Addiction vs. Physical Dependence

In Slate, Jerrold Winter notes some of the ways that Prince’s death is being used to hype “opioid addiction” stories,

But a rational discussion of the death of Prince—and of so many others—should not be guided by notions of “doctor-shopping,” an opioid “epidemic,” or vague images of those in pain enslaved by drugs. Instead, we should seek an understanding of the drugs of concern: how they work to relieve pain, how they kill in overdose, how deaths might be prevented, and how we should respond as a society both to their risks and to their benefits. Most important is to draw a distinction between physical dependence, which is a pharmacological phenomenon, and addiction, a term with multiple definitions, none of which is entirely satisfactory.

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The rumors that Prince entered a rehabilitation program to address a perceived painkiller addiction—whether or not the rumors are true—illustrate a general confusion about the difference between physical dependence and addiction. Many of Prince’s friends and acquaintances, including his longtime collaborator Sheila E., have attested to the physical pain and discomfort he suffered in his later years, owing to decades of strenuous performing. In the face of such chronic pain, many patients can be treated with an opiate to the point of physical dependence for an extended period of time without adverse medical consequences, resulting in a much higher quality of life. (It remains to be established whether an absence of skilled medical care—surely available to one of his status and means—contributed to the death of Prince.) Indeed, each of us, without exception, will become physically dependent on opiates if exposed to them in sufficient doses for a sufficient period of time. In physical dependence, adaptive changes take place in the brain; upon stopping the drug, a constellation of signs and symptoms appears which is called the opiate abstinence syndrome—the hallmark of physical dependence.

In contrast with physical dependence, however, a definition of addiction is harder to reach. Neuroscientists call it a brain disease. Others think it is simply a choice or a moral failing. I prefer to say that addiction is a behavioral state of compulsive and uncontrollable drug craving and seeking. Many of those treated for chronic pain will not become physically dependent. And even in those who do develop dependence, only a small fraction will become addicted, and even a smaller number will overdose. It would be cavalier to suggest that physical dependence upon an opiate is an entirely benign condition; we would best avoid it. But we should also avoid the notion that treating chronic pain creates “addicts.” Sufferers of chronic pain are not compulsively craving and seeking drugs. They are looking for relief from their pain.

Winter could have added that the way addiction is treated in the United States is often unscientific, relying on the methods pioneered by the faith based Alcoholics Anonymous. Gabrielle Glaser highlighted the vast gulf between the respect afforded to Alcoholics Anonymous and its actual results in the April 2015 issue of The Atlantic,

Nowhere in the field of medicine is treatment less grounded in modern science. A 2012 report by the National Center on Addiction and Substance Abuse at Columbia University compared the current state of addiction medicine to general medicine in the early 1900s, when quacks worked alongside graduates of leading medical schools. The American Medical Association estimates that out of nearly 1 million doctors in the United States, only 582 identify themselves as addiction specialists. (The Columbia report notes that there may be additional doctors who have a subspecialty in addiction.) Most treatment providers carry the credential of addiction counselor or substance-abuse counselor, for which many states require little more than a high-school diploma or a GED. Many counselors are in recovery themselves. The report stated: “The vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.”

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In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent. That is just a rough estimate, but it’s the most precise one I’ve been able to find.

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A meticulous analysis of treatments, published more than a decade ago in The Handbook of Alcoholism Treatment Approaches but still considered one of the most comprehensive comparisons, ranks AA 38th out of 48 methods. At the top of the list are brief interventions by a medical professional; motivational enhancement, a form of counseling that aims to help people see the need to change; and acamprosate, a drug that eases cravings. (An oft-cited 1996 study found 12-step facilitation—a form of individual therapy that aims to get the patient to attend AA meetings—as effective as cognitive behavioral therapy and motivational interviewing. But that study, called Project Match, was widely criticized for scientific failings, including the lack of a control group.)

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