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    • 15 APR 16
    When Dependence Crosses into Addiction—and When It Doesn’t

    When Dependence Crosses into Addiction—and When It Doesn’t

    Opioids can be addictive, but not everyone who takes them becomes addicted. Not even everyone who becomes physically dependent on them develops an addiction.

    What’s the difference between physical dependence and addiction? Why does it matter?

    Pain medication can be prescribed legitimately, used appropriately and still lead to physical dependence that requires a medically managed taper when the drug is no longer needed to control pain. The physical dependence may not have progressed to addiction, as most people on pain medications do not have the disease of addiction. Only about 10-15 percent of people using legitimately prescribed pain medication end up losing control. The difference between physical dependence and addiction revolves around loss of control over the drug use and difficulty in not relapsing even after a taper.

    Opioids bind to opioid receptors in the brain, spinal cord and other areas of the body, reducing the sensation of pain. Opioids are used to treat moderate to severe acute pain, such as the pain after surgery or following an injury, and for the chronic pain associated with illnesses such as cancer.

    Over time, patients who continue taking opioids develop a tolerance for them and need a higher dose to achieve the same pain relief. The need for increasingly higher doses often concerns patients who worry they have developed an addiction. Tolerance is a predictable biological response to opioids and many other medications. It is not necessarily indicative of addiction.

    Almost all patients who use an opioid pain medication like fentanyl, hydrocodone, morphine, oxycodone, OxyContin and Dilaudid for more than a month also will experience physical withdrawal symptoms when they stop taking the medication suddenly. Withdrawal symptoms include agitation, anxiety, muscle aches, insomnia, runny nose, elevated blood pressure, dilated pupils, rapid heart rate, sweating, abdominal cramping, diarrhea, nausea and vomiting. Withdrawal from opioids is not usually life threatening. Physicians can ease symptomatic relief while gradually assisting patients taper off the opioid medication once pain has resolved.

    In the case of opioids, withdrawal is not always a symptom of addiction. Withdrawal may last several days or longer, depending on the taper rate. Afterward, the patient is free of any physical dependence on the medication and most will have no further interest in the drug. An addict, however, will continue to crave and be preoccupied with the opioid after the pain and withdrawal symptoms have gone. That is the distinction between an addict and a person who is simply physically dependent: The addict cannot let go.

    Loss of control, use despite the harm it causes, preoccupation with the drug and craving all signal addiction. It’s worth noting most individuals who abuse opioids do not receive them by prescription. The Substance Abuse and Mental Health Services Administration reports that 70 percent of people abusing pain relievers obtained them illegally.

    Several behaviors indicate a patient has an elevated risk of addiction. These include:

    Unsanctioned dose escalation or taking extra medication without medical approval
    Repeatedly reporting that a prescription was lost
    Multiple requests for early refills
    “Doctor shopping” or looking for multiple prescribers to write prescriptions
    Closely monitor a patient who reports no improvement in pain relief with an increased dose. More medication will typically provide some pain relief for a regular patient, but a drug addict may get worse. Other indications of addiction include selling the medication, obtaining drugs from others, falsifying prescriptions, injecting medications intended for oral use, and using illegal drugs or other controlled substances when they cannot obtain prescription pain medications.

    Patients with a history of substance use disorder deserve good pain management as much as any other individual, but strict safeguards should be in place to reduce their risk of abusing the drugs. For acute pain, surgeons or other physicians may work with a patient’s addictionologist to develop a pain management program that effectively relieves pain while minimizing the chance of abuse. Other steps include charging someone besides the patient with possessing and controlling the medication, destroying or returning any remaining medication when no longer needed and reinforcing substance abuse therapy afterward to address the possible resurgence of old urges.

    Individuals with active substance use disorders or a history of one should not receive opioids for chronic pain. There is little evidence to support the effectiveness of opioids for chronic pain, according to the Centers for Disease Control and Prevention,1 and the ongoing access to drugs can be too tempting for those in recovery. The CDC issued new guidelines in March recommending nonpharmacological and non-opioid therapy for all patients before prescribing opioids outside of active cancer, palliative or end-of-life care. Alternative therapies include yoga, meditation and physical therapy.

    If non-opioid alternatives do not provide adequate relief for a patient with substance use disorder or a patient develops an opioid addiction, the CDC recommends a long-acting medication such as buprenorphine can be used in combination with behavioral therapies.


    CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. Morbidity and Mortality Weekly Report. March 18, 2016;65:1-49.

    1. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. Morbidity and Mortality Weekly Report. March 18, 2016;65:1-49