When I appeared on a Texas radio show in May this year, one caller exemplified a huge problem in the way we talk about addiction in America, one that has serious implications for pain patients, people with addictions and babies born exposed to drugs.
"Chris from Houston" said he's taken opioid painkillers for six to seven years, allowing him to function, despite chronic pain, at what he called "a very labor intensive job." However, if he doesn't take his pills, Chris suffers withdrawal symptoms. Concerned, he asked whether this makes him "an addict."
That question has massive implications for Chris's health—and even his freedom and that of his doctor. It also has significant repercussions for drug policy. The wrong answer can literally put people in prison. And yet confusion about how to label Chris's experience is widespread, appearing everywhere from a recent survey in the Washington Post to doctor's offices across the country.
According to the way I see addiction—and the National Institute on Drug Abuse and the most recent version of psychiatry's diagnostic manual, the DSM5, agree with me—Chris doesn't qualify, so long as his description of his situation is accurate. What he describes experiencing is physical dependence, a natural consequence of taking certain medications over time. Addiction, in contrast, consists of compulsive drug use despite negative consequences.
"Physical dependence occurs very frequently with repeated opioid exposure, but dissipates promptly after a few days of opioid tapering and discontinuation," explains Nora Volkow, director of the National Institute on Drug Abuse. "Addiction occurs only in those vulnerable and is a slow process that, once it has occurred, can take months and even years to overcome and requires persistent treatment."
In other words, if pain medications are making your life genuinely better and improving your ability to love and work, what you are experiencing if you have withdrawal symptoms is dependence, not addiction. People with diabetes, for instance, are dependent on—but not addicted to— insulin; people on certain antidepressants are dependent on them, but, again, not addicted.
On the other hand, if drugs make your life worse and you still can't stop taking them, that's addiction.
This may seem like a trivial or academic distinction, but it shapes policy and medical decisions that affect people like Chris. For instance, if he told his doctor he's addicted, the doctor would have a legal obligation to either taper the drugs no matter how much they might be helping his pain—or else come up with a rock-solid reason why he should continue to be treated with them for pain despite addiction.
That's because, under federal law, it's illegal to prescribe opioids to supply people with addiction—except for in two special and restricted cases for the use of methadone and buprenorphine. If doctors believe that a patient is addicted and then carry on prescribing medications like Oxycontin, the DEA or state authorities will happily take away their medical license or even criminally prosecute them. In cases like Chris's—where opioids have apparently been used without problem for years and are continuing to work—being denied access can lead to agony and disability, not "recovery."
"Even patients themselves [confuse addiction and dependence] and feel guilty about it and feel like something is wrong with them," says Richard Saitz, professor and chair of community health sciences at Boston University. "They are often treated as if something is wrong with them, when there's nothing wrong at all. All of that ends up leading to actions or policies or guidelines that are really misguided and address the wrong thing."
Much of this confusion results from the history of our understanding of addiction and a very unfortunate decision made by a DSM committee in the 1980s. Early definitions of addiction often did indeed see it as being identical to dependence, in part because physical withdrawal symptoms can be objectively measured and researchers were trying to minimize subjectivity.
These conceptions of addiction as simply needing drugs to avoid withdrawal were based on observations of people with alcoholism or opioid addictions. These folks generally have very visible physical withdrawal syndromes: Opioid withdrawal involves shaking, sweating, vomiting and diarrhea, and with alcohol, there can also be hallucinations and potentially deadly seizures.
Cocaine, in contrast, doesn't have such an obvious and reproducible withdrawal syndrome: While people quitting coke often become irritable and strongly crave the drug, they don't generally look and act physically ill.
This difference led to the development of the belief that there are two separate aspects of addiction: "physical dependence" and "psychological dependence"—an idea that remains popular in the public mind today.
Back then, since physical dependence was seen as more severe, so were addictions that had physical withdrawal symptoms. Meanwhile, drugs that produced mere psychological dependence were seen as not especially dangerous: a 1982 Scientific American article described snorting cocaine as being roughly as addictive as potato chips.
Then, of course, came crack, which no sane person would argue is not among the most severe addictions. Researchers revised their views, recognizing that the essence of addiction is the craving and compulsion to keep doing it no matter what— even if you don't get physical symptoms when you try to stop.
Unfortunately, when the DSM-III committee on addiction issues convened to update the manual in the 80s, they couldn't come to consensus on a suitably medical-sounding diagnosis. Many argued for the simple clarity of addiction, but others thought that the term was too stigmatizing. By one vote, the diagnostic label became "substance dependence."
Chuck O'Brien, professor of psychiatry at the University of Pennsylvania, was a member of that committee. In a 2006 editorial published in the American Journal of Psychiatry, he and his co-authors wrote: "Experience over the last two decades has demonstrated that this decision was a serious mistake…[It] has resulted in confusion among clinicians regarding the difference between 'dependence' in a DSM sense, which is really 'addiction,' and dependence as a normal physiological adaptation to repeated dosing of a medication."
"…if addiction is properly understood as compulsive drug use despite negative consequences, maintenance [for opioid addicts] cannot be seen as addiction."
The editorial, co-written with NIDA's Volkow and another colleague, concluded, "It is clear that any harm that might occur because of the pejorative connotation of addiction would be completely outweighed by the tremendous harm that is now being done to patients who have needed medication withheld because their doctors believe they are addicted simply because they are dependent."
But that's not even the only problem the "d word" has caused. For starters, if addiction and physical dependence are seen as the same thing, then maintenance treatments with buprenorphine or methadone—the only treatment known to cut the overdose death rate by 50 percent or more—really are "substituting one addiction for another," as critics often claim.
But if addiction is properly understood as compulsive drug use despite negative consequences, maintenance cannot be seen as addiction. What maintenance does, in fact, when it works most effectively, is replace compulsive drug-seeking (in the face of harm) with simple physical dependence. This is not a problem if someone has a safe, regular supply.
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An accurate conception of addiction also has implications for the fate of children exposed to drugs in the womb. During the crack era, stigma against "addicted" babies did real harm: Teachers, parents and medical professionals viewed so-called "crack babies" as doomed to be either helpless invalids or psychotic criminals. Of course, babies can't get addicted, since a helpless infant cannot pursue drugs despite consequences and doesn't even know if what he craves is drugs or a diaper change. But at least one study found that the derogatory labeling produced more punitive responses from adults and lowered their expectations of the children—in itself a harmful outcome.
In fact, much of the damage initially attributed to crack exposure in babies turned out to be associated with stress and poverty—and could be ameliorated by a loving, stable home.
In 2013, the DSM-5 finally dropped dependence from its terminology, and addiction is now generally known as "substance use disorder, moderate to severe." Sadly, many media outlets and public officials have yet to recognize this essential rethink. And when the people meant to inform the public about addiction don't even specify what the term means, we're failing everyone. Addiction is not dependence, and dependence is not necessarily a problem.
Until America understands that, needless suffering will continue.
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