explanations for simple minds or simple PROPaganda!

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      Most of us prefer simple explanations, but when you so many entities involved in or connected to this supposed “opioid crisis” it becomes clear that it’s not a simple problem.

      Foolishly, all they’ve done so far is throw all their resources into regulating legal prescription medications, reducing pain relief by “deprescribing” prescription opioids, the least problematic part of opioid use when so many others are ingesting
      all kinds of substances (cocaine, heroin, methamphetamine) contaminated with illicitly manufactured fentanyl.

      Liked by 1 person

      Reply
  3. wrmsmiles

    Hawaii is still having a hard time discerning between the two terms also. After sending them the Addiction is Not Dependence article, Dr. Singers article last week on dependence vs. addiction, the letter differentiating the 2 terms from former FDA commissioner Gottlieb and the APA write up on the two terms, they still ran with a PSA insisting that dependence can happen in less than a week.
    They then go on to say “Many people don’t know that if you have been taking prescription opioid or narcotic pain medication for more than one week, you could be at risk for opioid dependence* and not even know it,” said Director of Health Bruce Anderson. “Learning about the risk and about alternative treatment options is the first step to keeping you and your family safe.” Last year, approximately 650,000 prescriptions for opioid or narcotic pain medication were dispensed in Hawai‘i.

    *Dependence refers to physical responses to substances such as increased tolerance (needing more substance to achieve desired effect) and withdrawal (substance-specific symptoms when it is no longer taken). Although dependence does not necessarily constitute addiction, it can often accompany addiction.

    Here’s the kicker. The next line indicates that “This campaign is one of many initiatives currently happening to curb opioid dependence in Hawai‘i,” Now why do we need to curb opioid dependence and not alcohol dependence or anti-depressant dependence or insulin dependence or statin dependence? I whole hardheartedly agree that the correct term should be to CURB OPIOID ADDICTION or any and all addiction. We can’t just through out the term addiction because we don’t like the way it sounds. This is ludicrous and has gone to far. Their survey should not even be given to legacy patients because they have no disclaimer indicating that “The criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.” In fact you’re asked point blank if you experience certain symptoms just after stopping for one say. I’m beginning to believe in the term “coconut wireless” now as it seems like no one here bothers to read material put out across the ocean.

    Liked by 2 people

    Reply
  4. canarensis

    “I’m furious about how delicately addiction is treated, how much care is taken not to make people with addiction “feel bad”, even when it throws all pain patients under the bus.”

    Me too, my friend. To the point that at times I’m sure my head is going to explode from the rage.

    Liked by 2 people

    Reply

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