Evidence that opiods are addictive
August 31, 2018 10:49 AM Subscribe
I had a disagreement recently with someone who told me that the latest research shows that opioid addiction for most people is due to underlying issues of depression/isolation/other mental health problems. I am under the (strong) impression that there is very good science that the substances are themselves, irrespective of mental health, chemically addictive. Can you point me to good scientific research that supports the latter claim? (or the former; I am open to being wrong)
The point of contention is not the concept that people often start taking opioids, or take them longer than they would otherwise, for mental health reasons. It is also not that helping with mental health issues helps people to overcome the physical additions. It is also not that some people are more susceptible to addition. It is specifically about the physical/chemical nature of addition (what it takes to stop).
I've read accounts here and elsewhere of very happy people getting addicted after taking them purely for pain, and know that that is the standard narrative, and that this is the working assumption of many researchers in the field. But I don't have the time/expertise to properly distinguish between these two conclusions.
I'm not looking for webpages that summarize the issue, but rather want to know what the most rigorous scientific studies show.
I have access to most scientific journals. Thank you!
The point of contention is not the concept that people often start taking opioids, or take them longer than they would otherwise, for mental health reasons. It is also not that helping with mental health issues helps people to overcome the physical additions. It is also not that some people are more susceptible to addition. It is specifically about the physical/chemical nature of addition (what it takes to stop).
I've read accounts here and elsewhere of very happy people getting addicted after taking them purely for pain, and know that that is the standard narrative, and that this is the working assumption of many researchers in the field. But I don't have the time/expertise to properly distinguish between these two conclusions.
I'm not looking for webpages that summarize the issue, but rather want to know what the most rigorous scientific studies show.
I have access to most scientific journals. Thank you!
Your friend may be referring to the Rat Park experiment. I recall that there were articles talking about it recently, maybe in the Guardian or Independant, made it sound like a recent study - or maybe someone has replicated it. I'll see if I can find it but the jist of it was that rats had free access to opiates but those that had all their ratty needs fulfilled in a giant rat theme park, weren't interested in the opiates.
posted by missmagenta at 11:01 AM on August 31, 2018 [9 favorites]
posted by missmagenta at 11:01 AM on August 31, 2018 [9 favorites]
(FWIW, happy people getting addicted after taking opiates for pain doesn't mean your friend is wrong necessarily, pain is depressing and often increases social isolation and decreased activity)
posted by missmagenta at 11:04 AM on August 31, 2018 [2 favorites]
posted by missmagenta at 11:04 AM on August 31, 2018 [2 favorites]
[Animal] studies have demonstrated that the rewarding effect is not dependent on preexisting conditions; that is, exposure to the drug is sufficient to motivate drug-taking behavior.
.....in a study that examined the effects of feeding condition and palatability of the diet, rates of [addiction] became slower with increasing levels of food satiation, particularly when the food options were enriched.17
In addition, these acquisition methods have revealed a number of physiologic and organismic factors that predict vulnerability to drug self-administration, including basal and stress-elicited corticosterone levels,78 dopamine release in brain regions associated with drug reward,32,40 genetic strain,93,104 innate saccharin preference[...]
posted by the agents of KAOS at 11:05 AM on August 31, 2018 [1 favorite]
.....in a study that examined the effects of feeding condition and palatability of the diet, rates of [addiction] became slower with increasing levels of food satiation, particularly when the food options were enriched.17
In addition, these acquisition methods have revealed a number of physiologic and organismic factors that predict vulnerability to drug self-administration, including basal and stress-elicited corticosterone levels,78 dopamine release in brain regions associated with drug reward,32,40 genetic strain,93,104 innate saccharin preference[...]
posted by the agents of KAOS at 11:05 AM on August 31, 2018 [1 favorite]
I think the conflict here is the loose use of the term "addiction," which in modern medical literature is defined not by chemical dependence but by meeting criteria that describe the effect of the substance/behavior on the patient's life, e.g. "Taking the substance in larger amounts or for longer than you're meant to," "Not managing to do what you should at work, home, or school because of substance use," and "Using substances again and again, even when it puts you in danger." Because of this ambiguity we tend to use the term "substance use disorder" rather than addiction.
