later in life.
TERMINOLOGY OVERVIEW
Addiction is a chronic, relapsing brain disease characterized by compulsive drug seeking and use, despite harmful consequences. At one time, addiction was a pharmacologic term that referred to a person’s using enough drugs to cause tolerance and physical dependence. In fact, we now know a person can have addiction without developing tolerance or physical dependence.
Tolerance means that more of the drug is needed over time to experience the same effect, and it commonly occurs with long-term use of opioids.
Physical dependence is characterized by being unable to stop using the drug without feeling terrible and developing a syndrome known as withdrawal.
Drug dependence is a synonym for addiction and is a set of behaviors involving problematic use of mood-altering substances over a continuous period of time.
Symptoms a person might display include:
• Having problems with controlling use, and thus having an unpredictable outcome once he or she begins using a substance.
• Trying to cut down or stop, but being unable to “stay stopped.”
• Being preoccupied with the drug and continuing to use it even though it is causing problems.
• Not doing the things he or she used to do and “chasing the high”— spending time and energy getting the drug and using it.
With addiction, the problem exists not so much with the drug itself, but with the way that drug works in the brain and nervous system. Some of you are destined to develop addiction because of how “well” the drug works—both physically and emotionally.
You were probably wired differently from birth, and with continued exposure to a drug, particularly an opioid (whether you started taking it for pain or not), you eventually became addicted.
Some people develop tolerance and physical dependence. These phenomena occur with continued exposure to certain substances over time. With increased use of certain drugs (e.g., an opioid), the body reacts by decreasing the effect of the drug, in this case, pain relief. This is tolerance. Consequently, in order to achieve pain relief, you increase the dose of the drug. This adjustment works temporarily, but eventually the need for still-increased doses will occur. Eventually, the drug seems not to work any longer, which results in using stronger, more potent drugs in an escalating upward spiral.
If you become tolerant to the drug, this indicates that your body is “normalized” in the presence of the drug. In fact, you may become so used to the drug that you need the drug to feel normal. Without it, you feel terrible. This is physical dependence.
When the drug is discontinued abruptly, you will feel withdrawal—in effect, the opposite feelings that the drug caused. So if opioids cause decreased pain and some amount of calm and well-being, then withdrawal consists of increased pain and anxiety, body aches, stomach and muscle cramps, diarrhea, nausea, vomiting, insomnia, and agitation. This outcome is one of the main reasons some of you will feel the need to continue the opioid, since, when you try to stop or even reduce the dose, you feel terrible.
So what is the solution to this awful problem? You feel that you have to take the drug to feel any level of pain relief, even though it barely works. In fact, as you’ll learn, it actually may be making the pain worse due to a phenomenon known as opioid-induced hyperalgesia. You might consider cutting down the dose of the opioid; however, that presents the immediate problem of withdrawal. In the short run, cutting down or stopping will make you feel much worse. This is because the withdrawal of the opioid from your system inevitably causes a temporary increase in symptoms, including pain. This effect makes the process of coming off opioids challenging but not impossible. You may be tempted to substitute one opioid for another, which may temporarily delay the process.
We have treated hundreds of people with pain who are tolerant to and dependent on opioids. The withdrawal process is best done under medical supervision and temporarily, you are likely to feel worse. But on the other side, when the opioids have left your system for a week or two, your pain will diminish and you will start to feel better. The discomfort of withdrawal may continue for a while, even for several months in some, but eventually your nervous system will readjust to the absence of opioids and you will return to a state of well-being that has escaped you for years.
Addiction is a chronic disease similar to other chronic diseases such as type II diabetes, cancer, and cardiovascular disease. –National Institute on Drug Abuse
Four Stages of Addiction
As with many illnesses, to understand the progressive nature of the disease of addiction, we have broken it down into stages. People who have addiction started in stage I and will inevitably end up in stage IV if not treated. The progression from stage I to IV may occur rapidly or may take years or decades. Stopping drug use might halt the disease process, but treatment is still necessary. Further, if use is restarted, the disease process will pick up where it left off. Like a passenger on a train traveling from New York to California, if you get off in Chicago (stage II), you will “reboard” in Chicago and continue west, heading inevitably toward stage IV, disability, and eventually death. Here are the stages in further detail:
STAGE I
Stage I addiction begins with the first ingestion of a mood-altering drug. The feelings that occur are related to mood change. This is often a sense of “normalizing” the world, euphoria, or an energized sense of well-being. This sensation may be especially true of the first use of opioid painkillers. The pain goes away—both the physical and the emotional pain. Although there may be no outward behavioral changes yet, such drug use cannot be considered “safe” because in persons with the neurobiological risk for developing addiction, subsequent use may result in substance abuse and life changes beyond the person’s control.
At this stage, family members generally have a greater awareness of the problematic use of substances than the addict. The developing addict may have an uneasy sense that there is something wrong, but denies it to him- or herself and others. The addict in stage I may cut down or even quit using for periods of time, but without recovery or treatment, typically he or she eventually resumes use and the problems recur and escalate.
A person with chronic pain and addiction may be defensive about drug use and answer any criticism or questions about it by rationalizing, for example:
Other characteristics of stage
