With so much attention focused on the opioid addiction crisis¹, many doctors are reluctant to prescribe prescription pain medications and many people are reluctant to take them. The fear of becoming addicted is often perpetuated by widespread media coverage of how “addictive” medications like Percocet, Vicodin, Oxycodone, and others can be. Rightfully so, they are not without risks. But much of the stigma² stems from misunderstandings about addiction, and what it means to become addicted versus dependent³ on medication—or any substance (like alcohol), for that matter. There’s a very clear distinction between the two. Learning to recognize the signs that you may have crossed the line can help you take advantage of the medical benefits of these medications without sliding down the slippery slope of addiction.

Understanding the risks

Nearly 100 million people in the U.S. alone suffer from chronic and acute pain. Opioids continue to remain a prominent treatment⁴ both in healthcare facilities and at home. When prescribed and used appropriately, these drugs are proven effective for resolving acute pain following an injury or surgical procedure. And in this case, the risk of physical dependency is low due to the short duration of use.

If, however, pain becomes chronic, continued daily usage—even if prescribed appropriately by a physician—is likely to result in developing tolerance. That means the patient needs more to achieve the same result.

Because over 66% of overdoses are opioid-related⁵, this makes the misuse of these drugs a serious, life-threatening risk. Physical dependency, defined by the onset of withdrawal symptoms if the medication is abruptly stopped, is also likely.

Substance use disorder (SUD) is the technical term for addiction)⁶. It can occur even when medications are properly prescribed. It up to the physician to screen patients for potential risk factors⁷ prior to prescribing. These range from a personal or family history of substance use disorder (including tobacco, marijuana, or alcohol) to co-occurring mental health disorders and any kind of trauma.

The more numerous and severe the risk factors, the more vulnerable a person is to developing a SUD. In these cases, more accountability is needed to reduce the risk of addiction.

Unfortunately, over-prescription of these drugs is also one of the leading risk factors in addiction.⁸ In all cases, physicians must constantly weigh the risk of dependency or addiction against the benefit of function.

Related Content:
Prioritizing Addiction Medicine: Key to Closing Gaps in Addiction Treatment
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Physical dependency is common in long-term use

Developing a dependency on a substance is quite easy and common in cases of long-term use, and it’s most often purely a biological process. Your body becomes accustomed to having the substance in your system and it becomes necessary in order to function without pain or discomfort.

The surest sign of physical dependency is what happens when the substance is suddenly taken away. If you develop withdrawal symptoms (irritability, nausea, vomiting, diarrhea, worsening pain, insomnia, etc.), your body has developed a physical dependency. To avoid the trauma of withdrawal once physical dependency develops, the medication must be slowly tapered off over time.  But physical dependency on a substance does not mean you’re addicted. If you’re able to discontinue the substance, whether suddenly or by tapering off, with no continued desire to consume it, you’re not addicted.

If dependency turns emotional, be careful

Substance dependency can also be psychological or emotional—you think you need the substance, even when your body physically does not. In fact, some substances cause minimal or no physical dependency but lead to a strong psychological or emotional reliance. This is common with most stimulants (like cocaine or Ritalin), LSD, antidepressants, and marijuana.

Discontinuing these substances can cause serious cravings, anxiety, depression, irritability, restlessness, insomnia, and mood swings among many others, which can make it very difficult to resist the urge to consume them.

However, since these psychological responses can often manifest in physical symptoms and there’s no objective way to measure an individual’s level of distress, psychological dependency becomes a very slippery slope toward addiction.

This is especially true for alcohol. First, let’s make it clear that alcohol isn’t a medication—it is not intended to fix a problem.

It’s purely recreational to enhance pleasure during good times. Yet many people use it to relieve stress or misery, and as with any substance, the moment you start using it for other than its intended purpose, you’re crossing into the danger zone.

That means the daily wine habit that began as one glass, then two to help you unwind, which is now up to a half or even a whole bottle every day, has almost certainly crossed the line.

Dependency vs addiction: If you’re willing to take risks, it’s time to get help

One way to identify the distinction between dependency and addiction⁹ is: what do you do when the substance is taken away?

