When choosing to take opioids for chronic pain, how can you prevent becoming addicted to them?
Does it mean I am addicted to opioids if I get sick when I stop them?
Is it inevitable that I will become addicted to opioids if I continue to take them regularly for a long time?
By the way, just what exactly is addiction?
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Integrative, CAM Approaches to Addiction Prevention:
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Opioid Addiction – What is it and How Does One Prevent It?
When addressing the prevention of opioid addiction in patients prescribed opioids for chronic pain, it becomes immediately evident that this is not a topic commonly considered or discussed. Rather, the emphasis in the medical community has been focused instead on identifying those patients who abuse opioids or who may already be addicted. But with the growing public concern over the “opioid epidemic” currently being fanned by politicized rhetoric, there is also a growing fear of opioids and their risk for addiction.
For those people with chronic pain who are unable to meet their pain management needs with non-opioid management, turning to opioids may be accompanied by not just the fear of becoming addicted but also the fear of being perceived as a drug addict by others. These fears can be magnified by concerns of friends and family who often lack knowledge of opioids and the management of chronic pain.
Like all fears, the fear of opioid addiction can be dispelled with the proper education and understanding of addiction, how and why it occurs and how to avoid it. It is therefore important to understand what opioid addiction really is and what distinguishes it from opioid use for chronic pain – especially when opioid use for chronic pain may be associated with physical dependence and withdrawal symptoms when opioids are suddenly discontinued.
So to begin with, what is opioid addiction not?
Opioid addiction is NOT defined by the presence of opioid dependence and withdrawal. Opioid dependence and withdrawal co-define one another. Dependence on opioids or other medications occurs when taking the medication over time results in neurologic adaptations to the continued presence of that medication, which in turn result in symptoms when the medication is withdrawn suddenly. The symptoms associated with this withdrawal of the medication are defined as withdrawal symptoms. These neural adaptations are normal and represent the nervous system’s adjustment to the medication. In fact, these adaptations generally result in improved safety associated with continued use of the medication. Dependency and withdrawal are frequently associated with various classes of medications including those used for treatment of anxiety, depression, insomnia and high blood pressure, in addition to those used to treat pain.
It is a common misconception in both the medical community and the public that dependency and withdrawal define addiction. They do not. Furthermore, while dependency and withdrawal symptoms may worsen with higher doses or extended use of opioids or other drugs, duration of use neither defines addiction nor does it represent an increased risk for addiction.
To understand addiction, one must first define addiction. The understanding of addiction has evolved significantly over the last two decades and recently led to a new definition as published in 2011 by the American Society of Addiction Medicine (ASAM), the authoritative U.S. society of physicians specializing in treating addictions:
The short definition of addiction:
“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
For the long definition of addiction, see: ASAM Definition of Addiction
Opioid Addiction Criteria:
__ Continuing to use opioids despite negative personal consequences from their use
__ Repeatedly unable to carry out major obligations at work, school, or home due to opioid use
__ Recurrent inappropriate use of opioids in physically hazardous situations
__ Continued use despite persistent or recurring social or interpersonal problems caused or made worse by opioid use
__ Tolerance as defined by a need for markedly increased amounts to achieve intoxication or get high
__ Using greater amounts of opioids or using over a longer time period than intended
__ Persistent desire to use opioids and/or unsuccessful efforts to cut down or control opioid use
__ Spending a lot of time obtaining, using, or recovering from the effects of using opioids
__ Stopping or reducing important social, occupational, or recreational activities in order to use to opioids
__ Persistent use of opioids despite acknowledgment of persistent or recurrent physical or psychological problems that are a result of using opioids
__ Craving or a strong desire to use opioids
How does addiction differ from drug abuse and misuse?
Medication Abuse and Misuse
These two terms are widely used, yet their definitions are as varied as there are individuals using them. The unfortunate consequence of this is a grave lack of understanding regarding their incidence, risks and consequences. Whenever reading an article or publication about opioid abuse or misuse, identify the specific definition the author uses to define substance “abuse” or “misuse” to better understand how meaningful the author’s statements or conclusions are.
