Why I believe that the mythical state of "pure" opioid dependence is really just a prelude to or a less severe form of opioid addiction.
As I touched on in my piece on warning signs of prescription drug addiction, some doctors like to draw a line between drug dependence and drug addiction.
Someone taking insulin for Type 1 diabetes, they observe, is dependent upon it. They must take it every day, and they cannot function without it.
However, they are not addicted to their insulin. They don't crave it, obsess over it, raise their dosage. They don't do dangerous things to obtain it or while under its influence.
That's all well and good for insulin; it's not an addictive, dopamine-releasing drug.
For drugs like benzos and opioids, which are physically addictive and trigger potent blasts of feel-good neurotransmitters in the pleasure centers of the midbrain, the story is very different.
For these latter types of substances, I believe that this mythical dependence versus addiction dichotomy is a convenient fabrication, a distinction without a difference.
***
One measure of how addictive a drug is uses the percentage of people who are exposed to it who become addicts. The higher the percentage, the more addictive the drug.
By this metric, opioids are one of the most addictive drug types, which is why moderate to strong opioids have always been classed as Schedule II Controlled Substances in the U.S. - the most restricted class of drugs that have a recognized medical purpose.
When you take opioids regularly, they change how your Central Nervous System's pain receptors work.
(For my review of mu opioid receptor dynamics, which covers tolerance and dependence as well as affinity and precipitated withdrawal, click here).
At first, opioids mimic the action of endorphins - those "endogenous morphines" that your body produces to lessen pain and reinforce behaviors that support survival and reproduction.
Thus, you feel a boost of euphoria and a reduction in any pain you might be experiencing.
With regular use, however, this system comes to anticipate and depend upon these external painkillers. To maintain balance, your body decreases the sensitivity of its opioid receptors, and it also reduces its production of endorphins.
At this point, your body has become dependent on whatever opioid you are taking. You won't feel mentally or physically well without it.
Should you stop taking the opioid, you will experience a great resurgence of pain - not just the pain that you originally had, which led you to take the opioid in the first place, but all kinds of pain all over your body (in addition to anxiety, insomnia, GI problems, and the other symptoms of opioid withdrawal).
In fact, you don't even need to stop taking your opioid of choice to experience these symptoms; this will happen naturally over time as you build tolerance due to the aforementioned adjustments that your body makes to maintain balance when the drug is being ingested regularly.
Tolerance, as well as burnout of the body's pain-blocking pathways from too-frequent stimulation by opioid drugs, lead to an increase in pain called opioid-induced hyperalgesia.
The drug that you began taking to mitigate pain is now causing it.
Unfortunately, the only way to avoid these negative consequences of regular opioid use is to increase your dosage or switch to a more potent opioid.
***
As you take opioids for weeks and months, your psychology begins to change, as well.
You begin to monitor your level of physical comfort or discomfort more closely. You become hyperaware of small changes in your pain levels.
Just as regular stimulation of the opioid receptor system leads to hypersensitivity to pain because the natural mechanisms for counteracting it stop working, regular bombardment of the midbrain pleasure centers with levels of dopamine that exceed those naturally produced by your body leads to its built-in reward and pleasure pathways being underactive.
You begin to measure pleasure against that unfair, preternatural level of dopamine release from opioids rather than against those produced by food, sex, exercise.
Naturally, you begin to crave that enhanced feeling of pleasure and to feel blah without it.
As a result of these changes, you dwell more and more on when you can take that next dose of your opioid.
When you do, the pain relief and euphoria that you experience becomes more important, more reinforcing. It begins to feel necessary.
Should you have a bad day, or maybe a few bad days in a row, the temptation to take an extra dose or two - "just this one time," of course - becomes overwhelming.
When you eventually do the human thing and give in and take a little extra, you have one foot over the threshold into full-blown addiction.
The next time that you encounter a rough patch of anxiety, depression, or situational stress, you can bet your bottom dollar that your brain is going to remember and turn to that pharma hack that worked so expediently before.
