I don’t think anyone is saying that people who take opiates for pain don’t get addicted–just that the addiction comes from the craving for the pleasurable feeling. If a chronic pain patient is required to take opioids long-term, and maintains the same level as prescribed, yes, there will be withdrawal symptoms if they stop. But that is not addiction. Addiction is when a patient (or anyone) has a pleasurable reaction and then starts to consume the drug for that, rather than for just the pain, and then ends up wanting more and more of the drug. Those receptors that allow a person to be at ease lose the capacity to fire off under natural conditions, and only the drug can fill that void.
A person who doesn’t enjoy the effect of alcohol is not just less likely to become an alcoholic–they will never become an alcoholic. Even if someone were to force them to ingest it for years, while they would have physical withdrawals after stopping, they would stay stopped as long as the experience had never been enjoyable. If the drug doesn’t hit those key receptors for a person, they won’t come to crave it.
People knew well over 100 years ago that sometimes patients get addicted accidentally.
In the 1870s, a gentleman by the name E. P. Roe wrote a novel about a man who was hospitalized after an accident, and while in the hospital got addicted to morphine.
I’m not sure either of those two things are true. For example, people (typically East Asians) with certain variants of the ADH and ALDH genes causing a buildup of acetaldehyde levels experience facial flushing and nausea when drinking. So drinking even small amounts of alcohol can be unpleasant for them. This is protective against alcoholism, but does not prevent it. This paper way back in 1983 found that 40% of Japanese people had ALDH isozyme I deficiency (a proxy for one of the ALDH genetic variants), but only 2.3% of alcoholics had it. Other research suggests the risk of alcoholism for people with these genetic variances is 1/2 to 1/8 the risk for people who don’t have it.
That is a big protective factor, but some people get alcoholism even when drinking makes them sick. I guess you can argue that they must be getting some pleasure out of drinking, or why would they bother, and that might be true.
Typically with opiates people develop a tolerance, and often any pleasurable feelings from the drug disappear, but the addiction remains. People addicted still crave opiates and suffer without them, even though they no longer are getting any pleasure from them. They are likely to increase the dosage in an attempt to recreate the euphoria from earlier in their usage. These increased dosages are one cause of overdoses.
On the other hand, there are drugs like marijuana which is not physically addicting in most people (there is no withdrawal when use stops). Many people enjoy using it, but are also able to abstain for long periods of time with no ill effects. It is an activity they enjoy, but not something they crave and are compelled to seek out. Certainly there are some people who do have drug abuse problems related to marijuana, but most users do not.
Yes. And the interesting thing to me is, how significant is this group? Experimenting with drugs is one thing. Taking a prescribed course of medication for pain relief, using the drug properly and, at the end of treatment finding yourself addicted is quite another.
Most heroin addicts started off by abusing prescription opioids (this Prescription opioid use is a risk factor for heroin use | National Institute on Drug Abuse (NIDA) for example), so we know that prescription opioids are typically involved, but papers like this typically talk about “abuse” of them, and so we don’t know about the addicted non-abusers. Are these people simply lumped in (for statistical analysis) with others who we might describe as “true abusers”?
I tried digging about (and I’m quite good - that sort of research was once part of my job) and data is remarkably elusive - all the more remarkable because you would have thought that Joe the good citizen, surprised to find himself addicted as a result of proper use of medication, would be the one who was likely to head straight back to the doctor and report the problem. This is data that should be readily available.
I’ll try a bit more digging when I get a chance.
j
PS - nothing about this is intended to be pejorative, that’s not how I’m using the term abuse/abuser. So don’t yell at me.
My daughter is 19 and had her wisdom teeth pulled last Spring. She got four vicodin and a “use 3 OTC ibuprofen when these are done until the swelling subsides.”
Mostly it’s a point of definitions. Drug abuse is defined as using a drug in a way that causes problems. Operationally on surveys like this a subject will be classified as abusing a drug when they have endorsed a certain number of items.
