Addiction Versus Dependence And Tolerance

Discussion in 'Fibromyalgia Main Forum' started by Mikie, Jul 12, 2006.

  1. Mikie

    Mikie Moderator

    From The National Institute On Drug Abuse 07/12/06 11:55 AM

    Even many docs cannot agree on what constitutes addiction and there seems to be a lot of confusion regarding this topic. I went to the National Institute On Drug Abuse and got some info regarding these terms. I posted this in another thread, but it's so important, in view of the fact that so many of us need pain meds and other heavy hitter medications, that I decided to give it its own post.

    Because this article is rather lengthy, I've added bold and italics where the article emphasizes the definations in question. I hope this helps when trying to make informed decisions regarding meds. Certainly, the potential for abuse, tolerance, and dependence are all germane to performing due diligence.

    Love, Mikie


    Definitions Related to the
    Use of Opioids for the Treatment of Pain

    The American Academy of Pain Medicine, The American Pain Society and the American Society of Addiction Medicine

    Consensus Document


    Clear terminology is necessary for effective communication regarding medical issues. Scientists, clinicians, regulators and the lay public use disparate definitions of terms related to addiction. These disparities contribute to a misunderstanding of the nature of addiction and the risk of addiction, especially in situations in which opioids are used, or are being considered for use, to manage pain. Confusion regarding the treatment of pain results in unnecessary suffering, economic burdens to society, and inappropriate adverse actions against patients and professionals.

    Many medications, including opioids, play important roles in the treatment of pain. Opioids, however, often have their utilization limited by concerns regarding misuse, addiction and possible diversion for non-medical uses.

    Many medications used in medical practice produce dependence, and some may lead to addiction in vulnerable individuals. The latter medications appear to stimulate brain reward mechanisms; these include opioids, sedatives, stimulants, anxiolytics, some muscle relaxants, and cannabinoids.

    Physical dependence, tolerance and addiction are discrete and different phenomena that are often confused. Since their clinical implications and management differ markedly, it is important that uniform definitions, based on current scientific and clinical understanding, be established in order to promote better care of patients with pain and other conditions where the use of dependence-producing drugs is appropriate, and to encourage appropriate regulatory policies and enforcement strategies.


    The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) recognize the following definitions and recommend their use:


    Addiction is a primary, chronic, neurobiologicneurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.


    Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

    In the case of sedative drugs, spontaneous withdrawal may occur with continued use. Tolerance Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.


    Most specialists in pain medicine and addiction medicine agree that patients treated with prolonged opioid therapy usually do develop physical dependence and sometimes develop tolerance, but do not usually develop addictive disorders. However, the actual risk is not known and probably varies with genetic predisposition, among other factors. Addiction, unlike tolerance and physical dependence, is not a predictable drug effect, but represents an idiosyncratic adverse reaction in biologically and psychosocially vulnerable individuals. Most exposures to drugs that can stimulate the brain's reward center do not produce addiction. Addiction is a primary chronic disease and exposure to drugs is only one of the etiologic factors in its development.

    Addiction in the course of opioid therapy of pain can best be assessed after the pain has been brought under adequate control, though this is not always possible. Addiction is recognized by the observation of one or more of its characteristic features: impaired control, craving and compulsive use, and continued use despite negative physical, mental and/or social consequences. An individual's behaviors that may suggest addiction sometimes are simply a reflection of unrelieved pain or other problems unrelated to addiction. Therefore, good clinical judgment must be used in determining whether the pattern of behaviors signals the presence of addiction or reflects a different issue.

    Behaviors suggestive of addiction may include: inability to take medications according to an agreed upon schedule, taking multiple doses together, frequent reports of lost or stolen prescriptions, doctor shopping, isolation from family and friends and/or use of non-prescribed psychoactive drugs in addition to prescribed medications. Other behaviors which may raise concern are the use of analgesic medications for other than analgesic effects, such as sedation, an increase in energy, a decrease in anxiety, or intoxication; non-compliance with recommended non-opioid treatments or evaluations; insistence on rapid-onset formulations/routes of administration; or reports of no relief whatsoever by any non-opioid treatments.

    Adverse consequences of addictive use of medications may include persistent sedation or intoxication due to overuse; increasing functional impairment and other medical complications; psychological manifestations such as irritability, apathy, anxiety or depression; or adverse legal, economic or social consequences. Common and expected side effects of the medications, such as constipation or sedation due to use of prescribed doses, are not viewed as adverse consequences in this context. It should be emphasized that no single event is diagnostic of addictive disorder. Rather, the diagnosis is made in response to a pattern of behavior that usually becomes obvious over time.

    Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may "clock watch," and may otherwise seem inappropriately "drug seeking." Even such behaviors as illicit drug use and deception can occur in the patient's efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.

    Physical dependence on and tolerance to prescribed drugs do not constitute sufficient evidence of psychoactive substance use disorder or addiction. They are normal responses that often occur with the persistent use of certain medications. Physical dependence may develop with chronic use of many classes of medications. These include beta blockers, alpha-2 adrenergic agents, corticosteroids, antidepressants and other medications that are not associated with addictive disorders.

