Addiction: Tolerance & Dependence
Following is managing editor Jennifer Lobb’s interview with Jennifer Schneider, MD, PhD, a pain management specialist and addiction medicine specialist. Dr. Schneider is the author of Living with Chronic Pain and numerous other books and wrote Addiction and Chronic Pain for the NPF last month.
JL: Tell me a little bit about how you became a pain specialist.
Dr. Schneider: Well, I started out as an internist in 1980 and became interested in addiction medicine about 10 years later because of family addiction problems. I then got additional training and certification by the American Society of Addiction Medicine. I was doing internal and addiction medicine and was sharing an office with a physician who specialized in pain medicine. He was one of these pioneers who was using opioids to treat chronic non-malignant pain in the early 1990s. He decided to move and asked if he could transfer his patients to me. Of course, I was freaked out like most doctors are, but he said “They’re good patients, it’s easy. All you have to do is just read the chart and keep doing what I’ve been doing.” I ended up learning from the patients, really, because these happened to be very responsible, reliable patients, so it was an education for me. I think that’s really the most effective way to convince doctors who are scared of prescribing – to actually see people who are benefiting from the treatment. And that’s what happened to me. I started getting referrals from other doctors to evaluate their pain patients, who they feared were “drug seekers,” who, in fact, were undertreated pain patients. I started getting requests to be an expert witness, so I decided that I better get some extra credentials and I became certified by the American Academy of Pain Management a couple of years ago.
JL: Let’s talk about how opioids work physiologically, in lay terms if possible.
Dr. Schneider: OK. There are receptors in the periphery and in the central nervous system that opiates bind to – mu receptors are the most important ones, but there are also delta and kappa receptors. When these receptors are occupied by opioids, they release some neuro chemicals that alleviate pain.
JL: What is the difference between physical dependence, tolerance, and addiction?
Dr. Schneider: There’s a huge difference. Physical dependence is a property of many different classes of drugs, not just drugs that can be abused. Physical dependence is a property of steroids, for example. What it means is that if a person stops that drug suddenly, there is a predictable physiologic response by the body.
For example, when you are physically dependent on exogenous steroids, meaning steroids that are outside the body in medication form like prednisone, your brain stops putting out chemicals that cause your body to release endogenous steroids, the steroids produced within your body. The pituitary gland normally puts out a hormone that stimulates the adrenal gland to produce epinephrine, which is adrenalin. When you’re on the steroid medication, the body stops producing it. What happens is, if you stop taking prednisone suddenly, your body is left without the endogenous steroids, the steroids your body usually produces. Clearly, the person has become physically dependent on the prescribed steroids and the solution to it – if they don’t need the medication any more – is to taper it slowly so that the body gets a chance to reverse those changes. Opioids also can, and usually do, cause physical dependence. The body makes changes to adapt to the opioids and if you stop suddenly, you get this unpleasant withdrawal syndrome.
That’s what physical dependence is – it has nothing to do with addiction. Addiction is not necessarily a physical thing. Addiction is a psychological phenomenon consisting of three elements. One is loss of control, which means you intend to use only so much but when you have access you keep taking the substance. The second is continuation despite significant adverse consequences, which means even if the substance – let’s say alcohol – is causing liver damage, you’re arrested for a DUI, or are fired from your job, you still take it. In fact, one of the major differences between chronic pain patients and addicts is that the opioids expand the life of the pain patient. They make things better – they improve the patient’s functioning and pain whereas with the addict, their life constricts and they become more and more focused on the drug that they are misusing. So you have the opposite effect, and that’s what I’m talking about when I say addicts continue to use it despite adverse consequences. Pain patients on prescribed opioids rarely have adverse consequences – they may have side effects from opioids but they don’t have these types of adverse consequences (eg, loss of a job, organ damage). The third element of addiction is the preoccupation or obsession with obtaining, using, and recovering from the effects of the drug.
Tolerance is the need for more to get the same effect. Tolerance is a big issue in prescribing opioids. Everyone knows that drug addicts have to keep increasing their dose to get a high. What most people don’t know is that tolerance to the different effects of opioids differs. What I’m saying is there are generally four effects of opioids on the body. Three of them we call side effects and these are sedation, nausea and constipation. The fourth effect is the desired one – pain relief. So opioids have four effects. It turns out that you develop tolerance – meaning that you get less effect as you continue the same dose or that you need more medication to get the same effect – to two out of those four effects: sedation and nausea. Doctors realize you don’t develop much tolerance to constipation and that patients taking opioids have to be on a bowel program. But, what most doctors and patients do not realize is that you don’t develop much tolerance to the pain-relieving effects of opioids. What happens – when it comes to pain relief – is that most patients, once they’ve reached an effective dose, stay on the same dose for a long time. Sometimes they need a little upward increase but it’s not a significant thing. The usual reasons that a chronic pain patient needs a dose increase is either that they’re doing more physical activities, or that their disease has progressed.
