Addiction vs Dependence

Thanks for the insight.

I have a sympathy for pharmacists. They really get stuck between the rock and hard spot sometimes.

use-what it was intended for...

misuse-not necessarily what it was intended for...

abuse-just for the f'ing hell of it...

don't know toooo many people using blood sugar med the last way, but do know of many using the other products that way,

AND, it don't matter how you use those, use 'em too much and you ARE dependent!!! aka--addicted!
IMHO

I've come here from time to time reading your blog. I never posted a comment here before.
I suffer from severe osteoarthritis from an auto accident of 30 yrs ago.
There are days that the pain is mostly managable just with two buffered aspirin in the morning, but I do have some very bad days when I can hardly stand on my arthritic ankle, knee and hip.
I mainly take aspirin to keep the inflammation at a minimum.
About a year ago I had asked my doctor for Oxycontin, just to be out of pain one or two days a week.
He flat out said no!
I had shoulder surgery last February (shoulder was worn out from many years of crutch usage) and he gave me Oxycontin for after the surgery. I took them as prescribed, the lowest dose of 20 mg.
I took them for two days and was amazingly pain free. On the 3 day after the surgery I took the prescribed dose after 12 hrs from the last one .. and oh my - apparently the intense pain from the surgery was NOT in need of Oxycontin and I had to keep lying down to help with the "woo headedness". What an awful feeling.
I have no idea why the addicts would want to feel this way, I couldn't imagine what it would feel like if I had taken it like they do, snorting or such.

I do wish they'd make an Oxycontin, less then 20 mg to help manage pain.

I take an occaisional Percodan to help with pain but would never take them on a daily basis, as for some reason I suffer from mild headaches the day after.
I can see why my OS said no to Oxycontin, I had no idea how strong they really are.
I've tried the Celebrex and they did not help to relieve my arthritis pain, and best to not take something that will need you to have liver testing!

Later this year I hope to have an ankle and knee replacement. First tho, my shoulder has to be "crutch ready".
Wish me luck!

and thanks to your blog, I so appreciate my pharmacist, and have even sent thank you notes for special ordering medications for me.
:)
susan

My problem is that the patients won't take their pain meds. Today I had a little old lady with chronic pain tell me she hadn't taken her Lortab in 3 weeks because she was "afraid of becoming addicted". A lot of my elderly patients believe this, and I have to do a lot of teaching in order to convince them that they can take their pain meds properly and not get "addicted". I have no idea why they get this idea into their heads. Maybe it's their generation or something. I hate to see them hurt so much.

OK Angry,

We can agree that there are many different connotations of the word 'addiction'. A simple google search brings up more than 20 wildly varying definitions. Some even specify that addiction has to be just with pain drugs or drugs in general when everyone knows that it can be with just about anything....(like this blogging thing maybe?) ;-) I always try to steer my patients away from using that word when I'm talking about treating chronic pain. As you noted, that negative connotation can really put a dent in appropriate pain management. I always steer them towards the word dependance and tolerance versus misuse/abuse.

Hey, here's a topic for your next article.... Big Pharma forcing patent law down our throats and keeping the cost of treatment in the stratosphere.... I'm thinking particularly of the drug 'PLAVIX'...but also OXYCONTIN.... Both briefly had generics available that would have brought the price down considerably (Plavix is about $4.00/tablet in acquisition cost for our hospital). But both 'parent' companies sued over patent infringment (or similar patent crap) and forced the generics back off the market! I'm not sure when Plavix generic will be available again, but I think Oxycontin generic isn't coming out again until 2009 or 2010?). That's such a load of crap! Those companies had plenty of exlusivity to recoup their R&D, which is quite the joke now-a-days anyway (how many TRULY NEW drugs are there coming down the pipeline?)...not many...just rehashes and release form changes....no originality...Not many NMEs....(new molecular entities).

You are absolutely correct! The difference between addiction and dependence is the psychological aspect--the drug seeking behavior. My Grandmother was absolutely dependent upon Oxycontin for her Stage 4 colo-rectal cancer (cancer that eventually took her life)!! However, thanks to Oxycontin she was able to function on a daily basis and live, in little or no pain-until the end.

Oxycontin is a fabulous medication!!

Crushing/snorting/injecting is not what a dependent patient does, it is was an addict does! Junkies and crapass ambulance chasing attorneys have produced the "stigma" of taking a medication such as oxycontin.

A cable-TV documentary on marijuana, "In Pot We Trust," succinctly illustrates the difference between dependency and addiction. The medical case for dronabinol is well-established, but the weed is still demonized, and people such as the stuttering cerebral palsy patient in the film must get their medication from drug dealers instead of legitimate sources. I still don't see why this drug isn't available legally in better legitimate drug delivery systems. It has genuine applications as a medication. Sure, people become dependent on it, but I am dependent upon atenolol, hydrochlorothiazide, and Prevacid.

