“PLEASE AUNT LUCY, DON’T BECOME AN ADDICT!”
Dependence Versus Addiction
Aunt Lucy is 72 years old. Young to the core, she still walks with her girlish swagger to the barn in her worn and dusty cowboy boots and with one swing hoists her heavy western saddle onto the back of her prized mare. She makes it all look easy. Lucy never had children but is surrounded by loving nieces and nephews and grand nieces and nephews. Two weeks ago, Aunt Lucy was thrown from her beloved mare when the horse spooked as they alarmed a nearby rattlesnake. Aunt Lucy spent 7 days in the hospital after breaking multiple ribs, her right wrist, and lots of bruises and scrapes.
The ribs were the concern. Aunt Lucy is sitting back in her reclining chair at home when she asks her 11-year-old grand-nephew, Josh, “honey, would you please fetch me my pain medication off the kitchen counter?” Josh becomes wide-eyed and blinks twice then states “Oh please Aunt Lucy, don’t become an addict!” At that Aunt Lucy lets out her still cute giggle and says “Josh, Aunt Lucy will be pitching that bottle of medication before it is even finished!” And so she did. Aunt Lucy continued to taper off her Oxycodone and in another five days was back on her mare and medication free.
There is often a misunderstanding amongst the public and even some clinicians about addictive medications. Specifically, the potential for addiction, and a lack of education on the fact that not every individual who takes prescribed medications with addiction potential; become addicted. The lack of understanding is particularly relevant to pain medications due to the opioid epidemic in our country, as well as warranted concern that President Trump will not prioritize this critical issue. The current plan to repeal and replace the Affordable Care Act could result in elimination of what were approved “essential health benefits.” This could include the reduction of substance abuse coverage, demonstrating an inconsistency as to government intention in terms of a fully committed approach to addiction treatment support. Thus far, actions seem conflicted at best. It is thus even more vital that professionals, families, people in recovery, and the general population unite to find and support the best solutions to save lives. The greater understanding treatment providers and the public have about addiction facts and terminology the stronger the solutions our partnering in fighting for the lives of our children, friends, neighbors, and humanity can be accomplished. First and foremost, it is important that we all fully understand that there is a difference between dependence and addiction.
The terms “opioid”, “opiate” and “narcotic” are used interchangeably today. They include:
Hydrocodone (Vicodin) (Norco)
Duramorph (Morphine Injection)
This is not an exhaustive list, but includes most opioids I hear about regularly in Arizona as a treatment provider. It is also important to know the “street names” for these drugs, as clinicians working with chemical addiction patients and as responsible adults, remaining educated on the opioid epidemic can only help address the problem by maintaining familiarity with terminology.
Street names for OxyContin include “kickers, killers, and hillbilly heroin.” Fentanyl is referred to as “China White, Apache, goodfella and TNT.” Heroin is also called “China White”, as well as “skunk, hell dust, horse, white horse, brown sugar, chiva, black tar”, and “big H.” Again, this list is not comprehensive.
There are also several “street drugs” containing deadly amounts of Fentanyl such as the “Super Pill” which users often believe to be Norco, a less potent opiate. W-18 which is said to be 100 times more potent than Fentanyl, is a synthetic opioid first developed in Canada in 1984. Chemists in China later developed the drug for consumers. These pain relievers, which are not prescribed in the U.S. are potentially deadly in any amount.
Kratom is the name of a tree indigenous to Southeast Asia. The leaves have been used in folk medicine as an aphrodisiac, as well as for pain reduction, to increase energy, decrease depression, heal wounds and at different doses acts as both a stimulant and a sedative. The leaves contain opioid compounds and may be chewed, made into a tea, or crushed and mixed with liquid for ease of ingestion. Some say
Kratom can block withdrawal symptoms from Oxycodone and Heroin and thus represents a potential treatment to assist opiate addicts. Kratom was an ingredient found in an energy drink on the market in the U.S. known as Viva Zen. In 2015 Viva Zen removed Kratom from its products though due to controversy over the compound although Kratom is legal in the United States. As of this writing however, five states have introduced legislation to ban it.
In late 2016, a synthetic opioid known as “pink” or U-47700 was classified by the U.S. Drug Enforcement Agency to a Schedule I drug; meaning the drug has no approved medical use and has the potential for abuse. This drug is extremely potent and made in illegal labs.
How do Opioids Affect People?