The questions asked will typically be things like:
[ul]
[li]Have you ever taken an opiate that was not prescribed to you[/li][li]Have you ever taken more opiates than were prescribed to you[/li][li]Have you ever tricked a doctor into giving you a prescription[/li][li]Have you ever stolen pills[/li][li]Have you ever gotten in trouble with the law for using opiates[/li][li]Have you ever missed work because you used opiates[/li][/ul]
So anybody who becomes addicted and is craving the drug is probably going to endorse enough of those items to be classified as an abuser.
I’m not an expert on opiate addiction, but I think it may be a substance where there is no such thing as an addicted non-abuser, because in order to maintain an addiction, somebody will have to be acquiring the drug someway other than an appropriate prescription or using illegal alternatives. Contrast to something like nicotine. Almost all users are addicted, but nobody refers to it as nicotine abuse, because it doesn’t cause inebriation or have the consequences associated with opiate or alcohol abuse.
Checking back in with the results of further research.
TL;DR Conclusion: not much has been published.
More detail: This review/meta-analysis:
Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety?
Igor Kissin J Pain Res. 2013; 6: 513–529. (Published online 2013 Jul 4. doi: [10.2147/JPR.S47182])
kinda confirms what I had been thinking.
The results on the editorials related to addiction in chronic nonmalignant pain patients are presented in Table 4. There were no editorials on this topic in 1983–1992, one in 1993–2002, and four in 2003–2012. For the same period, editorials on opioid addiction in general (the right side of Table 4) were numerous (171 from 2003–2012).
That is to say, as of 5 years ago, historically not so much had been done on rates of addiction as a result of pain management. That’s before we even get onto the issue of whether non-abusing patients get accidentally addicted. (Yes, I do realise this is based on counting editorials)
Of the papers referenced, one looks interesting albeit decades old:
Drug abuse, dependence, and addiction in chronic pain patients.
Fishbain DA, Rosomoff HL, Rosomoff RS. Clin J Pain. 1992 Jun;8(2):77-85.
It is concluded that these diagnoses [addiction etc] occur in a significant percentage of chronic pain patients. However, there is little evidence in these studies that addictive behaviors are common within the chronic pain population.
I’m not quite sure what this means, but it could be that it addresses the question in the OP. You seem to be able to get the paper through Researchgate; not something I’m familiar with (shocking confession: professionally I would just say to someone, could you get that for me please?) but reading the Wikipedia article on Researchgate, I thought I’d leave that step to someone with actual experience of it.
Other reading: CDC Guideline for Prescribing Opioids for Chronic Pain— United States, 2016 Deborah Dowell, MD, MPH; Tamara M. Haegerich, PhD; Roger Chou, MD
Mmm - you may be right. Or at least nobody much seems interested in making the distinction between an addicted non-abuser and an addicted abuser. If you had to guess why…
What you said; or
Very small numbers of addicted non-abusers; or
The focus is almost entirely on treatment (which may be bound up with the above); or
The definitions (addicted non-abuser and addicted abuser) are too complex to apply in a meaningful manner - which is also kinda what you said; or
Because the individual accounts of how a patient became addicted are just not being trusted; or
And of course it’s the working class/middle class/poor that get punished for this. Pharmaceutical companies made false claims and doctors believed them. So now lots of regular folk are not only hooked on drugs but being punished for it by laws restricting their access instead of laws to help them get proper physical and mental health care to help them get off narcotics and hopefully stay off/manage their addiction. That’s what this country does.
It’s important to note that opioid addiction is not how the general public conceives of it. Most people think of addiction as just a craving to get high, something along the lines of what might happen when quitting smoking. But it’s much more insidious than that, opioid withdrawal might not even involve craving at all, the main thing is that it makes one feel sick, often like one is dying, with crippling suicidal depression. Many continue to use not to feel high at all but simply not to be in agony. That said, maintenance solutions now exist that are much better than used to exist, so it doesn’t have to be the desperate situation it used to be. Still for some reason, despite knowing the dangers, new and ridiculously more powerful opiates continue to be brought to market.
I dislike linking to magazine articles instead of the actual scientific literature, but I haven’t had time to click through and read yet.