So why is it that heroin addicts need more and more? The reason is because tolerance develops very, very quickly to the euphoria-producing effects of the drug. What causes a buzz from a drug is not the concentration in the blood stream. For example, you can have pain patients who have a little bit of the drug in their body and other pain patients who have a very high level in their blood in order to get pain relief, but neither of these people are likely to experience a buzz. What causes a buzz is the rate of increase – rate of change – in the brain. People develop a tolerance very rapidly to this. So anytime somebody says, “Isn’t true that people become tolerant to opioids?” the answer has got to be, “What do you mean by tolerance? What specific effect of the opioids are you asking about?” That’s a really important point. You don’t just develop tolerance or not develop tolerance. It’s a widespread misunderstanding.
JL: Why is there such a stigma surrounding opioids?
Dr. Schneider: The Diagnostic and Statistical Manual of Mental Disorders provides definitions of various psychiatric disorders, including drug dependency. The thing that’s really confusing is that previous editions of this book talked about addiction, like drug addiction. But the psychiatrists, in their wisdom, decided that addiction was a bad word and they took it out of the book and substituted the word dependency.
JL: So it creates confusion with physical dependence. . .
Dr. Schneider: Exactly. So now, when you open the DSM-IV and you read about dependency, they’re talking about addiction – they are not talking about physical dependency. It’s created a huge confusion that is so immense that most doctors misunderstand this.
Part of the stigma is related to this incredible confusion. When I’m giving a talk to doctors, I start out with a true-false quiz, you know, to get their attention because most people sleep through talks [laughs]. Anyway, the first question I ask is, “True or false: Most patients who are on opioids for more than a short period of time and more than minimum doses become addicted.” I’d say 95% of the audience usually says that’s true. And of course, the right answer is that it’s false.
JL: That’s frightening.
Dr. Schneider: Well, it is frightening. And it shows you the huge confusion in the medical community. Obviously, patients are just as confused, as are journalists who are writing these scary articles in the newspapers about opioids and how you can become addicted.
Let me just put my two cents in about celebrities who blame their doctors, you know the ones who say, “My doctor made me addicted because I saw him for pain and he gave me these medications.” In some of these cases, these people had been treated for chemical dependency in the past. These are not people who don’t have risk factors and some of them undoubtedly should never have been put on some of these medications in the first place because of their history. What I’m saying is, most of these celebrities who say their doctors got them addicted are not exactly telling you what really went on but it certainly makes an impression on the public in thinking how easy it is to get addicted.
JL: What are some of the psychological factors that may cause a person to abuse medications? What makes someone more at risk for developing addiction?
Dr. Schneider: The biggest one is a history of addiction. If they themselves have had a drug addiction in their past and if they’ve been through treatment or are in recovery from drug addiction, they’re definitely more at risk psychologically and they’re probably more at risk physically because sometimes addiction causes brain changes that are fairly permanent.
A family history is a risk factor for two reasons. First of all, there are genetic predispositions to addiction that are very well established with alcohol addiction, less so with some of the others, but most addiction specialists think that there’s a tendency for vulnerability to all drug addictions to be genetic. The second thing is that growing up in a dysfunctional family creates some psychological vulnerabilities. In other words, if you grow up in an alcoholic family, you not only have the genetic predisposition, but you also have grown up in chaos and dysfunction. The thing about an addict is that the addiction is the number one thing in his or her life – more important than being a parent, so kids in this situation aren’t going to have the nurturing and attention they need.
People who’ve had psychological trauma in their lives are more vulnerable to addiction. I’ll give you an example of that related to Vietnam. The government thought it would be treating huge numbers of veterans coming back from Vietnam for drug addiction because so many of them used drugs while they were there. What they found out was that only a small proportion of them continued to use drugs when they got back to the US and were addicted. The others, when they got back to their regular lives, they stopped. Their use was situational – they were there in Vietnam, the situation was terrible, the drugs provided a great escape, but when they got back to the real world, they stopped. The question is, why did some continue to use and others didn’t? It turns out that the ones who continued to use were the ones who had vulnerabilities to begin with – people who had dysfunctional families, chaos in their lives, genetic predispositions.
When you’re talking about treating people with prescription medications, you’re going to have people who have this predisposition and have those who don’t – most of them don’t.
There’s also a matter of the support system people have. There was a small study done by Dunbar and Katz of 20 patients with a personal history of drug or alcohol addiction who were treated with opioids for some chronic non-cancer pain problem. They found that 12 did well and eight got back into addiction. When they looked at the reasons, the authors found out that the people who got back into uncontrolled use of the drug where those who, first of all, in the past were addicted to narcotics and not to alcohol, or else to multiple drugs; second, they were not involved in addiction recovery activities, like Alcoholics Anonymous; and third, they tended to have less family support and a less stable lifestyle. If you’re talking about someone who’s seriously involved in Alcoholics Anonymous, who has a job and a family, that person has a lot lower risk.
JL: Can a person who has had an addiction be treated with opioids?
