Addiction, Pseudo-Addiction, and Dependence

I am now in charge of the ‘expert forums’ for both addiction and chronic pain over at medhelp.org.  I was happy to take the position, as I had battled the folks on the ‘community forum’ in the distant past over Suboxone, and the expert forum allows me a small platform to present the other side of the discussion.  I will say again that I am not ‘wedded’ to Suboxone;  I don’t receive support or ‘kickbacks’ for this blog or for prescribing the medication;  I am motivated only by finding a way to reduce the misery in my patients caused by opiates.
Today was interesting;  I had a patient come in with one of his distant relatives, who happened to be a person I knew from recovery circles from years ago.  The person I knew has been active in twelve step recovery for many years, even running a halfway house for the past ten years or so.  I was impressed, and a bit surprised, that he brought his younger relative to my office;  I suppose I expected him to have some ‘anti-Suboxone’ sentiments, given his active role in AA and NA for so long.  But that wasn’t the case.  To my pleasant surprise, he seemed to agree with my perspective– we both have known people who died from their addictions, and we agreed that twelve step recovery has been, and always will be, reserved for the fortunate few who ‘get it’ and build an active recovery program.  Before Suboxone, maybe 5% would fall into that category… and the rest would suffer consequences over and over again.
Suboxone, he agreed, allows us to treat a much higher percentage of ‘suffering addictes’.  Is their recovery as ‘good’?  If ‘good’ means free of relapses, it is as good or better.  If ‘good’ means having the ability to move one’s life forward, relieved of the constant obsession to use– Suboxone is as good or better.
I hear all of you, by the way– saying ‘there he goes again…’
I am posting something that I posted over there, about the difference between the terms listed above.  Sorry if this is a bit boring;  it is a Thursday, though, so what do you expect?
The Post:
Thank you for pointing out something that is often confused. I will do my best to summarize the differences—I encourage people to do some reading on their own, using the following comments as a starting point.
‘Addiction’ is not a name for a condition listed in the ‘DSM’, the book that psychiatrists use to identify and characterize mental illness.  The condition most people would likely see as most similar would be drug dependence, which is distinguished from drug abuse by physical dependence and other things that are associated with heavier use, and by a pattern of negative consequences related to using.
I think I have already confused everyone.
Addiction is not formally defined by psychiatrists, but when I talk about addiction I am usually referring to the relationship that a person has with a substance or other object of addiction.  If a person wants to stop drinking, but can’t bring himself to throw out the beer he just poured himself… and instead leaves the beer in the glass on the counter all day… he is in a relationship with alcohol.  Opiate addicts think about using constantly—they are enjoying the last dose for only a few minutes before trying to feel if it is still there, or if it is starting to go away… and then if it is going away, how much longer do I have?  What is left?  Do I have any money?  Where can I get some?  Who is holding?  Where can I find him?  Uh oh—is that sweat?  I’m sweating, not good.  Is that my belly making noise?  Better get moving…
You get the idea—life becomes all about using, and not even about the ‘joy’ of using (as if!) but about the need to find the next one, and the one after that.  Addiction takes a great deal of mental energy.  Opiate dependence, or alcohol dependence, or cocaine dependence, are the official terms for ‘addiction’ in the DSM.  If you google DSM criteria for drug dependence you will find the formal criteria that must be met to qualify for the condition.  Drug dependence, or addiction, usually include physical dependence… but not always.  For cocaine for example, the addiction or ‘cocaine dependence’ can be quite severe with very little ‘physical dependence’.  The same is true for alcohol.
Physical dependence is when the body becomes more and more ‘used to’ the substance, so that ‘tolerance’ occurs—meaning larger and larger doses are required to get the same effects.  Tolerance is usually associated with ‘withdrawal’.  Physical dependence is NOT identical to ‘drug dependence’ or to addiction.  You can become physically dependent on non-addictive substances, such as blood pressure medication;  suddenly stopping a beta-blocker will result in ‘rebound hypertension’, which is a form of withdrawal.
‘Pseudo-addiction’ is a more complicated concept, but is probably the most commonly occurring of all of these conditions.  The term refers to a person being prescribed a dose of pain medication that is not sufficient to treat the pain, and in response the patient takes amounts of medication beyond what has been prescribed.  The patient feels guilty for doing so, and exhibits many of the signs of addiction, including feeling ashamed, covering up the use, being less than truthful about the use, and perhaps doctor shopping.  The patient’s doctor learns of this behavior, and responds by reducing the medication, ‘since the patient is addicted’.  This, of course, just makes the patient go to greater extremes to find relief from the pain.
There are so many problems with how narcotics are prescribed; doctors often fear getting in trouble, even when there is no real risk of that happening.  On the other hand, there have been some extreme cases where good doctors have been prosecuted or disciplined for care that turned out to be appropriate, but that attracted the attention of the licensing board for some reason.  I see one pattern over and over… the patient complains of pain, and the doctor writes a script, without spending any time discussing the limitations of the medication and the problems that occur from tolerance.  The patient returns and asks for more, or maybe even runs out early;  the doctor scolds the patient as he/she writes for a higher dose.  As time goes on, the patient gets higher and higher doses, each time suffering a new round of scolding so that he feels as if he is doing something wrong.  At some point the doctor is suddenly angry.  He has been getting more and more nervous inside;  many doctors don’t like confrontation, and so they don’t want to talk openly about what is happening…so they pretend everything is fine.  But when the dose gets to a certain point— or perhaps a pharmacist calls the doc and asks ‘are you sure you want to write for THAT many?’—the doc blows his top!  The patient, meanwhile, doesn’t know what has happened, and what he did wrong.  Suddenly the nurses and other office people are giving the patient funny looks, and the doc ‘isn’t available’ to talk anymore.  Sound familiar?
If I had any ‘pull’, I would have medical schools teach a formal course in prescribing narcotics.  I even think that narcotic prescribing could warrant a new medical specialty.  At one point I had a separate ‘division’ to my practice that I called the ‘Wisconsin Opiate Management Center’, and my goal was to prescribe narcotics the ‘right’ way, using adequate education, treatment contracts, meetings with pharmacists in the case of abuse concerns, etc.  I thought it was a great idea… and I still do.  But most doctors want to run the show themselves, or so it seems, anyway.