Opioids act by attaching to what are called opioid receptors. These receptors are known as G Protein- Coupled Receptors. They constitute a large protein family of receptors that are found not only in the brain but the spinal cord and our digestive tract. When opioids attach to their receptors, the result is a reduced perception of pain. This linkage also triggers the same process in the brain that when activated rewards us with feeling pleasure for having engaged in life-sustaining behaviors. We receive a chemical reward for eating, quenching thirst, and having sex as examples.
Most people will experience some drowsiness when ingesting opioids but there are some who will experience a more euphoric response to these pain medications. This euphoric response in some can be the set-up for resulting addiction to the medication.
Physical dependence may occur for someone who is ingesting pain medication for a long duration. Physical dependence occurs due to a normal adaptation to chronic use, taking a pain medication as prescribed, but not necessarily becoming addicted to it.
Dependence is a state in which the individual functions normally only when the drug is present. A physically dependent person will experience some withdrawal symptoms when the medication is reduced or stopped. A slow drug taper preferably manages this.
An individual can take pain medication as prescribed and become dependent on the drug, but not become addicted to it. A drug dependent person can also develop tolerance over time and not feel the same pain reduction with the same dosage. This makes the issue of dependence versus addiction even more difficult to understand as the report of increased pain requiring higher dosing to manage can look very much like addiction.
Addiction can also include physical dependence but is characterized by compulsive use and compulsive seeking of the drug, a lack of controlled use, and continued seeking and using even after experiencing severe consequences as a result of use. People who are addicted will also find other ways to ingest the pain medication, not taking it orally as prescribed, for example, but injecting or snorting it in search of a greater, faster high.
Addiction is currently defined by The American Society of Addiction Medicine as “a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain…”This represents only a small part of the definition which is several pages long and can be found on the organization’s website at: asam.org.
The Difference between Dependence and Addiction:
What is key about addiction and the brain is that addiction impacts the reward center of the brain and involves the neurotransmitter Dopamine. Increasing compulsive use of an opioid by an addict wears out the reward center and its circuitry. As the addict uses more and more, the Dopamine system floods the brain synapses, (communication from one neuron to another flow across a synapse); which causes the brain to adjust itself by reducing its number of Dopamine Receptor Cells. The result of the brain’s compensation by receptor reduction is what causes desensitization for the addict. The addict thus requires more and more of the drug to acquire the same effect and feel normal. This process is very different from what occurs for someone taking pain medication as prescribed.
The dependent individual is not engaging in compulsivity and taking more and more of their medication to acquire a Dopamine surge. Dependence actually occurs in an entirely different part of the brain and does not occur solely within the reward center of the brain. Dependence takes place in the Thalamus and the Brain Stem. Addiction occurs entirely in the reward center of the brain.
Many who have been prescribed some of these drugs have successfully managed chronic pain. Many have benefited in receiving needed assistance with debilitating pain. Thus, I do not condone the complete dissolution of opioid pain medication in the United States unless we find and make available other medications or medical solutions to treat physical pain. Those who become addicted to pain medications in addition need access to therapies and treatment that assist with alleviation of the emotional pain. The opioid epidemic did not develop as a result of legitimate pain patients suddenly crossing the line into addiction. It is not that simplistic. Many who developed opioid addiction in recent years were not pain patients but rather people who had a family member or friend being treated for pain and in varying ways the medications were diverted to the addict. Research is also showing that many opioid addicts also had a prior addiction to a chemical substance.
If pain medications are banned, sadly those with addiction will find substitute substances. The cognitive ability of addicts is impaired as a result of their use and results in distorted thinking, which includes inability to see the grey area of available options. The addict’s black and white thinking is limited and to resolve the opioid problem with a black and white approach does not provide the needed solution. More focus on the root cause of addictions seems a logical area to devote funding towards for long-term solutions. The first priority however must be the provision of affordable and effective treatment for all. No easy task. Banning opioid prescriptions is not the answer for the current epidemic entirely if we ignore the people needing chronic pain relief and who will not seek these medications for a “high.” As we make strides in educating the public on alternative methods of treating pain such as acupuncture, mindfulness, movement therapies, and massage to name only a few, and legalize new medications to control pain that do not come under the control of Big Pharma, I support educating ourselves on all we can to save lives and continue to help those who suffer.
In short, someone can be dependent and not addicted, and someone can be addicted and not dependent. Confusing? Yes, but the research supports the above. Aunt Lucy is also doing well, fully recovered, and not on any medications.