The number of prescriptions for opioid painkillers has risen dramatically in the U.S. over the last several decades — nearly doubling for teens and young adults between 1994 and 2007 — and concerns about the abuse of these drugs are also growing. The trouble is that there is still much confusion, among doctors, patients — and journalists — about what “abuse” or “addiction” really means: how do you know when legitimate use of prescription painkillers has turned into a problem?
Most people tend to equate addiction with withdrawal. If a person becomes so dependent on a drug that stopping it causes physical symptoms of withdrawal, then he or she must be addicted, right? The Washington Post would say, yes. (More on Time.com: Overeating: Is It an Addiction?)
An article titled “Addiction to Painkillers is a Growing Problem — How to Kick It,” which ran on Sunday, tells the story of Nichole Marie Case, a woman who became physically dependent on opioids while being treated for back pain. When a pinched nerve in her spine caused severe and unremitting agony, Case was prescribed a cocktail of opioids, including hydrocodone and oxymorphone. She took them as prescribed for eight months, at which point she said her back started feeling better and she decided to stop the drugs abruptly, without telling her doctor. The Post reports:
Suddenly, she was in the throes of withdrawal, like heroin addicts go through on TV shows, she said. She was nauseated, sweated profusely, and her nose ran constantly.
“Man, that was like hitting a brick wall,” she said. “It felt like having the worst hangover of your life combined with the worst flu. It was miserable.”
It’s a compelling story, but not one of addiction. Indeed, needing a drug to avoid withdrawal symptoms does not mean a person is addicted: certain antidepressants, antispasmodics and blood pressure medications can also produce withdrawal, which in some cases can be fatal if the drug is not tapered slowly. But the difference is that these drugs don’t produce a high — like opioid painkillers do — and no one robs pharmacies to get them, so they are not considered addictive. (More on Time.com: Is Marijuana Addictive? It Depends How You Define Addiction)
Let’s go back to Case’s story:
Case took the drugs as her doctor prescribed and didn’t experience a high.
“But I didn’t like taking them, because I couldn’t drive or do much of anything,” she said. “I think I was pretty much in a state of screwed-up most of the time.”
The drugs actually made Case feel sort of rotten — pretty much the opposite of the way they make addicts feel. So, why is her experience being used as an example of drug addiction?
Some of the confusion may stem from the currently used medical term for addiction — “substance dependence.” That’s the label you’ll find in psychiatry’s diagnostic handbook, the DSM; to most people, however, it’s far from clear. “Dependence” suggests to the non-expert that physical dependence is important, but, as we noted above, needing a substance to function does not necessarily mean a person is addicted. (More on Time.com: Are Stoners Really Dumb, or Do They Just Think They Are?)
Yet “substance dependence” also implies psychological dependence — compulsive use of a drug despite negative consequences — and that really is addiction, though it doesn’t involve physical need or withdrawal. Crack, for example, does not produce physical withdrawal symptoms upon cessation, but no one would argue that it is not addictive.
Addiction experts like Nora Volkow, head of the National Institute on Drug Abuse, define addiction this way: “loss of control over the intense urges to take the drug even at the expense of adverse consequences.” In other words, addiction is defined by key elements: intense urges (drug cravings), behaviors (drug seeking) and loss of control (seeking drugs despite negative consequences). Case exhibited none of these characteristics. Indeed, as the Post reports:
[Her doctor] weaned Case off the opioids slowly and painlessly after she told him of her withdrawal symptoms. Today, she said, her back rarely hurts and when it does, she pops a couple of ibuprofen tablets.
If Case had been addicted, here’s how her experience might have played out: She would have taken higher than prescribed doses of her drugs. She would have escalated her use against medical advice. She would have had difficulty quitting when the drugs were properly tapered. She would have craved the drugs when she wasn’t using them, which would have put her at risk of relapse. (More on Time.com: Fighting Teen Drug Use with Plain Facts)
Finally, there’s another clue as to why Case’s story isn’t one of addiction: it started at the doctor’s office, not on the street. Despite many media reports that suggest otherwise, the vast majority of painkiller addictions start with recreational, not medical, drug use. That’s why 80% of Oxycontin addicts also report having taken cocaine: their addiction starts with a mix of street drugs, not with a legitimate prescription.
Cases like Case’s are frequently confused for addiction. But, thankfully, the next edition of the DSM, due out in 2013, will help clarify things by doing away with the term “substance dependence.” What will the new medical term for addiction be? “Addiction.”