Opioid Physical Dependence versus Opioid Addiction: What’s the Difference?

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Many people, including doctors, are confused about the difference between physical opioid dependence and opioid addiction. To further complicate the issue, in the past, psychiatrists used the word “dependence” interchangeably with addiction.

They are not the same.

By physical dependence, I am referring to normal changes human bodies makes when exposed to opioids for longer than several weeks to months.

Our bodies like to keep things level. When we ingest opioids for more than a few days, our bodies compensate, and make changes to help minimize the effects of opioids. Over time, it will take more opioid to have the same effect, which is called tolerance. Then if opioids are suddenly stopped for any reason, we experience a backlash in the other direction, due to the body’s adaptations. We will feel physical withdrawal signs and symptoms: increased heart rate and blood pressure, nausea, vomiting, diarrhea, sweating and chills, goose bumps on our skin, muscle and joint pains, anxiety and insomnia. This happens to human bodies when exposed to opioids for long enough, and then stopped suddenly.

The presence of physical withdrawal symptoms alone is NOT the same thing as opioid addiction.

For addiction to exist, the person taking opioids must have psychological manifestations. Such a person suffers from the obsession and compulsion to use more opioids, even knowing bad things happen with opioid use. A person with addiction neglects other important parts of life in order to focus on the use of opioids. She may use the drug in ways it’s not meant to be use – injecting, snorting, or chewing for faster onset. She may start using opioids to treat negative emotion, and mix them with other drugs for different effects. She may use opioids even when not in pain, for the effect the drug has on her.

Having the brain of an addict is like having a car with the gas pedal stuck all the way down. An addicted brain may be able to see sharp curves ahead, and even recognize that slowing down would be prudent, but still feels powerless to do so.

It’s often a scary ride.

A person with only physical dependence may feel bad if she stops opioids too quickly, but she would be able to taper if done slowly enough, because the mental obsession to keep using more isn’t driving the drug use. She may feel physical pain return as the opioid is tapered, and may have to slow the reduction in dose, but that’s a different issue.

So we see it’s possible to have physical dependence to opioids without actual addiction.

It’s also possible to have addiction to opioids without physical dependence.

For example, if you put an opioid-using addict in jail, she will undergo physical withdrawal. By the time she’s released, she may longer have the physical dependence (Though many opioid addicts have a post-acute opioid withdrawal that can last for days, weeks and even months. These people’s bodies may have lost the ability to manufacture endorphins, our bodies’ natural opioids.). But if nothing has been done to treat her real problem, the obsession and compulsion to use opioids will return, and she will relapse.

Too many family members of addicts, cops, judges, and even doctors have the false expectation that physical detoxification from opioids is the same thing as treatment. Often the addict is judged harshly for failing at treatment, when the addict wasn’t even given effective treatment. Because detox alone is not treatment.

Opioid addiction is treated with talk therapy, consisting of motivational enhancement counseling, cognitive/behavioral counseling, 12-step facilitation counseling, or a mixture of counseling techniques.

Success rates are markedly improved when medication-assisted treatment with buprenorphine, naltrexone, or methadone is added to counseling.

I’m writing this blog after a visit from a new patient at my office. This nice lady had been accused of being a drug addict by her doctor. She’s been on the same dose of opioids for the last three years, never runs out early, doesn’t misuse her medication, and has urine drug screens that show only the medications he prescribes. At her visit with me, she denied shooting, snorting, or chewing her medication for faster onset. She’s never obtained opioids from friends or acquaintances, and doesn’t use any other drugs including alcohol.

Yet she told me that for some reason, her doctor made the comment to her, “If I didn’t prescribe these pills for you, you’d be buying them off the street.” She was appropriately offended, but also worried she might have addiction. She tried to stop her opioids suddenly, but got sick. She took this as evidence she was addicted, so she came to see me for an evaluation.

I assume she’s telling me the truth, because why else would she waste time and money coming to see me? She has no evidence of addiction that I can detect.

I recommended she go back to her doctor, and ask him to taper her dose down, slowly. This should be a gradual process, so that she doesn’t have withdrawal that interferes with her life. Usually, a 15% drop every two to four weeks is a good rate of decrease. I told her that if she develops addiction, I’d be happy to see her again, but for now, she doesn’t need my services. She does need to communicate her desires to taper with her existing doctor.

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12 responses to this post.

  1. Thank you so very much for this post! It seems the difference between addiction and physical dependence has to be explained on a near daily basis in advocacy work — and it’s an extremely important distinction. SAMHSA has even made it clear they are very different things. What really is frustrating is hearing folks talk about babies being “born addicted…” Not possible!

    Anyway, thanks for this! I’ll enjoy having a link with credible sources to post when this issue comes up!

