Overview
A person uses an opioid pain reliever exactly as prescribed for several weeks following a major injury. When the dosage is decreased, they become restless, sweat, vomit, and struggle to fall asleep. Have they become addicted?
Not necessarily.
There are multiple responses that opioids might trigger in the body, including tolerance, physical dependence, or withdrawal, and misusing opioids and having opioid use disorder, or OUD, are different concepts, although these terms are often used interchangeably. The differences between the two are important since confusing physical dependence with OUD can stigmatize those who take prescribed opioids correctly, and can lead to risky decisions, such as sudden cessation of taking the medication.
5 Similar Terms That Are Easy to Mix Up
Tolerance – The development of decreased sensitivity to opioids with repeated exposure to it, leading to an increased need for a higher dose to achieve the same effects. It occurs during medically supervised opioid use and is not, by itself, enough to determine the presence of OUD.
Physical dependence – Adaptation of the body to the repeated exposure to an opioid. The sudden termination or quick reduction of the dose might cause the withdrawal symptoms.
Withdrawal – A set of symptoms developing as a result of a sudden drop in the level of opioid in the body in someone who experiences physical dependence on opioids. The symptoms might include such sensations as agitation, sweating, muscle aches, nausea, vomiting, diarrhea, abdominal cramps, running nose, yawning, insomnia, and others.
Misuse – The use of the prescribed opioid drugs other than the one they were prescribed for, such as taking the drug in a larger dose, more frequently, or taking medication that belongs to someone else.
Opioid use disorder – A diagnosis that describes a specific pattern of misuse of opioids which has led to the impairment or distress. According to the CDC criteria for OUD, at least two of the 11 criteria must be present during 12 months, and it is worth mentioning that tolerance and withdrawal do not count when the opioid use is medically supervised.
Physical Dependence Doesn't Necessarily Equal OUD
One distinction is between the physiological adaptation and a certain pattern of compulsive use of opioids.
While a patient using opioids for chronic pain develops physical dependence on opioids but continues using it according to the doctor's prescription, they have no strong cravings, no loss of control over their medication use, and no tendency to continue using opioids in spite of the major harm.
The word "addiction" is usually used to refer to compulsive use of drugs in spite of the damage it causes, while OUD is a diagnosis with certain criteria.
Rab Nawaz, M.D., Expert contributor to MyOpioidRecoveryTeam, has discussed this difference regarding the long term opioid use.
"Patients on long-term opioid therapy have developed physiological dependence. This is not addiction."
This statement shows a certain truth behind the opioid use: a person's withdrawal after decreasing the dose shows only physiological dependence on opioids, but not OUD.
The distinction is also supported by a scientific description of the process provided by Nora D. Volkow, M.D., director of the National Institute on Drug Abuse. NIDA calls addiction a medical disorder affecting the brain and the behavior, not the lack of willpower or moral principles.
Withdrawal Is Harder Than Just Feeling Uncomfortable
Opioid withdrawal can be very unpleasant for a person experiencing it. In healthy adults, it is not considered potentially life threatening like in the cases of withdrawal from sedatives or alcohol, but this doesn't mean that it should be ignored.
Vomiting and diarrhea can cause dehydration. The pain can worsen. The anxiety and insomnia can be hard to deal with. Also, it can contribute to the continuation of the opioid use if a person is trying to stop.
Dr. Nawaz has talked about the influence of expectations on withdrawal:
"Patients often come in expecting withdrawal to be over in 24 hours."
The time and length of withdrawal vary greatly depending on the type of opioid, the dose, the duration of its use, other medications, and the health of the patient.
Another problem can arise from a decrease of tolerance. If the person tries to return to the previous dose after some time, the body might not be able to tolerate this amount of the drug, causing the risk of an overdose.
That is why those who take opioids regularly shouldn't stop long term treatment abruptly without medical supervision. CDC guidelines recommend individual approach to reducing the opioid dose or stopping its usage, and warn against fast tapers in the absence of the immediate threat for life.
One Case of Misuse Doesn't Necessarily Mean OUD
Suppose someone is prescribed one tablet of an opioid every six hours after an operation, but takes an additional tablet because of a severe pain.
Taking the medication in a larger dose than prescribed is considered misuse. This should be taken seriously as it increases the risk of overdose.
Clinicians evaluate the use of opioids. Such signs might include repeated use of a larger dose than intended, unsuccessful attempts to decrease the use, intense cravings, spending much time obtaining or using opioids, continuing the use despite health or interpersonal problems, using opioids in a hazardous situation, and abandoning important activities in favor of opioids use.
Considering the whole pattern helps to exclude those who developed tolerance or experienced withdrawal.
The Treatment Should Correspond to the Problem
Physiological dependence, poorly controlled pain, opioid misuse, and OUD might need different approaches to the treatment.
If the person is physiologically dependent on the prescribed opioid, they can continue taking the medication if it brings more benefit than risk. In case of the termination of treatment, the gradual reduction can help to avoid withdrawal symptoms and other complications.
In the case of OUD, medical treatment options are available. The FDA approved treatments include buprenorphine, methadone, and naltrexone, and the medication therapy of OUD is connected with the lower risk of overdoses and general mortality.
Buprenorphine and methadone interact with the opioid receptors in the body in a regulated way, reducing the withdrawal symptoms and cravings, and naltrexone blocks the opioid receptors and requires an opioid-free period before its administration, because starting the therapy too soon can trigger the withdrawal.
The medication can be combined with behavioral health care, peer support, recovery services, treatment of co-occurring disorders, and assistance with practical problems, such as finding employment or housing. No single path to recovery fits everybody.
It is especially important to remember that the detoxification alone is not considered the treatment of OUD. CDC guidelines say that the withdrawal without the medication therapy increases the risk of return to opioid use, overdose, and overdose death.
Better Terminology Leads to Better Treatment
Calling all the cases of physical dependence "addiction" is the source of unnecessary fear and stigma. The reverse mistake can also be dangerous. The dismissal of the uncontrolled and repeated opioid use as mere physical dependence may cause a delay in the treatment of OUD.
A person can be physiologically dependent on opioids without having OUD. Someone can misuse an opioid without meeting the criteria for OUD. Finally, a person having OUD is experiencing a medical condition, not a moral failing.
Recovery is possible, and proper treatment can reduce the harm caused by opioids significantly.
An opioid overdose is a completely different problem from the opioid withdrawal, and it should always be treated as a medical emergency. If someone isn't awakened, breathes very slowly, or stops breathing, the emergency services should be called immediately, and the naloxone must be applied, as several doses might be required until the arrival of the ambulance.
Correct terminology allows understanding what exactly happens and choosing the proper medical assistance.
About the Medical Contributor
Rab Nawaz, M.D., is an expert contributor to MyOpioidRecoveryTeam, where he contributes to the evidence-based education on the opioid use, recovery, treatment, and related health issues.
Medical sources
Centers for Disease Control and Prevention. Opioid Use Disorder: Diagnosis.
Centers for Disease Control and Prevention. Clinical Practice Guideline for Prescribing Opioids for Pain.
Centers for Disease Control and Prevention. Opioid Use Disorder: Treating.
National Institute on Drug Abuse. Drugs, Brains, and Behavior: The Science of Addiction.
Substance Abuse and Mental Health Services Administration. Medications for Opioid Use Disorder and opioid overdose prevention resources.