An example of the type of prescription opioid discussed in this article. These original formulation OxyContin pills, which contained 40 milligrams of the highly potent opioid oxycodone, played a major role in instigating the opioid addiction epidemic in the United States. Their extended-release coating did not work, meaning that the entire dose was released into the user's system almost immediately. This coating could also be wiped off with a damp cloth, meaning that the pills were often ground up and snorted or injected. The high from taking one of these pills was equivalent to snorting two to three bags of high-purity East Coast powder heroin.
As I've written about elsewhere, OxyContin was so prevalent during my high school years (2003-2007) that kids would be walking around social events with golden smears on their clothing from wiping the extended-release coating off the pills. Appallingly, there were also an 80-milligram and a 160-milligram formulation originally on the market; despite Purdue's incredible political influence, which it bought with the billions of dollars in OxyContin profit, these ultra-high-dose formulations were withdrawn from the market relatively early on because they caused disproportionate numbers of overdoses (shocker, I know).
If you ever need an example of true evil, look no further than the Sackler family that owns Purdue. After Purdue fought for years to conceal or contradict evidence that OxyContin was highly addictive and malfunctional, the United States' Food and Drug Administration (FDA) forced Purdue to reformulate OxyContin to make it truly tamper-resistant and to ensure that its extended-release mechanism worked properly.
Despite this history, to this day Purdue continues to market the original formulation of OxyContin in China and other countries (it's easy to tell because the original formulation pills are marked "OC" and the reformulated ones are marked "OP"; plus, the original formulation has a coating that is wiped off very easily with water and is easily ground up, whereas the new formulation is a waxy mess when you try to grind it up, and its coating cannot be removed with water). I obtained the original-formulation, 40-mg pills in Shenzhen, Beijing, and Guangzhou, where Chinese doctors commented on how many foreigners showed up looking for them.
I've said it before, and I'll die on this hill: Those Sackler family members who were directly involved in Purdue's operations during the OxyContin epidemic deserve to face criminal prosecution. Reading their emails, which were released during the discovery processes for the many lawsuits brought against them, was one of the most sickening experiences of my life.
***
A responsible doctor won't prescribe opioids indefinitely.
He or she knows that there is no winning move in the chess game of chronic pain management with opioids, so he or she will A) advise procedures that target the source of the pain rather than masking it; B) recommend Cognitive Behavioral Therapy, mindfulness exercises, and other effective psychological tools for reducing pain; and C) switch to less addictive or non-addictive painkillers, which also pose less risk of overdose and will not cause withdrawal when stopped.
My life has provided me with a behind-the-scenes look at pain management medicine.
In my experience, ethical doctors would be absolutely appalled by how many apparently "good" pain management patients, the ones who seem stable, are running out of their meds early, buying supplemental meds or other drugs on the street, or are hitting up friends and relatives with similar prescriptions.
Their patients will go to shocking lengths to conceal their addictions because their supply of the drug that they are addicted to depends upon it.
***
Now, not all of those opioid-dependent patients necessarily meet the criteria for a diagnosis of drug addiction under the current definition.
We have a functional definition of addiction, meaning that impairment in one or more areas of life due to drug-taking is necessary to diagnose addiction.
Some of these opioid-dependent patients are able to mask their craving, obsession, and dose escalation for months or even years.
They hide their loss of function - missed days of work, impairment on the job, social withdrawal - behind whatever diagnosis is responsible for their chronic pain.
I have been in addiction treatment with many such individuals, whose spouses and children were floored to learn that there was no money to pay the monthly mortgage because mom or dad had secretly spent all of the family's savings on pills (it's also common for prescription drug addicts to rack up tens of thousands of dollars of credit card debt through online pharmacies and doctor shopping, which their spouses and friends / family are clueless about).
***
Again, if opioid-dependent patients seem out of sorts, at times - shaky, sweaty, unable to work or even get out of bed - of course they do; they have chronic pain.
If they seem a little groggy, a little loopy at other times - of course they do; they're being treated for chronic pain.
And who could be so cruel as to suggest that they stop taking their opioid medicine?
After all, it's the Only Thing That Works™.
Addicts are consummate deflectors and deniers, and in this scenario, they have been given the ideal shield.
***
In the United States, there are entire lobbies for patients on opioids for pain management, which fight any legislation that restricts the prescription of opioids.
This explains why it took so long for the U.S. to curb the prescription of OxyContin, a heinously addictive, high-dose formulation of a high-potency opioid whose extended-release mechanism was malfunctional, meaning that essentially the entire dose of the drug was released into the user's system at once.
