The Medical Freedom Channel

(Note: Most of the following originally appeared on the Free Market News Network site, on Tuesday, April 05, 2005, as part of a series of healthcare-related columns I was writing there at the time. I intend to rely on this prior work from time to time, both in lieu of constantly having to wrack my brain for a new editorial each week, and because some of those pieces are pretty timeless and deserve a wider audience. Additionally, I’ve begun to put out the word for “Guest Commentaries,” and hope to have one of those now and then to break up the monotony of my own voice filling this space.)

This column is devoted to debunking some widely held myths about “addiction” — and to clarifying the ways in which these misnomers have been used to perpetuate the persecution of chronic-pain sufferers, in the name of “stopping the drug trade.” And to do this we need only to focus on a few definitions:

Addiction

According to Webster’s, “addiction” is: “[A] compulsive need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal (broadly: persistent compulsive use of a substance known by the user to be harmful).”

This would seem to indicate that any use of a substance on a regular basis, for whatever reason, represents “addiction” to that substance. We casually refer to “coffee addicts” or “chain-smokers” in this way, perhaps with some justification, since both caffeine and nicotine have been proven to be at least somewhat physically addictive, and thus “hard to kick.” However, we misuse this term to describe those for whom substance use is a medical necessity, just to keep life physically bearable.

According to a reliable medical source, in actual physiological and medical terms true “addiction” is something much more restrictive: “a psychological and behavioral disorder … characterized by the presence of all three of the following traits: (1) loss of control (i.e., compulsive use); (2) continuation despite adverse consequences, and (3) obsession or preoccupation with obtaining and using the substance.”

Furthermore, “As an addiction advances, the person’s life becomes progressively more constricted. The addiction becomes the addict’s number one priority, and relationships with family and friends suffer. The addict’s inner life becomes filled with preoccupation about the drug. Other activities are given up. Life revolves around obtaining and using the drug.This constriction is an important characteristic that distinguishes use of a drug by an addict from its appropriate use by a patient with chronic pain. A patient who is addicted to drugs may keep increasing the dose without discussing it with the doctor, might repeatedly use up the medications early, go to several physicians for opioids and lie about seeing other doctors, might inject their oral or topical drugs, or sell drugs to get money with which to buy other drugs.

“These behaviors are not typical of most pain patients. Patients who take opioids for chronic pain hopefully expand their life, the opposite of what happens with addicts. Pain patients feel better and are able to increase their activities. They may begin gardening, going to movies, playing with children and grandchildren, and many are able to return to work.”

Tolerance

A far more appropriate concept for the condition of those regular users of pain-pills, for whom this medication is not only prescribed but essential for their existence, is “tolerance.”

Once again we begin with Webster’s: “tolerance: the capacity of the body to endure or become less responsive to a substance (as a drug) or a physiological insult with repeated use or exposure.”

However, once again, this is only part of the definition, as is noted by our medical source: “Tolerance means that a person needs more medication to continue getting the same effect. This is also true of addiction. With time, the addict needs more of the drug to obtain the same mood-altering effect. This is why cigarette smokers tend to increase the number of cigarettes they smoke. When opioids are taken for chronic pain, tolerance develops to some of the opioids’ effects (eg, nausea and sedation will lessen) but not to others (eg, constipation and pain relief will continue as long as a patient takes the opioid). Unless the source of your pain progresses, as is true of many cancer patients, you are likely to remain on the same dose that gave you adequate pain relief when you first took the drug.”

And from another source, the website of Dr. William Hurwitz, the Virginia pain-doctor pilloried by the DEA and the courts last year, for simply attempting to help his own patients: “One important characteristic of opioid medications is that they are capable of inducing tolerance. Tolerance refers to a decrease in the effect of a drug in response to repeat exposure. As applied to opioids, this means that after a few days to a few weeks of exposure to a particular dose of medication, that dose becomes less effective in relieving pain.”

However, as Hurwitz goes on to note, “it also becomes less likely to cause nausea, fatigue, euphoria, or respiratory depression. The flip side of this is that it takes more medication to achieve the same level of pain relief. Fortunately tolerance to most side effects develops before tolerance to the pain relieving properties of these medications. Most patients become tolerant to the depressing effect of these medications on respiratory drive early in the course of treatment. Early tolerance to respiratory depression makes these medications safer than is commonly believed and provides for a considerable range of safe dosing.”

“Individuals vary in the extent to which they become tolerant to these medications,” he concludes. “Some maintain adequate pain relief at modest doses for very long periods of time. Others require doses to be raised frequently to maintain effect. It is our experience, however, that most patients reach a plateau within the first few months of treatment, after which only small adjustments in dose are necessary. Even at high doses, these medications do not appear to cause organ damage.”

Dependence

Of course, the most proper term for all of this is neither “addiction” (implying erratic behavior, even dangerous conduct in some instances) nor “tolerance” (which merely means the body becomes accustomed to a dosage-level and requires a bit more (in some cases) for it to remain effective).

The more appropriate term is “dependence.” Again, let’s begin with Webster’s: “the quality or state of being influenced or determined by or subject to another.”

But when we expand on that from our medical source, we again get a much more limited perspective: “Most pain patients taking opioids are not addicted to drugs. What is true of them is that they usually become physically dependent on the drug. Physical dependence has nothing to do with addiction. It simply means that a habituated user will experience certain symptoms if the drug is stopped abruptly.”

In other words, it’s the withdrawal from these substances, over and above the agonies they are taken to ameliorate (and which now recur in the absence of the medication), that create the larger problems. When this withdrawal process is done under uncontrolled conditions, as with the street-drug user, it can lead to major complications; when done under a competent pain-specialist’s care, it may still involve some agonies, but with the right guidance and monitoring the process can produce a productive member of society — one free from the burden of a cured ailment, as well as that of its curative painkillers.

* * *

The problem, of course, is that this perspective may give more weight to the “just say no!” anti-drug crusaders, who continue to confuse the “recreational street use” of controlled substances with the medically necessary treatment of continuing and chronic pain. This ignores the plight of those who truly must remain medicated, just to cope with their chronic-pain issues: Those pills, patches and other measures are often merely allowing them to conduct their lives, in spite of these irreparable conditions; the assumptions from other people they must also overcome just add to their burdens.

The result is a fear-based context, present in hospital emergency rooms as well as individual doctor’s offices, one that makes physicians and nurses alike assume they’re supposed to focus on “stopping drug seeking addicts” and sending them to detox — long before they even begin to diagnose and treat those who are honest chronic-pain sufferers in need. Changing that paradigm and those attitudes is a major piece in the puzzle of treating “drug addiction.”