    Zac Talbott
    NAMA-R TN

    Reply

    • Posted by Stephen Kurt on August 18, 2014 at 9:07 am

      You’re right Zac. Nowadays pregnant women also use drugs without even thinking of their babies. I hope people who are suffering from addiction will undergo Drug Addiction Rehab Treatment to avoid this incident.

      Reply

  2. Posted by Matt on August 18, 2014 at 12:41 am

    Outstanding and informative blog as always. My only critisism is that you don’t post more often. I developed a physical addiction to Opiods while in Hospital for a month after a very bad fall. In Hospital they had me on huge doses of Morphine, fentanyl, oxycodone and ketamine. When I was released I soon realised that I had a dependance and unfortunately my Doctor kept prescribing me 300mg of Morphine daily. Over time I became addicted obtaining Opiods from different Doctors.
    Fortunately I obtained help and are now in an Opiod Treatment Program and I take Suboxone daily but also have counselling weekly. You are so right that with Opiod addiction the best chance of recovery is utilising a multidisciplinary approach.
    Thanks again for your weekly blogs because you obviously have a very deep understanding of what a lot of us are going through.

    Reply

  3. Posted by Pat Bowman on August 18, 2014 at 12:43 am

    I ran into this years and years ago, when I first saw and recognized the difference. ASAM recognized it as well frequently referring to those with a chronic condition, such as pain, as developing solely a physiological dependence. Yet too few medical prescribers and providers really understand the difference.

    A mentor of mine, over 20 years ago, aptly commented “Mr. X? If we can get rid of the physical issue he has, he will never use that medication again.” How right that mentor was!

    There is a vast difference in treatment for have those with “true addiction” and those with “simple” physiological dependence. Many doctors, therapists, and substance abuse treatment providers need more informantion/education about assessing and helping the people who have physical dependence but NO addictive behaviors.

    Thank you for sharing this!

    Reply

  4. Posted by Kraig on August 18, 2014 at 1:08 am

    Mine was more about dependence than addiction but it just examines why you actually use.

    I started suboxone in February this year. I was combining too much codeine in formulas mixed with ibuprofen and paracetamol to treat spondy pain in lower back, pain I couldn’t bare at night trying to sleep.

    In July 2014 I was diagnosed with non Hodgkin’s lymphoma DLBC. Tumours in upper gut and left cheek. Lucky I’m strong and in early 40s to try and beat it as I’ve just commenced chemotherapy.

    The point I wanted to make is that given my life’s recent cancer diagnosis the Will to try and survive has over ridden and morphed any addiction or dependence I may have had to opiates. To give my self the best chance of survival I went from 16mg of Suboxone to 4mg overnight, so that there is not too much interaction with chemotherapy drugs (which generally are not contraindicated). Also I experienced very little withdrawal going down that quick which also supports the theory that less is more on suboxone. When I dropped down to the lower dose of suboxone I immediately commenced prednisone at the request of my haemotologist, this is a wonder drug for nausea and pain sufferers from cancers like non Hodgkin’s that I have. So as I cut back on suboxone by 200% overnight, the prednisone immediately picked me up getting rid of nausea and general lethargy.

    By the way I’m not suggesting to take prednisone to get off suboxone, it only worked for me because I have NHL. Always do it through your addictions specialist doctor as I have. And I’m no way clear of Suboxone. In fact I may always require some pain assistance medication to treat my muscle spasms. However, if I do beat cancer and then get well I’d like to use the experience to be completely suboxone free and completely reset my CNS.

    Reply

  5. Posted by kevin on August 18, 2014 at 6:28 pm

    That was my problem. After 4 months I still felt bad after detoxing from 200mg at 10 mg til 100 and 5mg til 0. I never had my natural endorphins or addrenalin return. Once I came home from riding with a friend that was a long haul truck driver, the very first day I came back I got a pill and started my addiction again. I knew from day one of finishing detox that I would. It was inevitable. I feel that I will always have to be on methadone maintenance and I’m not gonna lie. I’m scared to death. I don’t want to be this way. I don’t want to have to depend on the methadone clinic. They care about me there but do u think they are gonna care if something happens and I can’t pay? They will cut me off in a heart beat and it scares me. This blog has discussed rapid detox and the risks. I wish this was possible for me. I would love to check into a hospital for a week. Do the rapid detox while sedated for a few days and come out of the hospital normal (for lack of better words) again. But same way after detoxing last time. Am I ever gonna b normal again or am I just doomed with the damage I have caused my body by taking 20 to 30 lortab for 8 yrs and then went to maintenance and I had my rock bottom

    Reply

    • Posted by Charlie on August 24, 2014 at 4:16 pm

      Kevin- I’m not a doctor- but the “damage” you feel “doomed” with from the Lortab usage would likely have been mainly to your liver, because of the high acetaminophen (Tylenol) content in the old “Lortabs”. (500mg.) Rather than living in a state of doom- ask your MD about it. He may check your liver’s enzymes, etc. and be able to help you get an idea of what (if any) long-term damage was done. As I understand it (again, medicine is not my field) the liver has amazing regenerative ability.