I don't think there is anyone anywhere in the mainstream of scientific discourse disputing that opioids themselves induce a dependence or tolerance (what you refer to in your question as "physical/chemical addiction"). However, there are many substances that induce dependence but rarely if ever cause addiction (ie use disorder). For example, see the many numerous AskMeFi questions about how to taper off of SSRIs.
Likewise, in the right context of individual/family support/medical support/social support, even substances that are typically associated with "addiction" can be used chronically without causing the problems that define addiction. For example, terminal cancer patients are often on round the clock opiates for weeks if not months or years without developing "addiction." This isn't because cancer patients are somehow nobler people or having cancer magically makes you immune to the effects of opioids, but they are a population who stereotypically have all the characteristics aligned to not develop addiction: they have honest, frequent check ins with their physicians; they have appropriate, consistent access to the medications they are physically dependent on; they are supported in adjusting their daily responsibilities to match the requirements of their pain management regimen, not the other way around, and so on.
posted by telegraph at 11:10 AM on August 31, 2018 [26 favorites]
I don't think there is anyone anywhere in the mainstream of scientific discourse disputing that opioids themselves induce a dependence or tolerance (what you refer to in your question as "physical/chemical addiction"). However, there are many substances that induce dependence but rarely if ever cause addiction (ie use disorder). For example, see the many numerous AskMeFi questions about how to taper off of SSRIs.
Likewise, in the right context of individual/family support/medical support/social support, even substances that are typically associated with "addiction" can be used chronically without causing the problems that define addiction. For example, terminal cancer patients are often on round the clock opiates for weeks if not months or years without developing "addiction." This isn't because cancer patients are somehow nobler people or having cancer magically makes you immune to the effects of opioids, but they are a population who stereotypically have all the characteristics aligned to not develop addiction: they have honest, frequent check ins with their physicians; they have appropriate, consistent access to the medications they are physically dependent on; they are supported in adjusting their daily responsibilities to match the requirements of their pain management regimen, not the other way around, and so on.
posted by telegraph at 11:10 AM on August 31, 2018 [26 favorites]
I think you’re arguing at cross-purposes, and you’re both right. Your friend is correct that opioids (like many recreational drugs) can cause psychological dependence. You’re right that they also cause physical dependence. If your friend is arguing that they only cause psychological dependence, they’re wrong and you’re right.
I’m not an expert, but I think you’re unlikely to find a recent paper on whether or not opioids cause physical dependence, as it’s the accepted scientific consensus and there would be significant ethical issues around running a study to reconfirm that with humans. However, here’s a paper that goes beyond “do they cause dependence Y/N” to explore the mechanism(s) causing physical dependence on various opioids in rat models. Removing the opioids consistently resulted in withdrawal symptoms once the rats were physically dependent; that’s unlikely to be due to a population of accidentally mentally ill rats.
Note that the opioids were administered to the rats and the rats had no choice about receiving them. Given different choices, that rats may not have self administered the opioids, or may not have administered them to the extent needed to become physically dependent - that’s where your friend’s argument comes in.
posted by chappell, ambrose at 11:24 AM on August 31, 2018 [7 favorites]
I’m not an expert, but I think you’re unlikely to find a recent paper on whether or not opioids cause physical dependence, as it’s the accepted scientific consensus and there would be significant ethical issues around running a study to reconfirm that with humans. However, here’s a paper that goes beyond “do they cause dependence Y/N” to explore the mechanism(s) causing physical dependence on various opioids in rat models. Removing the opioids consistently resulted in withdrawal symptoms once the rats were physically dependent; that’s unlikely to be due to a population of accidentally mentally ill rats.
