In a recent hearing before Congress, the Food and Drug Administration (FDA) Commissioner Scott Gottlieb spoke about the devastating impact of the opioid epidemic and what his agency is doing to address it. While Dr. Gottlieb is not the first to note the massive scale of this crisis, he did bring up one often-overlooked component of its much-needed solution – distinguishing between an opioid addiction and a physical dependence on opioids. Although frequently conflated, differentiating between these two conditions is essential to break the stigma associated with what has proven to be the most effective form of opioid addiction treatment: medication-assisted treatment (MAT) – a treatment approach that combines the use of medications such as methadone and buprenorphine with behavioral counseling.
To make progress in ending the opioid epidemic and help people with addiction, families, health professionals and policymakers must understand and appreciate the important difference between physical dependence and addiction, and acknowledge that medication is an essential part of the solution to this crisis.
BUT WHAT EXACTLY IS THE DIFFERENCE BETWEEN PHYSICAL DEPENDENCE AND ADDICTION?
As Dr. Gottlieb pointed out, and as described in our report, Addiction Medicine: Closing the Gap between Science and Practice, physical dependence is not the same as addiction. Physical dependence occurs when the brain adapts to the effects of a drug and develops tolerance. In other words, an individual will require more and more of the drug to achieve the initial positive effect and will rely on continued use of the drug to prevent painful and uncomfortable withdrawal symptoms.
Opioids, even when used as directed, can cause physical dependence. This can also be the case for other medications that the body and brain adjust to and come to depend on in order to maintain normal function. However, if misused -- either by taking a larger amount than prescribed, for a longer time than prescribed, or for non-medical purposes – opioids, can lead to addiction, a disease that interferes with, rather than maintains, normal functioning.
Unlike addiction, physical dependence can easily be managed and resolved by slowly lowering the dose, or “tapering.” A person who is physically dependent on prescribed opioid medications, such as Vicodin or OxyContin, but is not addicted, will not experience a loss of control, strong cravings, compulsive drug use, a failure to meet work, social, or family obligations, or other negative symptoms that characterize addiction.
On the other hand, a person who has addiction no longer takes a drug just to feel its effects, but rather to escape withdrawal and simply feel closer to normal. Addiction affects the parts of the brain responsible for decision-making and self-control, so a person suffering from addiction will continue to use the drug despite serious life consequences, such as losing a job, getting arrested, or suffering an overdose.
While the opioid-based medications used in MAT to treat opioid addiction may lead to physical dependence, they do not typically cause a person to become “addicted” when used as prescribed by a doctor.
WHY IS DISTINGUISHING BETWEEN PHYSICAL DEPENDENCE AND ADDICTION THE KEY TO ENDING THE OPIOID EPIDEMIC?
Promoting the widespread use of MAT is one of the key steps the FDA is taking to help address the opioid crisis. However, as Dr. Gottlieb explained, a lack of public awareness about the distinction between physical dependence and addiction is a challenge that must be overcome to ensure that people with opioid addiction receive the treatment they need.
“The stigma reflects a view some have that a patient is still suffering from addiction even when they’re in full recovery, just because they require medication to treat their illness,” Dr. Gottlieb stated. “This attitude reveals a flawed interpretation of science. It stems from a key misunderstanding many of us have of the difference between a physical dependence and an addiction.”
The National Alliance of Advocates for Buprenorphine Treatment calls this topic, “the single most important concept to understand when learning about addiction and evidence-based treatment.” In his opening statement to Congress, Dr. Gottlieb explained, “Someone who requires long-term treatment for opioid addiction with medications – including those that cause a physical dependence – is not addicted to those medications,” and that the stigma surrounding MAT, because of this misunderstanding, “serves to keep many Americans who are seeking a life of sobriety from reaching their goal. In this case, in the setting of a public health crisis, we need to take a more active role in challenging these conventions around medical therapy.”
Simply put, asserting that people who use the opioid-based medications buprenorphine or methadone to treat opioid addiction are “just replacing one addiction with another” is misguided and wrong. It perpetuates the stigma against people with addiction who are merely trying to recover and get their lives back on track by using a proven, FDA-approved treatment method. It justifies policies that limit the availability of these medications for people who really need them. Moreover, it underlies one of the main reasons why rates of opioid addiction and its deadly consequences continue to increase, unabated, all across the United States.
Robyn Oster
Robyn Oster is a research assistant at The National Center on Addiction and Substance Abuse