      Reply

    • Posted by Benjamin Keith Phelps on September 18, 2014 at 3:46 am

      Kevin, this is why I just moved back to DC back in July after paying for MMT for 11 years… I got tired of carrying the burden of $14/day for it EVERY DAY of my life. I got laid off a few years ago & almost lost my treatment. Only the help of some wonderful friends & temp labor work that was hell got me through without a 10-day detox by the clinic for inability to pay. Here in DC, we have vouchers for treatment. You go to the Department of Health here, they call the clinic, done deal. I don’t pay a cent for my methadone now, & I never will again. If I lose my job, I don’t have to panic that I’ll be in withdrawal in 4-5 days… I’ll be just fine. If I end up in a homeless shelter, I’ll STILL get my methadone, if only I can drag my butt to the clinic from the shelter once a week. So, my point is that there are a few places that offer free treatment, & I know that moving is not always an option for everybody. But if it IS an option, you might wanna consider it FOR THE TIME YOU NEED TREATMENT, anyway. I hope NONE of us need it til we die, but we are not guaranteed anything. Every person & every single body on this earth are different. Just because Kathy & Jim could do it without methadone doesn’t mean you or I can. And just because buprenorphine was enough for Joe & Tina doesn’t mean it will be enough for Greg & Sue. It’s all unfortunately HIGHLY variable from person to person, which is why our doses vary so greatly. You may flourish on 60mg of methadone while I need 160mg. Don’t beat yourself up for needing methadone. Take it, & take every day as it comes. If you can move, think about it. If you can’t or don’t want to, all you can do in that case is to continue living each day that way – one day at a time. I know that’s a cliche & a platitude, but it’s all you can do. None of us can make it so that you don’t need the drug anymore. That’s your own body’s lack of endogenous opioids, in all likelihood. I hate it as much as you or anybody else – I can’t stand being dependent on a clinic & their rules & regulations everyday. But it’s what we have until something better comes along. I wish you well.

      Reply

  6. Posted by Benjamin Keith Phelps on August 19, 2014 at 5:11 pm

    This is a bit off-topic from the well-written blog you posted here, but connected in a way, b/c it made me think of how far too many of us are treated when we are addicted & walk into the door of a methadone clinic for help. I’ve watched FAR too many walk right back out b/c the staff behaved as though they had all the time in the world to mosey around, get coffee, talk, & joke around with other staff members as the person is sitting there in withdrawal awaiting the first dose. Now let me be the FIRST to acknowledge here that I a) I’m not pointing out any particular clinic, doctor, or staff, & b) I DO know & understand that a lot of work must be done before a patient is given a schedule II narcotic to take. I know a physical is often required, or at the VERY LEAST, a visit with the doctor so a prescription can be written, based on his or her judgment (up to the federal limit of 40mg on the 1st day). What I don’t understand, & maybe Dr. Burson can clarify this for me a bit, is why instead of doing the urine test & seeing the doctor, many clinics make the addict sit, often times in full-on withdrawal – which if you don’t know, is a hell you can’t even IMAGINE until you’ve experienced it – waiting for God-knows what, & then doing paperwork that I know SOME of which has to be done prior to dosing, but much of which is just information that could be taken down afterward, while the addict is letting the dose do its job & calm the chaos his or her body is going through. At a Raleigh clinic that many of you may remember I left in Sept 2013, b/c they treated us like inmates & used tactics like withholding dose for problems like paruresis & had no alternative in place. 100% of urine tests were observed, & it got so bad at one point that we had to turn and face the nurse (they did NOT send in a man with a man, and a woman with a woman – they sent whomever was available, so if it caused you mental stress that a female was watching you, as a male, we’ll say for example, well then, hate it for ya. You might not get dosed today. Anyway, that clinic, when I did my intake, they made me wait for a solid hour or more in the lobby before anybody ever came out to do ANYTHING to get the process started. Then it was give a sample – under close observation, of course, & as always. So as always, it took me drinking enough water until I was about to explode before I could get my bladder muscle to relax enough to allow me to start the stream of urine flow. Had I been in withdrawal, I’d have probably messed my pants up trying to squeeze that hard. I’m not trying to be graphic, but to relay the truth of the matter. Then upon getting the dip-stick results back showing that I had methadone in my system (thank God I was a transfer, not a new patient), they they took me back to an office where they proceeded to ask every single drug I have EVER used, what the years were, how did they make me feel, did I ever become addicted to them, & when the last time I used them was. And I DO MEAN ALL OF THEM. That process ended up taking well over an hour. I’ll stop the story of my intake here to make the main point – a well-run clinic should try to understand that at the moment an addict comes in in withdrawal – particularly if a patient has waited 3 days to x-fer over to bupe from methadone – but even if coming off the street from being on a high dose of heroin everyday, that s/he is seeking relief, & nothing else is on his or her mind at that moment except getting relief from the withdrawal. Most of you already do know this, I’m sure. But remember it’s just about THE MOST we can do to sit through seeing a doctor & doing the bare necessities before being dosed & then being able to focus on getting things done that need doing. Keep that in mind so that if you can put a piece of paperwork off until after the new patient has been dosed, don’t put him or her through dealing with signing it before you let him or her dose. I just moved to DC & into a clinic that I won’t name, but they have a policy that they make people go to group on group days BEFORE they can dose. I find that to be uncalled for, unneeded, & at worst, downright cruel! The fast metabolizers wake up sick most of the time, so it’s all they can do to get themselves to the clinic to get some relief. Then you’re gonna make them sit through group – which here, often runs anywhere from 1 hour to 1.5 hours – before they can be taken off hold to be dosed? Come on, people. Why is all this necessary when people are coming in for help? Dr. Burson, I’m sorry if I got too far off topic for your tastes with this one, but your article made me think of someone coming in to get on methadone while sick, as I have done before myself, though not recently, I’m happy to report. And I felt like somebody ought to say something about it. I feel like clinics should make it a priority that when they do an intake & it’s someone in withdrawal, they should be gotten to the dosing window just as quickly as possible, so that they can begin to feel better. After all, THAT’S when you’re gonna get their attention towards what you wanna ask them about anyway….