For the purposes of this web site, and statements attributed to Dr. Ehlenberger, the following definitions apply:
“Medication Abuse” is defined as the use of a drug for purposes other than as indicated or prescribed. “Purposes other than as indicated or prescribed” include using a medication such as a pain medication for sleep, anxiety, to improve mood or to get high, rather than strictly to relieve pain.
“Medication Misuse” is defined as the use of a drug for purposes as indicated or prescribed, but at doses other than as indicated or prescribed. For example, taking a pain medication 5 or 6 times/day for pain when prescribed only 4 times/day for pain would be considered “misuse.” Medication misuse also includes taking a prescription medication as previously or routinely prescribed, but without a current prescription.
What is the basis, or root cause, of addiction?
ASAM’s new “Definition of Addiction” shifts away from focusing on the psychological element of addiction to redefining addiction as a neurological disorder and an imbalance in the brain’s “reward circuitry,” referred to as ‘Reward Deficiency Syndrome’ (RDS). While earlier descriptions of addiction placed the burden of addiction on “weakness of will” and other personality “deficits,” we now understand that the nature of addiction lies in disrupted or compromised neural processes.
“Reward Deficiency Syndrome (RDS),” a term first coined by Ken Blum in 1995, can now be defined as “A brain reward genetic dissatisfaction or impairment that results in aberrant pleasure seeking behavior that includes cigarette smoking, other addictive drugs, excessive eating, sex, gaming/gambling and other behaviors.”
These other behaviors include disorders such as binge eating, OCD, ADHD, Tics, Tourette Syndrome, autism, Asperger Syndrome, “perverted” sexual practices and others. The relationships of these disorders becomes apparent with the understanding of the common genetic and neurochemical factors underlying them.
The basis of RDS theory is that humans are reward-driven creatures and that hehavior is heavily influenced ty the reward associated with that behavior. Hunger drive is driven by the reward of feeling satiated or full after eating. Sexual drive is driven by completion of the sexual act. Emotional drives are driven by the emotional reward of expressing the emotion, be it anger or passion. When an individual experiences chronic or extremely stressful emotional or psychiatric disruptions to their psychological well-being, they become “reward deficient,” manifest by imbalance in the reward center of the brain, the nucleus accumens (NAc). This imbalance is believed to be characterized by an insufficincy of dopamine in this part of the brain.
Associated with this new definition and understanding of addiction is a major paradigm shift in our approaches to prevention and treatment.
For more information on RDS, see: Reward Deficiency Syndrome (RDS)
Understanding Risks for Developing Opioid Addiction
The prevention of addiction begins with understanding why some people develop addictions and others don’t. The risk for addiction is broadly believed to be about 50% genetic, or inherited, and about 50% environmental, or based on a person’s experiences and life circumstances. It is believed that both genetic and environmental risks are based on the shared result of inadequate dopamine balance in the reward center of the brain.
Genetic Risk for Addiction
Over the last 20 years a number of genes have been identified as being associated with increased risk for the development of addiction. These genes are passed from parents to children, so if one’s parents or siblings have developed addictions, an individual may share the same addiction-risk genes and be more likely to be susceptible to addiction. Genetic-associated risk for developing addiction is best understood in context of the Reward Deficiency Syndrom(RDS), in which genetic DNA variants predispose an individual to be less able to maintain adequate levels of dopamine in the reward center of the brain,.
Individual genetic testing is now available that helps identify a person’s genetic risk for developing RDS. The genes tested identify those individuals who may be compromised in their ability to manufacture dopamine or those whose metabolism breaks down dopamine too rapidly – either of which may lead to inadequate dopamine levels and RDS. Other genes affect how many dopamine receptors are manufactured in the brain, leaving some people with insufficient numbers of receptors to maintain dopamine activity that leads to RDS. Understanding genetic risk provides insights to ways of overcoming an individual’s predisposition to dopamine deficiency and RDS through the use of nutriceuticals to aid in improving dopamine balance.
Environmental Risk for Addiction
Leaving aside for the moment that their may also be a genetic predisposition to psychiatric disorders, the presence of major life stressors including severe anxiety, depression, bipolar disorder and PTSD may be both manifestations of RDS or contributors to the risk of RDS. In either case, treating these underlying conditions is an important means of preventing addiction by reducing the risk or severity of RDS. In addition to treatment specifically directed at the psychiatric disorder, treatment directed at RDS should also be engaged.