Dr. Schneider: Yes, definitely. But it depends. It depends on exactly these things I just talked about. I’ve treated people with opioids for pain who have had an addiction history, but the first thing I do is ask about their history – how long ago was the addiction? If it was 30 years ago rather than one year ago, well, that’s going to make a big difference. What, in terms of recovery activities, are they involved with? Their lifestyle – are these people who have family support or are they living alone? The other thing is, when I treat anyone with an addiction background, I first of all make sure I’m aware of the addiction and if I do decide to treat him or her, I make sure that they have structure around them.
In other words, if they’re involved in recovery work, they need to have a sponsor and they need to make sure that their sponsor is aware that they are being treated with opioids for chronic pain and that their sponsor is supportive of the treatment. They need to talk about it. I tend to be less willing to give them breakthrough pain medications because the short-acting opioids cause more euphoria because they get into the brain faster. Anybody I have the slightest concern about, I’m not going to put him or her on a drug for breakthrough pain. In fact, I am more likely to use a drug like Duragesic, which is a two- or three-day fentanyl patch, so they don’t have to think about taking pills often. In other words, you don’t want them to be thinking about their next dose all day. My goal in treating all chronic pain patients is to have them think about their chronic pain meds the same way they think about their blood pressure medications. We just take them in the morning and evening and then we don’t think about it anymore. I want them to just be treating yet another medical problem with some medication that they take and not think about it.
I also do more urine drug screens on people with an addiction background. I don’t test everyone – it’s on a case-by-case basis, but I build more structure around them. For example, I had a guy who came in for back pain and when I did the urine drug screen, it came back positive for cocaine. I told him that if I was going to treat him, he was going to have to get his cocaine addiction treated. And he did – he started going to a recovery group and I kept getting urine drug screens on him to make sure there wasn’t any cocaine and to show him that I was serious. You have to build motivation for people to change. Change is hard for anybody – I mean, look at losing weight – most overweight people can give a lecture on how to lose weight, but it’s hard to actually follow their own advice. I told him, “If cocaine shows up in your urine again, I’m not going to prescribe for you.” So, in that way, I gave him incentive to get involved. He eventually became self-motivated.
It’s very tricky though. If a pain patient has an addiction background and looks like they are at risk, I wouldn’t recommend that anyone who doesn’t have both an addiction background and a pain background treat them with opioids.
JL: What credentials or experience should a patient who had a previous addiction look for in a physician? How do they find a physician like you who has the background in both?
Dr. Schneider: Well, it’s difficult. They need to find someone who’s a pain management doctor who’s going to be sympathetic to pain issues who is also knowledgeable about addiction. They’re not that common.
JL: Is there an organization they can look into?
Dr. Schneider: There’s the American Society of Addiction Medicine, with more than 3,000 addiction medicine doctors. You can look them up on the Internet at www.asam.org. The problem is some of them are very much against using opioids for chronic pain, but there is a minority in the organization that truly understands. ASAM has a special pain and chemical dependency committee, of which I’m a part, of doctors who are very knowledgeable in both areas. It is possible to find someone – start out with a pain specialist. Sometimes the pain specialist can refer the patient to an addiction specialist to get an opinion on his or her situation. That’s another way to go.
JL: What can patients do to help their families understand how and why these opioids may be appropriate for them?
Dr. Schneider: This is a big problem for pain patients. Sometimes I have patients coming to see me specifically to get off the opioids. Naturally, these are exactly the people who have never abused drugs; they’re the opposite of people who I agree should be off opioids. My first question when somebody comes in and their specific agenda is getting off the morphine that they take for chronic pain is, “Why? Why do you want to get off it?” And along with that, I ask, “Is the medicine helping you? If the medicine is helping, why do you want to get off of it?”
Do you know what most of them tell me? Not because it’s giving them side effects. Why do you think they want to get off of it?
JL: Because their family wants them to?
Dr. Schneider: Exactly. They’re are getting heat from their friends and family – they hear things like “You’re an addict,” and “If you’re not, you will be,” and “This is terrible.” The patients feel stigmatized. That’s the main reason they want to stop taking opioids.
When I find out that it’s their family, I ask them “What’s your plan for dealing with your pain after you stop taking these medications?” and, you know, they never have a plan. They just don’t want to take the heat from their family anymore. What I usually do is explain to them about the difference between addiction and physical dependence, which of course their families don’t understand and the patients don’t either, I give them an article on my web site (www.jenniferschneider.com) that I wrote for a case management journal that explains a lot of this and is fairly easy to understand, and I suggest that they bring their family member in with them because the family member is never going to listen to the patient. What’s going to happen is that the patient will go home and say, “The doctor said I should stay on because….” and the family member isn’t going to buy it. They’ll think the patient is just hearing what they want to hear, so it’s better if the family member hears it directly from me. This is a big issue. If a spouse is very opposed to having his wife or her husband being treated with opioids, I will not prescribe unless the spouse comes in and we can get the situation worked out.