    When drugs that induce physical dependence are no longer needed, they should be carefully tapered while monitoring clinical symptoms to avoid withdrawal phenomena and such effects as rebound hyperalgesia. Such tapering, or withdrawal, of medication should not be termed detoxification. At times, anxiety and sweating can be seen in patients who are dependent on sedative drugs, such as alcohol or benzodiazepines, and who continue taking these drugs. This is usually an indication of development of tolerance, though the symptoms may be due to a return of the symptoms of an underlying anxiety disorder, due to the development of a new anxiety disorder related to drug use, or due to true withdrawal symptoms.

    A patient who is physically dependent on opioids may sometimes continue to use these despite resolution of pain only to avoid withdrawal. Such use does not necessarily reflect addiction.

    Tolerance may occur to both the desired and undesired effects of drugs, and may develop at different rates for different effects. For example, in the case of opioids, tolerance usually develops more slowly to analgesia than to respiratory depression, and tolerance to the constipating effects may not occur at all. Tolerance to the analgesic effects of opioids is variable in occurrence but is never absolute; thus, no upper limit to dosage of pure opioid agonists can be established.

    Universal agreement on definitions of addiction, physical dependence and tolerance is critical to the optimization of pain treatment and the management of addictive disorders. While the definitions offered here do not constitute formal diagnostic criteria, it is hoped that they may serve as a basis for the future development of more specific, universally accepted diagnostic guidelines. The definitions and concepts that are offered here have been developed through a consensus process of the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine.

    [This Message was Edited on 07/12/2006]
  2. Mikie

    Mikie Moderator

    Bumping for the evening crew. I do hope people will take the time to read this as it contains some very important info for us.

    Love, Mikie
  3. lovethesun

    lovethesun New Member

  4. suzetal

    suzetal New Member

    This information is important for those of us that take narcotics.I am one of them,

    When I feel I do not need to take them I don't.Thats when I'm having a good day.

    When I'm in a bad flair I take them.

    Thank you for posting this info.

    For Every Day A New Dawn Will Come...........Sue
  5. Lolalee

    Lolalee New Member

    Mikie, I'm glad that you posted this. A couple of years ago I questioned my doctor about addiction and dependence on pain meds. I was curious because I'd been taking narcotic pain meds for a while and there was so much hype in the media about pain med addiction and abuse. In an effort to put my mind at ease, he gave me an article entitled "Distinguishing Intractable Pain Patients from Drug Addicts" by Joel S. Hochman, MD. The article compared the Addict Characteristics to the Intractable Pain Patient Characteristics.

    I never thought I was addicted, but wondered why some people felt "high" or craved more drugs. I never had that feeling. I would take my meds when I had pain, they helped my pain and that was it. After reading this article it was clear to me what the difference was. The article I speak of has similar information to the one you have posted. It is, however, a bit more detailed. If you or anyone is interested in reading the article I mention, you can Google search the title and doctor's name as listed above. You will find a listing under Practical Pain Management magazine. Unfortunately, the entire article is not included, but you will have the option of ordering the back issue that contained the article.

    Thanks again for the info you have posted.


  6. Mikie

    Mikie Moderator

    I appreciate them. It seems to me that if we are all working from some common definitions and terms, it will help us to be able to communicate here and cut down on miscommunication and misinformation.

    As several of you mentioned, it is also good to know we are not addicts. Addiction to pain meds is always a concern but a very small number of those who take opiods for chronic pain get high.

    Psychological addiction is a complex phenomonen and can include physical dependence and tolerance and I think that is where some of the confusion comes into play.

    Gigi, I'm sorry, I didn't see your post. I've been so tired that I know I'm missing things. I am a big fish fan and also a fan of fish oil capsules. My Mom took them religiously and she lived until 92 and was sharp as a pin and almost always in a good mood.

    Love, Mikie

  7. Mikie

    Mikie Moderator

    For the most part focuses on illness, rather than wellness. Then, when one gets sick and needs pain treatment, some of the docs run screaming from the room. They have been brainwashed and have the prevailing "Reefer Madness" mentality which the DEA promotes.

    There are good docs out there who understand our kind of pain and the need to address it. I was very lucky in that my SSD atty. referred me to a pain specialist who was very good.

    I was also lucky to find a good specialist willing to prescribe the Klonopin which I so desperately needed in order to get much needed quality sleep.

    This doc and my PCP were willing to prescribe long-term Doxycycline and Famvir so I could start to recover from years of chronic infection. My specialist was also willing to try the Heparin injections which helped a lot with the infections and the nasty fibrin overgrowth in the blood. Many with chronic infections have the fibrin problem where pathogens hide out.

    I consider these brave docs heroes because they were willing to go outside the conventional "medical wisdom" and do some real healing.

    I used to say that I had never gotten a high from pain meds but not long ago, I had to take some Vicodin, which is very, very rare for me now. It was due to a painful injury. I did get a little bit of a high from it. I recognized it immediately. I don't like feeling like that and am not worried about addiction because I don't crave that feeling. If I need the Vicodin in the future for pain, I will take it as it's very effective. I will just be aware of the side effect. I may have had the high because I no longer suffer from severe chronic pain. This was an injury. I think people are less likely to get high when opiods are taken for chronic pain.

    Thanks for your interest. I also think this is very important info for all of us. Most of us have, at one time or another, taken meds which are commonly referred to as "addictive," a misnomer. I've even seen it in patient info handouts. While it is important to know that these meds have a potential for addiction, tolerance, and/or dependence, it is also important to know the difference.

    Glad if this has been helpful.

    Love, Mikie

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