OxyContin led to millions of addictions - hundreds of thousands of drug overdoses - tens of thousands of cases in which people who could no longer get pharmaceutical opioids turned to heroin and fentanyl (I wrote about this domino-like succession of addictions here).
As casualties mounted, Purdue, the Sackler family-controlled pharmaceutical company that created OxyContin, paid doctors to come up with sophisticated excuses for why the drug was wreaking such havoc.
One of these doctors, who has since acknowledged that his theory was the result of motivated reasoning - utter b*llshit contrived to make a ghastly high consultant's fee, in layman's terms - came up with a brilliantly evil explanation for why so many OxyContin patients came to their doctors requesting higher doses of the drug or to be able to take it more often. (Those same patients were often "losing" their prescriptions, running out early, and so on).
Purdue explained that such patients were experiencing pseudoaddiction, a phenomenon in which patients seem be drug seeking because their pain is undertreated, leading them to ask for more of the drug, more often.
What was the solution to pseudoaddiction, you wonder? More OxyContin, of course.
It is a shocking testament to the credulousness or indifference of doctors who studied pharmacology for 12+ years of postsecondary education that they believed and repeated this balderdash from pharma reps.
Needless to say, there was nothing "pseudo" about pseudoaddiction.
The FDA has finally acknowledged the reality of opioid addiction risk.
It is becoming nigh on impossible to obtain a long-term prescription for opioids (unless it is for PRN, "as-needed" rather than daily use).
This is exactly how it should be because opioids are not effective with regular use. In fact, not to beat a dead horse, but they actually increase pain when taken regularly for extended periods.
These revised FDA guidelines are in line with how most other countries' medical systems use opioids, within which they are almost exclusively administered during surgery and end-of-life care.
Needless to say, patients in these countries are not being tortured out of their minds with untreated post-surgical and chronic pain. There are more effective options, albeit ones that sometimes require a bit more work on the part of both doctor and patient.
***
I'll end with an analogy involving a much more common and less-addictive drug: alcohol.
If someone has one drink in the morning, two drinks at lunch, and four to six drinks a night, every night, for months or years on end, what do suppose are the chances that that person will end up with a healthy relationship with alcohol?
Taking opioids daily for chronic pain is an analogous situation.
In my opinion, dependence is a state of pre-addiction, early addiction, or hidden addiction.
And it's not just opioids that this dependence-vs-addiction distinction is invalid for.
The same arguments advanced above in regard to opioid dependence and addiction also apply to benzos and perhaps even addictive stimulant drugs like amphetamines and cocaine.
I focused on opioids simply because their mechanism of action means that craving / obsession and tolerance / dependence set in with particular vehemence and relatively early on.
Nearly anyone who becomes physically dependent on opioids is eventually - and often quite quickly - going to become addicted to them.
Addiction is simply the psychological and behavioral manifestation of the way that the brain's physiology adjusts to the regular presence of these drugs.
Let's put this dependence versus addiction dichotomy in the trash along with pseudoaddiction and all of the other bogus science funded by pharmaceutical companies hell-bent on protecting their right to poison people with highly addictive and damaging substances.
Bold Brian updates: I'm focusing on finishing the "Last of the Laowai" series about my time in China (Part II here) before school is in session. I was hoping to have Part III ready for publication this weekend, but it turned out to be longer than expected, and I don't want to rush it. It'll be out within the next few days, though.
My methadone taper is going - uh, about as well as a methadone taper can go. I'm pushing the dosage down fairly quickly during the last couple of weeks of summer vacation because I can "afford" to be sick right now. I've definitely experienced a spike in drug dreams and cravings during the last month, which is something that I'm paying attention to.
The good news is that I'm starting to realize some of the benefits of tapering off of such a powerful opioid. I've experienced a surge in creativity and energy in general lately, which I've used to write and edit. The downside of that is protracted, severe insomnia, so I've been walking and running eight to 12 miles a day to try to exhaust myself enough to get four to six hours of sleep per night.
Overall, I'm feeling okay and very committed to being off of maintenance. Thank you to everyone who has expressed support.
Be well and enjoy your summer!
Comments