What is addiction? (And what is not)

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A patient once visited me.  I had been treating him for several years.  Although there was distant history of illicit drug use and use of methadone in the past, more recently he had been prescribed opiates for pain.    He has a severe neurological disease that leaves him in chronic pain.  When he uses pain medication, he is able to function and go to work.  He does not use more medication than needed. 


We were talking about addiction and he said “Doctor, surely there are two types of addicts.  Some who use illicit drugs and as a result do nothing with their lives and others, like me, who use the medication in order to function”.   He feels anyone who has a consistent use of an addictive medication is an addict.  Certainly, if he did not get his medication he would have physical withdrawal symptoms.  I am sure he would obsess over the lack of medication and might go to extreme measures to obtain the drugs. He might buy heroin on the streets.  He might lie, juggle several physicians or forge prescriptions.  To all persons who know him superficially, he is typical addict.  He even identifies himself as one.  But he is not!!!


There is a great deal of confusion of what addiction is.  The DSM is the official handbook for all behavioral health problems.  It details the characteristics of all the various psychological diseases such as depression, schizophrenia as well as substance abuse.  Over the past 40-50 years-the criteria for addiction has changed.  In the first edition of DSM, addiction is defined solely by the presence of tolerance and physical dependency, which occur universally in chronic pain patients.  Behaviors were not considered.  Certainly, with these criteria, addiction will occur in everyone using opiate pain medication chronically. 


In recent years the diagnostic criteria have changed.  The official definition of addiction per the DSM 4, the current version of the DSM, is an improvement as it begins to looks at behaviors as well as physiologic consequences of the use of a substance.  The definition is as follows:


A maladaptive pattern of substance use leads to clinically important distress or impairment as shown in a single 12-month period by 3 or more of the following:

2-Physical Dependence

3-The amount or duration of use is often greater than intended.
4-The patient repeatedly tries without success to control or reduce substance use.
5-The patient spends much time using the substance, recovering from its effects or trying to obtain it.
6-The patient reduces or abandons important social, occupational or recreational activities because of substance use.
7-The patient continues to use the substance, despite knowing that it has probably caused physical or psychological problems.


It is important to note that criteria one through five can still be seen in patients using opiates chronically for pain.  Even though they are an improvement from prior criteria, they still fail to differentiate patients with addiction from those with chronic pain.  For this reason, the American Society of Addiction Medicine, the American Pain Society and the American Academy of Pain Medicine have put out a collaborative definition of addiction and it is as follows:


Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing it development.  It is characterized by behaviors that include one or more of the following:

1-   Impaired control over drug use

2-   Compulsive use (use when you do not want to use)

3-   Craving for the substance

4-   Use despite harm. (That is, the patient must recognize that the substance is impairing their overall ability to function and continue to use)


It is important to note that this last definition of addiction looks mainly at behavior and complex feelings, and does not consider the simple physiologic adaptations of tolerance and withdrawal.  Item number four deserves more focus.  If a person is more functional because of his use of pain medication, he is not being harmed by it.  If he uses the medication as prescribed, without taking more medication than he intended, then there is no addiction.  Most patients will not be craving for their drugs if they are on a steady dose and not in withdrawal.


Early in my career, I worked with an addiction medicine physician who felt that abstinence was a goal in and of itself.  I have seen the results when people, stable on the use of an addictive substance, have undergone detoxification in order to reach the ideal of abstinence.  It was not a good experience.  Abstinence should not be the ultimate goal.  Rather, optimal functioning in the physical, psychological and social domains should be that goal. 


Nevertheless, just because there is a true physiological reason for pain, does not mean that it is okay to be using opiates.  Many people with real disease often are worse off secondary to pain medication use.  It can be difficult to determine who is better off and who is worse off.  The intensity of pain is not a reliable indicator but needs to be considered in conjunction with the patient’s daily activity and their overall psychological functioning.


People are not machines.  On any given day, the patient may be tired, cranky, in a bad mood.  We all have our bad days.  So I ask you not to condemn a patient, who is taking these medications, because they are impaired from time to time.  However, if the patient is over-sedated, irritable and/or depressed with any regularity, addiction may co-exist with the pain.  If a determination is made that the patients overall condition is worse because of use of a pain medication, counseling and possible detoxification needs to be considered.


In sum, if you use a psychoactive substance, do not assume its use is wrong.  Discuss with your doctor why you use the drug.   Make sure he is comfortable with the concept of addiction and how to distinguish it from physical dependency.  If necessary, discuss it with an addiction medicine specialist.  Than, follow your instinct.  It will usually be right.


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