Opiods: Addiction vs. Dependence (and Getting the Meds You Need)

Pain patients are highly unlikely to be addicted to painkillers (opiods). They are, however, likely to become dependent on a drug, which is very different than addiction.

If you stop taking an opiod, you may have withdrawal symptoms, including nausea, vomiting, diarrhea, sweating, muscle twitching and aches and pains, and increased pulse and blood pressure. Even though this list is reminiscent of the withdrawal scene from Trainspotting, it doesn’t mean you’re an addict. It means that you have a physical dependence on the drug.

You can develop a physical dependence and experience withdrawal symptoms with many different meds, including antidepressants, but you aren’t addicted to them. It works the same way with opiods. Docs make a schedule for to reduce the amount of a drug we take slowly to avoid these unpleasant symptoms, but they may be inevitable. Just as you might be nauseated and dizzy when you stop taking an antidepressant, you may have diarrhea and a racing pulse when you stop taking opiods. (For a personal tale of dependence and withdrawal, read Chapter 19 in All in My Head by Paula Kamen.)

Tolerance is another physical phenomenon that may cause fears that you’re addicted to opiods. Maybe a small amount of a drug relieved your pain initially, but over time you need higher and higher doses to maintain the same level of pain relief. Like dependence, tolerance is not a sign of addiction.

Patients who take opiods may exhibit addict-like behaviors (called pseudoaddiction) — like hoarding pills and being preoccupied with taking the next dose at the precise time it is OK to do so. Understandably, seeing a patient with these behaviors make a doctor very cautious. However, pain patients stop behaving like addicts when they get adequate pain relief.

That deserves repetition and it’s own paragraph: Pain patients stop behaving like addicts when they get adequate pain relief!

Pain specialist Scott Fishman sums up the difference between patients who are dependent and those who are addicted well: “The difference between a patient with opioid addiction and a patient who is dependent on opioids for chronic pain is simple. The opioid-dependent patient with chronic pain has improved function with his use of the drugs and the patient with opioid addiction does not.”

You may be reassured that you’re not an addict, but that doesn’t mean it will be any easier to get docs to prescribe opioids. Here are some thoughts for patients seeking pain relief with opioids:

  • It will probably take multiple visits to a pain specialist to get a response. He or she needs to get to know you and your case before prescribing opioids.
  • A specialist at a pain clinic rather than a pain specialist in a solo practice or one in a team of many different types of doctors may understand your pain better.
  • Pain specialists may not give you the time of day if you haven’t seen a neurologist or headache specialist first.
  • Patients who say they’ve tried everything to treat their headaches often haven’t. There are so many preventives and abortives available that there are probably many that you’ve never considered. This may be a sticking point with a pain specialist. (Although I know that many readers have tried just about everything.)

And some recommendations:

  • If your neurologist agrees that the next step for you is opiods, ask him or her to call or send a letter to a pain specialist to explain this.
  • Have your neurologist’s office send your medical records to the new doc before your appointment.
  • Look for a doctor who specialized in pain medicine during his or her residency (probably through a fellowship).
  • Seek out doctor who finished residency recently. He or she may be more afraid of legal repercussions, but may also have more current attitudes about pain management.

P.S. I’m afraid this reads like a tip sheet on feeding a prescription painkiller addict’s habit. Chronic pain management with opiods is absolutely necessary for so many people that I’m publishing it anyway. So there.


12 Responses to “Opiods: Addiction vs. Dependence (and Getting the Meds You Need)”

  1. Angel Says:

    It drives me nuts that every doctor and hospital has that “pain scale” but many won’t actually do anything to adequately help reduce your pain.

  2. Diana Says:

    Thank you. I’ve been taking fiorinal with codeine for more than 7 years (have had migraines >25 years). At first only as a backup plan to the triptans, which were working pretty well, and more frequently as the migraines became worse.

    I can’t help that they got worse, and I feel awful about having to rely on codeine the way I do. I once asked for a prescription of just fiorinal to see if I could get by on that, and had to realize then that it is the codeine I need to keep the pain at bay.

    I do function better with it – much better. Without it I’ll develop a hellish migraine, guaranteed, and with it I’m pretty much fine except for the occasional flareup.

