Addiction Medicine
Understanding Opioid Dependence | Dependence vs Tolerance | About SUBOXONE
Addiction is a brain disease and a chronic behavioral health disorder that has several complex causes. The most effective and widely utilized method of treating addiction is the multidisciplinary approach.
Dr. Stuart Finkelstein has been a leader in treating addiction for over 20 years. His multi-level approach to treatment of addiction addresses each patient’s physical, psychosocial and spiritual needs. He utilizes many different methods for meeting the needs of the recovering patient. Each method is specifically designed for each individual patient. Dr. Finkelstein recognizes that chemical dependency is a medical illness that requires medical treatment.
Understanding Opioid Dependence
More and more, opioid dependence is being accepted as a chronic disease, much like high blood pressure or diabetes.
Yet unlike these other diseases, opioid dependence carries a very powerful stigma. (To illustrate: Imagine that you are interviewing for a new job. Would you think twice before asking whether the company’s health plan covers costs related to your insulin dependence? Would you also not hesitate to ask about coverage of costs related to your opioid dependence?)
This stigma is rooted in the centuries-old belief that opioid dependence is a moral failure. It was only within the last 20 years that researchers began to realize opioid dependence was a medical condition caused by changes in the brain—changes that didn’t go away, sometimes for months, after patients stopped using opioids.
Today, opioid dependence in the United States is growing at unprecedented rates. Sadly, fear of the stigma associated with treatment keeps many people from seeking help.
Removing the stigma of opioid dependence is critical to helping patients receive proper care. A key part of achieving this goal is wider recognition that opioid dependence is a medical—not a moral—issue.
The information here is offered to help promote better understanding of opioid dependence as a medical condition by exploring the prevalence, biological origins, impact on behavior, and symptoms of this disease.
Sometimes, the best way to begin correcting a problem is to step back and examine why that problem exists in the first place. Whether the person struggling with opioid dependence is you or someone you care about, understanding this disease—what causes it, what contributes to it, and why it persists—is a key to being part of the solution.
The information here is provided to help explain and make some sense of opioid dependence, so that you feel better equipped to undertake, or help someone else undertake, the necessary steps toward treatment and recovery.
The Potential for Addiction
Why Opioid Dependence Is a Disease
Role of Medicine in Treatment
The Potential for Addiction
Rewarding survival behaviors
The human brain is designed to promote behaviors it recognizes as directly linked to its survival.
Basic life functions—such as eating and sex—stimulate receptors in the brain’s “reward circuit” to release dopamine, a chemical that produces an intensely pleasurable feeling known as “euphoria.”
It doesn’t take long to learn that certain activities will be “rewarded”—that is, that they will prompt dopamine release and pleasurable sensation. This positive reinforcement is the brain’s way of encouraging behavior important for survival.
Triggers
In addition to functioning as a reward, dopamine is also the brain’s way of ensuring that the experience itself will not be easily forgotten. Dopamine release activates the areas of the brain involved in memory formation to record details about the environment where the event occurred.
Which details the brain chooses to record can range from the obvious (where the incident occurred, who was there) to the obscure (a billboard passed on the way, the temperature outside). There is no way to know ahead of time what details the brain has stored. But whatever they were, when those circumstances are encountered in the future, they will trigger memories of the good feelings produced by dopamine, and, often, a desire to recreate that experience. The technical term for these memories is “conditioned associations,” but most people familiar with opioid dependence refer to them as “triggers.”
Tricking the brain
The act of rewarding (also called reinforcing) a behavior increases the chances of its being repeated. This is why the most important behaviors to reward are those related to survival.
By coincidence, some drugs have molecular structures very similar to those of chemicals that naturally occur in the body. This similarity allows the drugs to activate the reward circuit, stimulate dopamine release, and cause euphoria.
One result of this euphoria is that drug-taking behavior is rewarded, thereby increasing the chances that the behavior will be repeated.
Another result of this reward is that the brain begins to think drug-taking is actually necessary for survival. To the brain, just the fact that an activity is rewarded at all means that activity must be important for survival.
The ability to activate the reward circuit accounts for some drugs being viewed as potentially addictive.
Opioids are among those drugs capable of activating the reward circuit to release dopamine and reinforce drug-taking behavior.
