A third major problem has been the lack of understanding of addiction and which persons have the greatest risk of developing addiction.
Dependence vs. Addiction
Opioid dependence develops when patients have clinical withdrawal as the dose is reduced or withheld. This is distinct from addiction, which is the compulsive, harmful, sometimes illegal use of a chemical substance.
A common misconception exists that anyone can become addicted by taking opioids. It is true that patients taking opioids for over three months do have an increased risk of developing addiction.10 Observational studies show that “of patients who receive a single opioid prescription in the emergency department, after surgery or at the dentist’s office, 1% to 6% end up using opioids for at least 12 months or being diagnosed with opioid use disorder.”11
The potential to develop addiction is neurochemical. Addiction develops when the limbic system (or the lizard brain) hijacks the brains frontal lobe. In the case of opioids (or alcohol, or other substances), the lizard brain derives such intense pleasure from the opioid stimulation that it demands more input, overriding the frontal lobe’s restraint. This is not a conscious act: the primitive brain takes over, and opioid use becomes compulsive and unrestrained.12
A prevailing assumption is that taking prescription opioids leads to heroin addiction. An analysis by the National Institute on Drug Abuse, National Institutes of Health and the FDA notes, “Available data indicate that the nonmedical [emphasis mine] use of prescription opioids is a strong risk factor for heroin use”; however, “heroin use among people who use prescription opioids for medical reasons is rare, and the transition to heroin use appears to occur at a low rate.”13
I do not make this point to excuse those with chemical dependency. We are all ultimately responsible for our actions, and if an addicted individual develops insight into their problem, it requires hard work and making good decisions to recover. The point is that only a minority of people are preprogrammed to develop addiction.20,21 It is often stated that many individuals who become addicted to illicit drugs start with prescription drugs, but it does not logically follow that all persons who take prescription opioids are at risk of becoming addicted.
So how does one know in advance that a patient is prone to develop addiction, that their brains are primed for addiction? Some situations are obvious, but in many cases it is not possible to know in advance, and therein lies the dilemma for the prescribing physician. One solution is to have, at the outset, a pain contract, which stipulates the rules for receiving opioids (or other controlled medications), and the understanding that violating the contract means the end of more prescribing. (In my experience, second chances have a very predictable negative outcome.)