    The guilt is so hard to deal with, that I try to see how long I can go without it some days, ignoring the nagging little pain that’s building up until it explodes, and then it’s too late. A regrettable mistake.

    I am extremely thankful my neurologist “gets it.” Without a way to manage the pain, at this point, it really truly is so unbearable I’d probably have to kill myself. My Dr. doesn’t even give me a bad time about it. I wish I could be easier on myself, this just isn’t the way I want to be.

    So thank you for this article. I needed someone to reaffirm what I already knew, but have a hard time accepting.

  3. nyyankee7 Says:

    I am thankful that I finaly read something by someone who understands. I have a back problem, pinched disc (I guess)as so the MRI suggests. The doctor put me on Oxycontin (10mg), one pill a day. I am 6 feet tall and weigh about 240 lbs., 10mg’s didn’t do it so I took 15mg’s twice daily. This not only allowed me to be basically pain free but let me concentrate on my work and family life without interference. I am not advocating the use of drugs as opposed to therapy, but I have gone through that as well. Therapy only worked for me for the first 30 minutes after leaving the pain management center office.
    I eventually (due to increasing my dosage)would run out and ask for re-fills (the doctor was afraid of prescribing these meds), I would get some but he never would agree on the dosage, continuing saga. My body would become dependent on the Opiod but I in no way was using for the “high”, if so the case, I would have taken even higher doses, taken a variety of other opiod’s, etc.

    To make a long story short, the doctor changed and decreased my medication to the point of high anxiety, high blood pressure, (withdrawal)etc. I was looked upon as a drug addict at the hospitals (the hospitals do nothing but give small doses of clonidine)and after visiting four er’s in a 10 day period, finally was told to take buttenox on an in patient basis at the hospital that treats addictions and withdrawls associated with them.

    After the first shot (within 5 Minutes) I was like a new person, 3 days later was feeling great and had gone home. Within 3 days the same symptoms happened. I seeked the treatment of a phychiatrist whom dis agreed with the treatment, said all I needed was methadone and on an out patient basis. He prescribed the methadone (pill form)and I took it (40mg’s daily) along with anxiety meds, etc. Eventually went down to 2 1/2 mg’s daily (doc says cant hurt and dont know why I feel I need it)and that is fine, still taking all kinds of other meds for pain (non-narcartic)which does nothing but depresses me further.

    The strange thing is that I was only on the Oxycontin for 2 months, other people take it for years and the doctor even agrees that at any time you can ween off it, so why the catastraphy. We all know that the drugs are not the answer, but until we learn how to deal with the issues, why not.

    If anyone knows what I can take, something similar to an opiod, codine, something with the med included as an ingredient, please let me know. kids are using these things and I dont know how they do it, wish I did.

    Feel free to e-mail me privately

  4. Mikey Says:

    My wife has been suffering for a long time from several ilness, including migraines, scoliosis and arthritis. She has had several operations and tried many drugs with no lasting success. Sometimes she just lays in our bedroom crying. Previously, she had been a happy mother of 3 who exercises and eats right. I feel she is beyond her limit of what she can take. No matter how hard she tries, her doctor will not give her anything strong for her pain. She tried a new doctor (GP), who told her he would need to see her several times to even consider prescribing anything, and that she needs to see other specialists. He was not sympathetic at all. What I want to know is, how do you go about getting narcotic pain meds? Do we have to order on line? Or how do we find a sympathetic Dr – trial and error?

  5. Abbe Says:

    Has anyone heard about migraine surgery? There’s a Doctor David Branch in Bangor, Maine who does it. I’m considering it, but my insurance won’t cover it. So I subsist on daily triptans and take fiorinal a few times a week if the triptans don’t do the trick.

    I’ve given up what I can to prevent the onset, but there’s always something. The most frustrating is getting migraines when I lift my head too quickly from a forward bend in yoga. Any suggestions on dealing with exercise-induced migraines apart from staying in bed, which I really do prefer?

    Although it makes the news a lot, I’m not convinced that this kind of surgery is a good idea. I suggest trying Botox before you make plans for surgery. It may help predict how effective the surgery would be for you.

    You could ask your yoga teacher for alternative poses that you can do while everyone else is doing forward bends. Maybe other types of exercise are less likely to induce a migraine for you.