I think the key to all this is, normal people do not score drugs on the street. Sort of like alcoholics; normal people do not store gin in the toilet tank so no one will know what they are doing. Addicts basically become a host for a drug to live through, and have no real lives or choices of their own. Chronic pain people have a life because of the drug. And they would give anything to not have to use it.

I'm sorry people get addicted to shit. But it's not really my problem. My problem is making sure the chronic pain people get what they need to keep going to work, or taking their cancer treatment, or whatever.

Once again, I love you. Great article. Most people have no idea whatsoever what addiction really is, and most will define it with withdrawal. I just took two courses in drug addiction with a wonderful professor (Dr. Michael A. Bozarth, some of you may actually know him, well known in the field of drug addiction). We were taught that withdrawal is neither sufficient nor necessary for addiction, and I completely agree.

I had a patient once tell me that his wife "needs to stay on hydrocodone because she's addicted". Last I checked, you need to be on hydrocodone because you're in pain, not because you're addicted.
Better yet, it has been over two months since she last had it filled, and it was for a 30 day supply. That's addiction? Give me a break. People don't have a clue what addiction really is.

It's just as bad as "I get a headache if I FORGET to have my coffee in the morning, so I'm addicted." An addict wouldn't forget.

Try, "I mugged a guy and stole his gold watch to trade it for a bag of blow." That there may be addiction...

I am glad to see your post. I have recently started reading med blogs, initially for the humor, but it is an addictive habit (reading med blogs). I have had chronic pain which began a few months after recovering from a groin lymph node dissection for stage III metastatic melanoma. I have read up on pain management issues because the last think I need is an addiction. I have tried to do everything right, not drink alcohol, etc. but often when the issue of pain management comes up, I hear one more story about someone who became addicted to pain meds. What they don't usually say initially is that the person was drinking a lot while taking the meds but when I ask that's often the case.

My pain doc has never discussed alcohol with me although the pharmacy labels warn against it. It was my medical oncologist who became concerned about my liver and made a change, sending the report to my pain doc. Sometimes I feel like my pain doc's primary concern isn't so much treating me but is making sure I have the lowest possible dose of pain meds (which on the face of it suits me if it weren't for the liver and tylenol issue).

Much of what your post said is what I've read in articles about how if pain meds are only used to treat pain and not for other reasons, the person may have a physical dependence but not an addiction. In my case I know I don't have an addiction because when changes are made in other meds I initially don't need the stronger pain meds. The problem is once I've adjusted to neurontin boosts it's not as affective and in order to work I do need other meds. I have an okay relationship with my pain doc but I don't think he's as concerned about my liver as he's concerned about other things.

Anyway, thanks for you thoughtful piece. Carver

Sometimes your posts are so harsh I'm afraid of my own pharmacist for weeks, but you always speak the truth. (I LOVE that you call doctors and yell at them for prescribing an inappropriate pain med!)

Uncontrolled chronic pain can look an awful lot like addiction. Many people with real pain end up in the ED because they can't get relief from their PCP, and they are often treated like drug-seekers, when they are only seeking relief. There is an attitude that people--or maybe only certain people--should just learn to live with a certain level of pain. That somehow wanting to be out of pain is a weakness in the patient's character.

If there are meds that can take the pain to near-zero without diminishing quality of life, why not let a patient be pain-free?

~Raven

I have to totally agree with you on this subject. Two years ago, my sister had metastatic breast cancer with no less than 9 different bone metastases sites. She would cry in pain just walking from the bed to the bathroom. She was so afraid of becoming "addicted" to narcotic pain medications that she refused them and tried to alleviate her pain with tylenol and advil. Being a pharmacist myself, I tried to talk to her and her oncologist about narcotic pain medications at length. After 3 months of nightly phone calls from my sister, I convinced her to follow her oncologist suggestion to use a home health morphine "patient controlled administration? pump for her pain. Two weeks later, she passed away. I am often haunted by the knowledge that she did not have to suffer in pain as much or as long as she did just because she was afraid of becoming ?addicted? to narcotic pain medications when she had a terminal illness.

One comment....

I agree there are different connotations to the word addiction (the DSMIV is probably the best to go with and that does support your comments). In explaining Oxycontin and fentanyl (I'm assuming you're talking about patches and not lollipops or injection), I wouldn't use the term 'abrupt euphoric' effects, because neither of them release right away. Fentanyl patches, in particular, can take 12 hours or longer to have their initial effect....

I often wonder what would happen if Coffee (caffeine) were to become the C-II substance that it probably should have been from the get-go? If you had to get a script for coffee, could you imagine the lengths people would go to get a cup from you? They'd probably bum rush the place at some point! I just think our society has a hypocritical approach to addiction (by sanctioning some and outlawing others....)

yes.. I always remind myself of the differance between addiction and dependance when I encounter some of our favorite customers...
It's hard to step back and think that when someone is on Hycodan syrup for the past 2 years... and never misses a refill every 12 days.