Prevention of Opioid Addiction – Identifying an Individual’s Risks
Identifying an individual’s personal risks is the first step in preventing opioid addiction. While genetic testing is a valuable tool when available, the cost of genetic testing is not yet covered by insurance in most cases and can therefore be prohibitive. But simply identifying an individual’s family history of addiction, including tobacco addiction, suggests the potential for increased genetic risk. There does appear to be a basis for chemical-specific risk for addiction in that a family history of alcoholism may more likely predict the development of alcholism than opioid addiction. Of interest also is that there appears to be a genetic role in the response to addiction treatment. For example, if an individual’s family member favorably responds to a medication treatment for stopping smoking, the individual has an increased likelihood of a favorable response to the same medication.
Opioid Response Risk
How a person responds to opioids can identify increased individual risk for opioid addiction. Most people simply experience a reduction of pain and the relief that goes with this pain reduction when taking an opioid. Studies indicate, however, that when a person experiences a sense of feeling energized when taking an opioid, statistically that person is more likely to develop an opioid addiction compared with those who don’t. Also, those people who feel a lifting of spirit or enhancement of mood when taking an opioid may be at increased risk for developing opioid addiction.
While these experiences per se do not dictate a path to addiction, the risk for addiction is particularly high in those whose motivation to take an opioid is based on achieving the experience of feeling energized or having their mood enhanced. The caveat here is to understand that it is important to limit one’s use for taking an opioid to the relief of pain only. Chasing these other experiences with opioids is highly risky and, when recognized, should be brought to the attention of the opioid prescriber. Changing to another opioid may reduce this risk. Sometimes these experiences are transient and fade away with continued use of the opioid.
Reward Deficiency Syndrome (RDS) Risk
Based on RDS theory, any increased risk for RDS may also be associated with increased risk for opioid addiction. Since RDS has genetic predisposition, assessing for personal or family history of RDS-related syndromes will help identify increased risk for opioid addiction. An individual with an identified RDS-related syndrome such as ADD, PTSD, OCD, anger disorder or others (see RDS) would be at greater risk for developing opioid addiction if the RDS-related syndrome is symptomatic and untreated or inadequately treated. Reduction of risk would be enhanced by treatment of the RDS-related syndrome.
Aside from specific syndromes or diagnoses associated with underlying RDS, any condition or circumstance that creates significant stress and/or disharmony in one’s life leads to a reduction in the balance of the reward areas of the brain. Thus a person becomes at greater risk for developing opioid addiction when times are stressful, particularly extreme life stressors such as death of a spouse or family member, loss of employment or one’s home and impaired health. While these risks may be obvious, responding to these risks may not be straight forward since reversing or overcoming these circumstances may not be possible. What is possible, however, is directing treatment at improving balance in the reward centers through dopamine enhancement techniques that may reduce risk of addiction in the face of stressful circumstances.
Treating “Reward Deficiency” as a Means of Preventing Opioid Addiction
Conceptually, “Reward Deficiency” may apply to any condition that results in a reduced sense of fullfilment in one’s life, a lack of contentment or a disruption in one’s satisfaction of existence. It may manifest in times of stress or be associated with many of the syndromes or conditions discussed above. It is important to realize that an individual may not recognize or be at all aware of their reward deficiency condition. It may only become apparent when this individual is exposed to a drug, chemical or behavior that triggers a substantial increase or spike in their dopamine levels which is associated with significant feelings of extraordinary well-being.
How these feelings of extraordinary well-being are experienced are different from one individual to another. For some it is a “high,” for others it is like “wow, now I know what it is like to feel normal.” However, the individual experiences the dopamine spike, it becomes a very powerful reward that results in an extraordinarily strong drive to achieve. Although it may manifest in much more subtle ways, this is how addiction starts and it may not at first be obvious to the person experiencing it.
The natural consequence of the reward deficiency condition is a drive to enhance pleasure either chemically or behaviorally. What makes drugs addictive is their capacity to make a person feel good and experience pleasure, which makes an individual with reward deficiency susceptible to a natural drive to use these drugs. On a neurochemical level, addictive drugs all increase dopamine in the reward center.