If you look for an alternative source when your prescription has expired—whether it’s with another physician or on the street—you’re likely addicted. “Doctor shopping” is one of the most common methods¹⁰ of procuring opioid medication in order to maintain a study supply.

If you lie to family and friends about your continued use¹¹ because you know it’s wrong, you might be addicted. If you hide your use or try to cover it up, that’s another warning sign of addiction. If you pursue illegal or dangerous activities to get your hands on more or alternative substances,¹² you’re almost certainly addicted.

The bottom line is that when you set aside rational thinking, self-preservation, and become willing to take risks—including taking more and more to get the desired effect–it’s time to get help. Unfortunately, when it reaches an advanced, persistent stage, the result can be permanent, irreversible changes in the brain¹³, which is why getting help early on is critical.

While there are many criteria involved in diagnosing addiction, even those with a physical dependency can benefit from treatment. In my experience, many with substance dependency are in denial about what’s really going on. They just can’t see it.

When people around you see the problem and you don’t, it’s probably there.  Whether or not you’re willing to call it “addiction” due to stigma or shame¹⁴ doesn’t change the fact that if you feel out of control, when it consumes your life or puts it at risk, the best thing you can do for yourself and those you love is to reach out for help.

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References

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1. Mark Calarco. Narcan must become as commonplace as CPR, The Hill; 8/31/20
2. Daniel Buchman & Peter B. Reiner.  Stigma and Addiction: Being and Becoming; Taylor & Francis Online; The American Journal of Bioethics. Vol. 9 Pages 18-19 August 2009
3. Jane C. Ballantyne, MD, FRCA; Mark D. Sullivan, MD, PhD; Andrew Kolodny, MD.  Opioid Dependence vs AddictionA Distinction Without a Difference?: JAMA Internal Medicine: Arch Intern Med. 2012;172(17):1342-1343.
4. Stoicea, Nicoleta MD, PhD^,∗; Costa, Andrew BS; et al. Current perspectives on the opioid crisis in the US healthcare system; Medicine: May 2019 – Volume 98 – Issue 20 – p e15425
5. Holly Hedegaard, M.D., Arialdi M. Miniño, M.P.H., and Margaret Warner, Ph.D.  Drug Overdose Deaths in the United States, 1999–2017. Centers for Disease Control and Prevention; NCHS Data Brief No. 329, November 2018
6. Holly Hedegaard, M.D., Arialdi M. Miniño, M.P.H., and Margaret Warner, Ph.D.  Drug Overdose Deaths in the United States, 1999–2017. Centers for Disease Control and Prevention; NCHS Data Brief No. 329, November 2018
7. What are the risk factors for addiction? Medical News Today – October 2018
8. Kolodny, A, Courtwright DT, Hwang CS, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Ann Rev Public Health 2015;36:559-74.
9. Jane C. Ballantyne, MD, FRCA; Mark D. Sullivan, MD, Ph.D.; Andrew Kolodny, MD.

   Opioid Dependence vs AddictionA Distinction Without a Difference? JAMA Internal Medicine, Arch Intern Med. 2012;172(17):1342-1343

10. Stoicea, Nicoleta MD, PhD; Costa, Andrew BSc; Periel, Luis BSc. Current perspectives on the opioid crisis in the US healthcare system. Medicine: May 2019 – Volume 98 – Issue 20 – p e15425

11. Lauren Sisler. Addiction and overdose are dirty words. That only makes them more dangerous.  NBC News. Sept 2020

12. Jake Arther. Jail can make drug addiction worse. Oregon decriminalizing hard drugs can break the cycle. NBC News. November 2020

13. Jane C. Ballantyne, MD, FRCA; Mark D. Sullivan, MD, Ph.D.; Andrew Kolodny, MD.  Opioid Dependence vs AddictionA Distinction Without a Difference? JAMA Internal Medicine, Arch Intern Med. 2012;172(17):1342-1343

14. Stephen Ebbett.  Commentary: Here’s what you can do to break down the stigma around drug addiction.  The San Diego Union-Tribune. December 2020