    Reply

    • Thanks for writing, and I hear what you are saying. We do ask patients to show up for intake in withdrawal, to help confirm the person is truly an opioid addict.
      Any delay is frustrating for patients who are feeling terrible. I’ve worked at 15 clinic sites, and seen all kind of ways to try to minimize the wait time. One problem is that for programs that make appointments for new patients, about half show up. this is consistent at each program where I’ve worked. So… do you double- book, to try to admit as many people who need help as you can, and hope it all works out? If you do, and both people show, there’s going to be a wait.
      If it’s first-come, first-serve, we eliminate gaps in the doctor’s schedule, and more patients needing help can be seen, but that can mean a very long wait. I once worked at a program where I would admit 20 or more patients in a day, and of course that was a nightmare for patients and staff. And probably not safe. I would not do that now that I’m a little more experienced.
      Then there are the fed/state requirements – much of that admission paperwork is mandated by agencies that say they must be done prior to admission. And much of it is necessary for safety reasons. I feel it’s unwise to admit a patient before I get drug screen results, for example.
      If we don’t do all of the informed consent, and take great pains to explain what methadone is and possible adverse reactions, we wouldn’t be doing our jobs. so some of the wait if absolutely necessary for good and safe treatment.
      The patient needs relief as quickly as possible, but I don’t think rushing the intake process is safe.
      Now, what the word “rushing” means may differ depending on whether you’re feeling terrible withdrawa or not.
      You make a good point, and I agree OTPs need to streamline the admission process as much as is safely possible.

      Reply

  7. Posted by Charlie on August 24, 2014 at 6:51 am

    Dr. Burson- I thought you might find my personal situation interesting, and hopefully it may even help you or another doctor in some way. I’m a chronic pain patient who switched to Butrans patches (buprenorphine 10mcg./hr transdermal patches) from 60mg. OxyContin per day. Being a little past the range on the “morphine equivalency” recommended for Butrans, it was going to be an interesting situation (for both me and my MD) but we decided to give it a go. As instructed, I waited until I was in full withdrawal from the oxycodone (tons of fun..) and applied the first bup. patch. (10mcg./hr) on day 3, I was about to give up, but I stuck it out another day. Waking up that fourth morning, I felt better than I have in years- pain level low, I felt energetic- basically like a new human being. After approx. 2 months, I’m still feeling as well as I did that 4th day. It was certainly worth those few hellish days to get to this point. Buprenorphine is a fascinating drug- a Godsend for so many people. For fellow PM patients- if you are on a full-agonist opioid, ask your doctor about transdermal buprenorphine!
    Thank you, Dr. Burson, for all the time and effort you spend educating us about opioids. Whether a chronic pain patient, or a patient being treated for opioid physical dependence- we all benefit!

    Reply

  8. Posted by John Mark Blowen APRN on September 17, 2014 at 4:59 pm

    Very worthwhile post, thank you.
    Off topic ( I don’t know how else to ask for a consultation… ) would you elaborate on your Split Dosing post by indicating how you initiate and maintain a split in pregnant women?

    Reply

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