However, most people who use opioids do not become opioid-dependent. This suggests that, while the reward circuit is responsible for opioids’ addictive potential, opioid dependence most likely involves additional factors.
Why Opioid Dependence Is a Disease
Opioid dependence is a chronic brain disease caused by complex, long-term, changes in the structure and functioning of the brain. The significant changes to brain “circuitry” common to opioid dependence have led physicians to classify it as a disease that interferes with normal brain functioning (for more on this subject, see Dependence vs Tolerance).
Most brain diseases are linked to a distinct behavioral symptom—for example, Alzheimer’s disease is linked to memory loss, schizophrenia is linked to mood changes, and opioid dependence is linked to compulsive opioid use.
While a portion of opioid-dependent patients may have elected to misuse opioids at some point, this does not mean their condition is not the result of disease. Consider the following:
1. Many chronic diseases either begin or are made worse by (or both) patients’ choices—for example, decisions about diet and exercise directly contribute to such common illnesses as high blood pressure, heart disease, and diabetes.
2. Regardless of whether patients’ opioid use may have begun willingly, once opioid dependence takes hold, drug use is no longer voluntary.
3. Although opioid dependence is preceded by repeated use of higher and higher doses of opioids, opioid use is actually only one of several factors that causes this disease—opioid use will not “become” opioid dependence all by itself.
Compulsive drug use
Opioid cravings and opioid withdrawal are both very powerful drivers of drug seeking and use. However, only opioid cravings are tied to compulsive drug seeking and use. Furthermore, the intensity of cravings can drive compulsive opioid use even though a person is not physically dependent on opioids and is not experiencing any withdrawal symptoms.
Cravings also seem to be one of the last symptoms of opioid dependence to go away completely. This persistence is most likely a reflection of the time needed for the brain to heal itself and restore some degree of predisease normalcy. Opioid cravings can occur months and even years after a patient’s last opioid use. Their suddenness and intensity can put patients’ at risk for relapse.
Why opioid dependence affects behavior
In addition to the reward circuit (see Rewarding survival behaviors), the brain has other ways to help ensure its survival. For instance, in response to a threat, survival is always the brain’s No.1 priority. In a crisis, certain sections of the brain “take over.“1 This is the origin of the “fight versus flight” response as well as the drives for sex and food, among other things.
The behavioral changes seen with opioid dependence may be explained by the result of a combination of different influences. One of these factors may be the brain’s “belief” that opioids are related to survival (see Tricking the brain). Another point to take into account is that, by the time a person develops opioid dependence, his or her brain can no longer function normally without opioids.
Under these circumstances, the motivation to obtain opioids comes from 3 places:
* Physical pain and discomfort caused by withdrawal symptoms
* Increasing anxiety due to powerful, unsatisfied opioid cravings
* Stress resulting from the brain’s fear that the current lack of opioids presents a threat to its survival
Regarding this last point, even though, logically, a person may know that opioids are not essential for life, as long as those parts of the brain in charge of survival behavior still believe opioids are necessary, they may override “higher reasoning.” Furthermore, to an opioid-dependent brain, not having enough opioids to satisfy cravings or suppress withdrawal is comparable to not having enough food to satisfy hunger.
The need to obtain opioids can become more important than that person’s safety because opioid-dependence can impair the mechanism by which information from certain areas of the brain—namely, those involved with judgment and caution—is received. The brain responds by taking whatever steps are necessary to see that its opioid “hunger” is met, which usually means pursuing opioids with all the drive of a basic instinct.
Role of Medicine in Treatment
Medicine is important for managing both the short- and the long-term effects of opioid dependence. Over the short term, medicine can help to relieve the opioid cravings and withdrawal symptoms that occur when use of heroin or opioid painkillers is discontinued. Medication can also be important over the long term as well.
Typically, the changes that cause opioid dependence will not correct themselves right away, even though the opioid use has stopped.3 In fact, these changes can trigger cravings months and even years after a patient has stopped using opioids. Consequently, overcoming opioid dependence is not simply a matter of eliminating drugs of abuse from the body.
The CSAT Clinical Guidelines for the Use of Buprenorphine recommend that patients stay on medication after they have “detoxed” from their drug of abuse. This gives patients time to learn new skills that can help them cope with cravings and other triggers that might otherwise make them vulnerable to relapse.
