FAQ on Opioids: Facts about Addiction, Pseudo-addiction, Physical Dependence, and Tolerance
Q: If I take opioids to help manage my pain, am I going to become addicted?
If you take your medication as prescribed by your physician, the chances are slim that you are going to become addicted. However, opioids can be very powerful and should be used exactly as directed by your physician.
Q: But if I stop taking drugs will I go through withdrawal? Isn’t this a sign of addiction?
No, there is a lot of confusion about addiction, and many physical reactions to opioids have been called “addiction.” If you are taking opioids your body is going to develop a physical dependence, and you would go through withdrawal if you stop taking the drug. All people who take opioids for a period of time can potentially have this withdrawal syndrome if the drug is stopped or the dose is suddenly lowered. This is not a problem as long as it is prevented by avoiding sudden reductions in the dose. Physical dependence happens with many types of medication, not just opioids.
Physical dependence is entirely different from addiction. Addiction is defined by a loss of control over a person’s use of a drug, compulsive use of the drug, and continued use of the drug even if it is harming the person or others. People who become addicted often deny that they have a problem, even as they desperately try to maintain the supply of the drug.
Addiction is a “biopsychosocial” disease. This means that many people who become addicted to drugs are probably genetically predisposed for it, but only develop the problem if they have access to the drug and take it at a time and in a way that leaves them vulnerable. The risk of addiction among people with no prior history of substance abuse who are given an opioid for pain is low.
People with chronic pain should understand the difference between physical dependence and addiction. Unreasonable fears about addiction should not be the reason that doctors refuse this therapy or patients refuse to take it.
Q. My physician has increased the dose of my medication because my current dosage isn’t working anymore. Is this need for stronger medication or a sign that something is wrong?
Not necessarily. Tolerance to opioids occurs, but is seldom a clinical problem. Tolerance means that taking the drug changes the body in such a way that the drug loses some of its effect over time. If the effect that is lost is a side effect, like sleepiness, tolerance is a good thing. If the effect is pain relief, tolerance is a problem. Fortunately, most patients can reach a favorable balance between pain relief and side effects then stabilize at this dose for a long period of time. If the dosage needs to be increased because pain returns, it is more commonly due to worsening of the painful disease than it is to tolerance.
Q: What is pseudo-addiction?
Pseudo-addiction is when patient behavior mirrors behavior displayed by people with drug addiction who are seeking to receive unnecessary pain relief. Patients may display medication-seeking behavior because their pain is not adequately treated. They behave as if they were addicted, when in fact it’s their pain which is not adequately treated. So we call this “pseudo-addiction”—not true addiction.
Patients with pseudo-addiction might return again and again to their doctor complaining of pain, watch the clock to take their next pill the second it’s due, learn a lot of medical information about opioids to try to determine better treatments, or run out of medication early because they have used more than prescribed in an effort to decrease their pain. People with addiction may display many of these same behaviors. The difference is what is driving the behavior—trying to improve pain or trying to obtain drugs to abuse.
As the behaviors can be the same, health care providers sometimes mistake true addiction for pseudo-addiction. Doctors need to carefully evaluate each patient to figure out what is the true reason for medication-seeking behavior.
In addition, many people with CRPS experience intermittent flares of pain that occur even though they are taking pain killers on a fixed schedule. The term for this is “breakthrough pain” because the pain “breaks through” the regular pain medication cycle. You should receive adequate medications for around-the-clock pain control at rest as well as medication specifically indicated for managing breakthrough cycles of pain.
If your pain is not being adequately treated, you should talk to your physician. Do not take more medication than is prescribed for you! In some cases, such as when you take methadone, taking more than is prescribed or mixing it with other drugs without talking to your physician can kill you.
Q: What should my physician do to make sure the drugs are appropriate for me?
Your physician will ask about pain relief; side effects; your ability to function physically, psychologically and socially; and if any of your behavior suggests problems in controlling your use of medication. You should always be completely honest in reporting the effects produced by the drug.
Q. What is an opioid contract? Does this mean my physician doesn’t trust me?
Most physicians will want you to agree to a contract that describes your responsibilities when taking the drug. Many physicians will even want to monitor your urine to make sure that you are taking only the drugs that should be taken. These contracts may include agreements that you will never increase the dose on your own, nor go to another physician to get additional prescriptions.
Physicians are under a lot of scrutiny from regulatory agencies to make sure they are prescribing opioids appropriately and your physician needs to feel secure in the knowledge that you are appropriately using the drug. Then he or she is free to act in your best interests. A good relationship between you and your physician is needed for long term opioid therapy to be successful.
Q: Every time a celebrity goes into rehab for addiction to prescription pain pills, my family gets concerned about the medication I am taking to manage my pain. How can I help them understand?
There are several good website that can help educate them, such as www.stoppain.org. Also, you might want to bring a family member with you when you have your next appointment—perhaps the physician or nurse can answer their questions and concerns.
Also, many of the people who control the news do not understand the difference between addiction, physical dependence, and tolerance either and “addiction” sells newspapers and magazines.
Q: My family is also afraid that opioids will make me “dopey.”
Although opioids can make people sleepy and cloud their thinking, this side effect is usually temporary and long-term therapy is usually associated with normal thinking. Many people fear that taking an opioid will cause them to become “a zombie,” unable to function even if the pain is relieved. Fortunately, this is not the case. Most patients can take these drugs for a long period of time and be mentally normal. Patients who have been stabilized on opioid therapy and are clearheaded can drive, work, and do whatever else is necessary.
However, if you are taking opioids and your family member truly believes you are having significant negative side effects, it may be helpful to have a discussion with your doctor, you and your family member. This may improve your treatment if you are having side effects that you’re not aware of, and your family member may gain information about opioids and pain treatment.
Opioids are not a cure-all. Although pain specialists now believe that many patients can benefit from this therapy, they also recognize that some patients do poorly. Some patients experience sleepiness or mental clouding that never clears, and others develop persistent nausea or severe constipation. Some patients actually do not function well when treated with these drugs. Finally, some cannot be responsible drug takers and a true addiction develops.
Basic terminology from How To Cope With Pain
Basics about opioids: from How To Cope With Pain
Q & A About Methadone from the RSDSA Review
Surviving a Loved Ones’ Chronic Pain (PDF)
May 11, 2009