  6. DamionKutaeff Says:

    Hello everybody, my name is Damion, and I’m glad to join your conmunity,
    and wish to assit as far as possible.

  7. Cols Says:

    As a sufferer of migraines for 24 years I will share will with you a drug which changed my life. It is taken on a daily basis for prevention. It’s called Topamax. It works really well. One of the side effects is weight loss which as a woman is truly a bonus!!! I have to agree myself I am tired of Docs who are afraid of painkillers. I am truly not looking to get high everyday, I just want the piece of mind to know if massive migraine pain happens I have meds to help.

  8. Dwayne Steinmetz Says:

    My name is Dwayne. I also suffer from extreme
    migraines. I get two or three fiorinal/codeine
    prescriptions a year, so I now have to by painkillers illegally when I can. It takes up
    alot my money and it’s illegal, but until I
    run across the right doctor I’ll have to keep
    it up. I’ts got to the point to where the only
    thing I can do is hurt so bad it incapacitates me.
    It is tearing my life and livelyhood apart.
    The bad part is knowone understands. They just
    I’m a junkie.

  9. Brian Says:

    I suffer from alot of what I’ve read here.There
    is a reason we can’t get the meds we need and it’s
    not the doctors fault. They don’t want us to be
    in pain constantly(or I would hope not). It’s
    the DEA scaring the shit out of them. I wouldn’t
    wan’t to jeopardize all I worked for either. We
    need to do something about these so called DEA
    agents harrassing our doctors. There are many
    people with the same problems. All we need to do
    is stand together and tell them enough is enough.

  10. Jim Benedict Says:

    I am a state worker with a history of 2 back surheries, intractible hip pain and episodic migraine headaches. I have been presribed Lorct (10/650), Fentanyl patch (50 mg every 3 days) and Diazepam as needed up to 3 times a day. I have been on this regime for over four years and up until a few months ago, its allowed me to work, function on a professional level and enjoy life. Lately, I have been given extra responsibilities (more committees, more travel and a great deal more work) After a month, my hip pain has become increasing in severity, my back pain can make it nearly impossible to get out of bed, and the Valium doesn’t have any effect. I want to talk to my Doctor about either increasing the doasage or changing to something that will return my quality of life but am afraid he will assume the worst. What can I do? This medicine allows me to live!! does not give me any “euphoira” as they call it and with the stigma attached to the poor souls who are “addicts,” I am afraid he will think I am one. Please give me advice here…I cannot tolerate this much more, wouldn’t dare look to the street, or ever go against his instructions. I am terrified because without relief I could lose my job. Any suggestions? Please?

    God Bless You all…I can totally understand what you are going through.


  11. syl c. Says:

    I have had 3 surgeries one being a cervical surgery the other two back with one a failed back surgery. I take Oxy, Actiq for breakthrough pain. The Actiq is truly amazing as it acts very quickly and I am blessed to have a docor who understands that I am not an addict but a human being struggling with immense pain and depression. Without these drugs I could not do daily activities. I can’t even imagine not having them as I don’t know what I would do considering the pain I suffer. The DEA should not scare doctors into not helping people like us that really need them. You need to find a good doctor who is sympathetic and can sort out the “good” from the “bad” and that entails looking at MRI’s getting medical history to back up your needs for these powerful drugs and using them exactly as they are prescribed I would not be here today if it were not for my doctor cause I surely would have taken my life to erase the pain.

  12. Todd Says:

    “Pain patients are highly unlikely to be addicted to painkillers (opiods).”

    Where do you get this information? I hate to say this but you are absolutely wrong. Pain patients are just as likely as anyone else to became addicted to pain pills. I would say more likely than most because they will be more likely to use pain meds.

    Do you write this to make yourself feel better? If this is to help people why no tbe honest so you can help. Don’t feel peoples heads with half truths adn nonsense.

    Opiod addiction is not rare it is an almost guarantee with prolonged use of opioates.

    You describe the physical dependence fairly accurately but leave out the fact that the worse part is the psychological cravings that go hand in hand with the physical.

    I don’t mean to come across as an instigator but this is blatantly misleading at best. People please do your research addiction is a horrible nightmare and opiod is the worst kind! Sorry

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