While the majority of abusers may start with prescription pills, it appears they’re typically not pill prescribed to the abuser: Prescribed Painkillers Didn’t Cause the Opioid Crisis
(This was about the statement: Most heroin addicts started off by abusing prescription opioids)
Assuming this is true… - well, the specimen ref I provided (post #25), which seemed fairly typical of what I was seeing, is a US National Institute on Drug Abuse publication. So I hope it’s reliable.
…were they prescribed by a physician? Or were they purchased off the streets? In post #25 I was talking about about how most heroin addicts started off by abusing prescription opioids. Taking up this question, I haven’t been able to make the link all the way back from heroin addiction to source of prescription opioids, but this:
Understanding the Rural–Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United States
Katherine M. Keyes, PhD, Magdalena Cerdá, DrPH, Joanne E. Brady, SM, Jennifer R. Havens, PhD, and Sandro Galea, MD, DrPH
American Journal of Public Health, 104(2). E52-E59
states:
Studies indicate that the large majority of adults who use opioids nonmedically obtain them from friends and relatives or from street-level dealers
for which there are six supportive references, which I haven’t looked at. If most heroin addicts start on prescription opiates and most prescription opiate abusers were not prescribed the drugs then I’m happy to conclude that it’s likely that most, or at least many, heroin addicts started on someone else’s prescribed opiates. So I haven’t quite answered your question, but pretty close - yes?
As I noted before, we’re in a field where data is remarkably elusive - and given how many publications address the Prescription Opioid Epidemic, I’m not sure why that is.
This is my guess, based on working with related studies and data, but I can’t point to anything that says my guess is conclusively true.
In order for data to be collected, somebody has to fund the studies, and in the US that is probably NIH, NIMH, and NIDA. There is always a delay between a problem starting, being recognized, and funding becoming available to study it. Once studies are started, it can take a few years to get useful conclusions.
There is also going to be a delay in researchers adding the appropriate questions to their studies not specifically focused on opiate abuse. Thinking back over the drug related questions asked of subjects in studies from the 90s and 00s, they might not even ask about prescription drug abuse. The closest might be a question about heroin and other opiates, which doesn’t distinguish between the different forms. Or something simple like, have you ever taken prescription medicine in a way other than prescribed, which doesn’t distinguish between opiates, amphetamines, or other abusable prescription drugs.
To defend the researchers: resources, including the subjects’ willingness to answer questions, are limited. If it’s 1994 and nobody is thinking about prescription opiate abuse as a problem, why would you take up valuable time by asking about them?
I agree with** Ruken** about not liking to link to magazine articles. This isn’t quite a magazine article, but pretty damn close.
In interview we have: Myth: Everyone gets addicted to pain drugs if they take them long enough. Reality: “The vast majority of people, when prescribed these medications, use them correctly without developing addiction,” says Marvin Seppala, MD…
Next - this was hidden away in one of the links in the article that Ruken linked to (!)
The Changing Face of Heroin Use in the United States
A Retrospective Analysis of the Past 50 Years
Theodore J. Cicero, PhD; Matthew S. Ellis, MPE; Hilary L. Surratt, PhD; et al Steven P. Kurtz, PhD July 2014
JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366
It appears to be source material for the NIDA article. Echo - you may find this interesting because “Our study used data from the ongoing nationwide Survey of Key Informants’ Patients (SKIP) Program, a key element of the postmarketing Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System. The SKIP Program consists of more than 150 publicly and privately funded treatment centers (key informants), balanced geographically with coverage in 48 states, that recruit patients/clients to complete an anonymous survey.”
Did anyone take a gander at the very recent study that I’ve linked to twice about young folks getting opioids from dentists? Here is a quick synopsis:
Of nearly 15,000 young people who received initial opioid prescriptions from their dentists in 2015, 6.8 percent had additional opioids prescribed between 90 and 365 days later, and 5.8 percent were diagnosed with opioid abuse during the 12 months after the initial prescription. In a comparison group that did not receive an opioid prescription from their dentists, 0.1 percent got another opioid prescription and 0.4 percent were diagnosed with opioid abuse over the same period.