As a physician I can tell you that prescribing decisions are made to CYA all the time. Early in my career I was sued by a 96 year old woman's family for prescribing prn morphine while she was in the hospital. Someone at the coroner told her that the dose of morphine given three days earlier contributed to her death, not her age, aspiration pneumonia, or underlying coronary disease. So after a few actual lawsuits, and reports to medical board for any untoward event, hardly anyone gets anything that could be possibly addicting albeit helpful. Had another doc in the area sued for elder abuse, higher potential monetary award than plain malpractice, for prescribing a terminally ill hospitalized patient morphine in the hospital. These things take their toll, and many of us have to work many more years before we retire, so no we don't go out on a limb for too many patients. Jeve

I see a few people commenting in this post and the other post about addiction being withdrawal or dependence. Think about this:

Some diabetics (type I or course) are dependent on insulin, but would you really say that they're addicted to their insulin?
People with thyroid problems are dependent on their thyroid medication, but are they really addicted to it? Many of them forget to take them at times.

SSRI's have withdrawal symptoms when you stop taking them, but have you ever heard of someone being addicted to SSRI's? Most people, when they go off them, hate the withdrawal so much that they will never use them again.
A lot of inhalors such as albuterol have withdrawal (and while there are some people who abuse them...just like every other drug) but you generally don't see everyone addicted to albuterol.

Keep in mind that just because one person seems "addicted" to something, it doesn't necessarily mean that the substance is addictive. When a large percentage of its users are addicted... then you know it's addictive. Often times when this happens, it's the person in and of themselves and not the actual drug
i.e. someone who is so obsessed with getting to sleep at night (which the obsession actually makes insomnia worse due to stress) being "addicted to ambien".

I could rant for hours... I'll stop

To Susan...

This goes back a number of days, but if you are reading the comments by now, good for you...

There IS a 10 mg dose of Oxycontin. So there is definitely a LOWER dose you should have been started on. 20 mg twice daily is a lot for an opiate 'naive' person...

I agree, only I feel the same way about sleeping disorders...sleep disorders are a chronic problem...take away the medication and the problem comes back...just something to think about

Gravelpit

thank you DrRX for your reply to my post.

[There IS a 10 mg dose of Oxycontin. So there is definitely a LOWER dose you should have been started on. 20 mg twice daily is a lot for an opiate 'naive' person...]

When I have my replacement surgeries (hopefully before the end of the year) I will ask for the lower 10 mg dosage. It was great to have NO PAIN while I was recovering from shoulder surgery.
I do take an occasional Percodan after my physical therapy sessions, but mostly ICE packs can help with pain and swelling.
I've had 4 surgeries to my ankle and 1 on my knee, next step is replacements.
It is nice to know that I have a stash of oxy's, since I have so many left, should I fall and suffer intense pain.
I'm not a klutz, I just fall alot because of weak worn out arthritic joints.
I am so looking forward to walking pain free, cane free, and having an ankle with range of motion.

Thanks Angry Pharmacist for this blog .. I have learned so much.
especially this - the life of a pharmacist is not an easy one.
You should see a massage therapist to get all that angst worked out, not to mention all that time on your feet.
Sure helps me ALOT!
blessings,
susan

They make an Oxycontin 10mg and a 5mg in the UK. Do you not have that in the US?

I have osteoarthritis because of a severe leg break five years ago. My docs will only prescribe me Vicodin 10/500 up to 8 a day. I have tried other OTC things and once had percocet, but even the Vicodin doesn't work. When I was in the hospital getting surgery for the break, after the surgery they'd give me shots of demerol for pain. That was the only time since my leg break that I've been without pain.

Why won't doctors prescribe stuff that ACTUALLY takes away pain rather than mountains of vicodin that make you feel slow and cranky all the time?

In a perfect world (with my leg break), I'd be able to go get a shot of demerol when I have huge flares of pain and that's it. Now that I've been on Vicodin for years, it feels like it will be impossible to get off.

I think it's the DOCTOR'S fault for being afraid to treat us the right way---they make US into Addicts and Dependants by not prescribing medicine correctly. Ugggh.

I am dependent upon my anxiety meds. They have greatly increased my quality of life. I have an understanding doctor, one who knows that lying in bed feeling panicky and making numerous, expensive ER trips is not living fully. I thank god for the medicine i have in my life. It has made an amazing difference to me, and hopefuly more doctors will avoid this almost "stigma" of prescribing someone something that is greatly needed.

I was involved in a motorcycle wreck June 23/07. Broken spine, 16 ribs (flail chest) 2 breaks of left femur, broken shoulder...
I have been on Oxycontin since the accident and it seems to be virtually impossible to find information on how to gradually reduce one's use of the drug; that is, an orderly withdrawl. It seems that everyone is convinced that I am an addict, despite the fact that I am asking how to stop using the drug. I don't need much help, but I would like some...

i've had chronic pain for over 20 years with no real help medically. i was diagnosed with endo and most recently lupus. when i asked the doctor for
pain meds his nurse asked why?, she was borderline
angry at my request. i'm still baffled by the
healthcare systems treatment of people who are truly suffering. i'm surely not living with this
daily pain, i'm existing.