The basis of addiction prevention is to eliminate or reduce conditions that drive or motivate addictive behaviors. On the basis of RDS theory, it is the neurochemical imbalance of dopamine that contributes to the drive to addictive behaviors. Therefore addiction prevention focuses on medications, nutriceutical supplements and behaviors that can enhance dopamine levels and reduce dopamine deficiency-related drives toward addiction.
Reducing Neurochemical Drives
Based on the dopamine deficiency basis of addictive risk, use of nutriceuticals that may increase dopamine levels in the brain offer potential benefits for stabilizing reward deficiency. Synaptamine, a supplement composed of multiple ingredients that have been shown to enhance dopamine levels in the brain, has excellent research evidence to support it’s effectiveness. Supplementing with Synaptamine, especially during times of stress such as when pain is inadequately controlled may be very effective.
For more information, see SynaptaGenX
Complementary and Alternative Medical (CAM) Options
While the multiple ingredients in Synaptamine likely have a synergistic benefit when taken all together, the individual components can be selectively taken to target specific mechanisms of increasing dopamine levels based on individualized needs.
See Passion Flower
See COMT Inhibitors
CAM treatment options include diet and nutritional supplements directed at increasing dopamine levels in the brain areas associated with RDS.
See Dopamine Diet
Reducing Psychological Drives
Motivators for Opioid Use
As noted above, limiting one’s motivation for use of opioids to pain relief only is of major importance in avoiding the path to opioid addiction. Reaching for opioids when “having a bad day,” to improve one’s mood or to enhance one’s energy level should be strictly avoided.
Opioid management for pain is directed at improving quality of life and enhancing activities of daily living by reducing pain enough to allow a person to function adequately. The goal of opioid management for pain is NOT to eliminate pain because this is an unrealistic goal and is likely to lead to higher and higher doses and a potential greater risk for abuse or addiction.
Behavioral Means of Dopamine Enhancement
There are many activities that have been shown to reduce addiction risk including pet therapy, yoga, meditation and other mindful exercises as well as simple measures to enhance reward experience. It is Dr. Ehlenberger’s strong recommendation that individuals with chronic pain spend at least 30 minutes every day in an activity that both requires their complete attention to the exclusion of all else and that is fun and/or enjoyable. This dedicated activity will result in a reduction in the suffering associated with chronic pain as well as an enhancement of reward balance in the brain, thus reducing the risk of addiction. It is a win-win.
General measures for reducing addiction risk includes the adequate management of chronic pain, adequate sleep, management of stress, anxiety and depression as well as maintenance of general physical well-being. Although somewhat obvious, it is also advised to avoid the company of those with drug abuse or addictive behaviors. Immersing one’s self in the world of others who abuse drugs or medications has a tendency to reset one’s sense of normalcy in a potentially harmful direction. Beware of impulsive behaviors in these circumstances, especially when drinking alcohol which impairs one’s judgement and leads to regrettable behaviors.
At Accurate Clinic we work with our patients to address chronic pain and addiction prevention by providing training in Cognitive Behavior Therapy (CBT), “mindful exercises” such as meditation and yoga, and self-hypnosis techniques. “The mind is a powerful thing” and one can be trained in using the mind to achieve great rewards.
See Using the Mind
Opiate Addiction Education
Addiction – Understanding Why
Addiction – Understanding Addiction Risk
- Imbalanced Decision Hierarchy in Addicts Emerging from Drug-Hijacked Dopamine Spiraling Circuit – 2013
Addiction – Treating Pain
- Use of conventional, complementary, and alternative treatments for pain among individuals seeking primary care treatment with buprenorphine-naloxone – 2012
- Characterizing Pain and Associated Coping Strategies in Methadone and Buprenorphine Maintained Patients – 2015
Emphasis on Education
Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.
For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.
Should you wish more information regarding any of the subjects listed – or not listed – here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.
For more information, please contact Accurate Clinic.
Supplements recommended by Dr. Ehlenberger may be purchased commercially online or at Accurate Clinic.
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