Dependence vs Tolerance
Tolerance, physical dependence, and psychological dependence are related—but still distinct—conditions that are often confused with one another. Understanding the difference between these conditions is important because the treatment considerations can vary widely. Pain patients, in particular, may be interested to learn that the likelihood of their becoming opioid-dependent is relatively slim, even when opioid use leads to tolerance or physical dependence.
Opioid Tolerance
Physical Dependence on Opioids
Psychological Dependence on Opioids
Common Characteristics of Opioid Dependence
Opioid Tolerance
Over time, repeated use of an opioid causes certain receptors in the brain to become tolerant (ie, less responsive) to opioids—in other words, more of an opioid is needed to produce the same effect. The neurological changes that cause opioid tolerance are predictable and well understood. These changes appear to correct themselves within a period of weeks after opioid use stops. Although tolerance is one of the traits often seen in opioid-dependent patients (see Common Characteristics of Opioid Dependence), in the absence of other symptoms, tolerance is not evidence of opioid dependence or misuse.
Physical Dependence on Opioids
A physical dependence on opioids means that the brain has made so many changes in response to repeated opioid stimulation that it now actually needs opioids to function “normally.”
Pain medicine and addiction medicine specialists agree that most patients treated with opioids for long periods of time become physically dependent on them.
If opioid use suddenly stops, patients who are physically dependent will experience withdrawal symptoms. Avoiding this withdrawal is the main reason behind the drug seeking and drug use of someone who is physically dependent on opioids.
(NOTE: SUBOXONE is not indicated for pain management. Patients with a clinical need for pain management should not be transferred to a SUBOXONE regimen, even if they are physically dependent on opioids.)
The neurological changes associated with physical dependence on opioids are predictable and well understood. These changes appear to correct themselves within a period of weeks after opioid use stops.
Physical dependence on opioids almost always precedes opioid dependence (see Common Characteristics of Opioid Dependence). However, unless other symptoms of opioid dependence are present, physical dependence should not be viewed as “proof” of opioid misuse.
Psychological Dependence on Opioids
Psychological dependence involves continued drug use for reasons other than tolerance and withdrawal, such as a desire to experience a drug’s pleasurable effects. The hallmark of psychological dependence—compulsive drug seeking and use—stems in large part from intense opioid cravings caused by complex neurological changes.6
An individual is generally considered psychologically dependent when his or her opioid use continues in spite of its negative effect on the individual’s life. For example, people who are opioid-dependent feel a need to keep using opioids even if it hurts their health, job, finances, or family.
Common Characteristics of Opioid Dependence
A person who shows 3 or more of the following behaviors over a 12-month period is most likely opioid-dependent:
* Opioid tolerance
* Withdrawal symptoms occur when opioids are not used
* Taking other drugs to help relieve the withdrawal symptoms
* Taking larger amounts of opioids than planned and for longer periods of time
* Persistent desire to or unsuccessful attempts to quit
* Spending a lot of time and effort to obtain, use, and recover from opioid use
* Giving up or reducing social or recreational activities; missing work
* Continued use of opioids, regardless of negative consequences
SUBOXONE is appropriate for the treatment of people who have become physically dependent or psychologically dependent on opioids AND who are not in need of opioids for pain management. SUBOXONE is not indicated for treating pain.
About SUBOXONE
SUBOXONE is the first opioid medication approved under DATA 2000 for the treatment of opioid dependence in an office-based setting. SUBOXONE also can be dispensed for take-home use, just as any other medicine for other medical conditions.
The primary active ingredient in SUBOXONE is buprenorphine.
Because buprenorphine is a partial opioid agonist, its opioid effects are limited compared with those produced by full opioid agonists, such as oxycodone or heroin. SUBOXONE also contains naloxone, an opioid antagonist.
The naloxone in SUBOXONE is there to discourage people from dissolving the tablet and injecting it. When SUBOXONE is placed under the tongue, as directed, very little naloxone reaches the bloodstream, so what the patient feels are the effects of the buprenorphine. However, if naloxone is injected, it can cause a person dependent on a full opioid agonist to quickly go into withdrawal.
SUBOXONE at the appropriate dose may be used to:
* Reduce illicit opioid use
* Help patients stay in treatment
by
* Suppressing symptoms of opioid withdrawal
* Decreasing cravings for opioids
For more information, contact our office at 562-633-1765