Note that the opioids were administered to the rats and the rats had no choice about receiving them. Given different choices, that rats may not have self administered the opioids, or may not have administered them to the extent needed to become physically dependent - that’s where your friend’s argument comes in.
posted by chappell, ambrose at 11:24 AM on August 31, 2018 [7 favorites]
People can die from opioid withdrawal (like alcohol and benzos). Doesn't that signify the addiction is (at least partially) physical?
posted by wearyaswater at 1:46 PM on August 31, 2018 [3 favorites]
posted by wearyaswater at 1:46 PM on August 31, 2018 [3 favorites]
Here's a piece by maias that covers some of the evidence around dependence vs. addiction.
posted by gingerbeer at 2:34 PM on August 31, 2018 [2 favorites]
posted by gingerbeer at 2:34 PM on August 31, 2018 [2 favorites]
A few keywords to look for would be physical dependence vs. addiction. Opiates definitely cause physical dependence eventually which leads to very tangible medical withdrawal symptoms, alongside psychiatric/behavioral addiction, as opposed to stimulants like cocaine, which mostly cause mental/emotional addiction, and physical withdrawal is very short term, if any (more of a "crash" than extended withdrawal). Even someone not addicted to opiates would experience withdrawal after taking them long enough. It's often the pain of withdrawal that leads to addiction.
posted by catatethebird at 5:19 PM on August 31, 2018 [1 favorite]
posted by catatethebird at 5:19 PM on August 31, 2018 [1 favorite]
I know you're looking for scholarly articles and this was the best I could come up with quickly.
I know you're not looking for summaries but it might be helpful to know how the medical field frames it so you know what to search for. For example a google scholar search on "mechanism of opioid tolerance" comes up with lots of stuff that looks helpful.
When I was in pharmacy school about 15 yrs ago we learned that what most people call "addiction" is actually 3 different things:
Tolerance -- when you need more and more of the substance to get the same effect
Dependence -- when you need to keep taking the substance to prevent going into withdrawal
Addiction -- continued use despite harm
Everybody who takes an opioid for a long time will develop tolerance. (The mechanisms are way more complicated than I'd realized before I started researching this just now!)
Everybody who takes an opioid for a long enough time at high enough doses will go into withdrawal if they stop suddenly. Lots of people will say that someone is "addicted" if they can't stop suddenly without withdrawal, but that's dependence, not addiction.
So your friend is right, addiction in the sense of "continued use despite harm" doesn't happen to everybody, and is more likely to happen to people with underlying mental health challenges. But you are right in saying that the drugs are especially "addictive" -- anything that causes tolerance and dependence the way opioids do is going to end up with a lot of people addicted.
posted by selfmedicating at 6:41 PM on August 31, 2018 [4 favorites]
I know you're not looking for summaries but it might be helpful to know how the medical field frames it so you know what to search for. For example a google scholar search on "mechanism of opioid tolerance" comes up with lots of stuff that looks helpful.
When I was in pharmacy school about 15 yrs ago we learned that what most people call "addiction" is actually 3 different things:
Tolerance -- when you need more and more of the substance to get the same effect
Dependence -- when you need to keep taking the substance to prevent going into withdrawal
Addiction -- continued use despite harm
Everybody who takes an opioid for a long time will develop tolerance. (The mechanisms are way more complicated than I'd realized before I started researching this just now!)
Everybody who takes an opioid for a long enough time at high enough doses will go into withdrawal if they stop suddenly. Lots of people will say that someone is "addicted" if they can't stop suddenly without withdrawal, but that's dependence, not addiction.
So your friend is right, addiction in the sense of "continued use despite harm" doesn't happen to everybody, and is more likely to happen to people with underlying mental health challenges. But you are right in saying that the drugs are especially "addictive" -- anything that causes tolerance and dependence the way opioids do is going to end up with a lot of people addicted.
posted by selfmedicating at 6:41 PM on August 31, 2018 [4 favorites]
Read this article. It is well sourced and you can read the primary sources easily.
Then read this one. Pain medication has many other harmful side effects and pain patients are far more likely to experience those than addiction. It's also fairly well sourced and has a completely different editorial slant. Interesting to read both!
Basically everything you've been told about pain medication by the media, your friends, movies and your doctor is probably wrong. It's effective and rarely abused by chronic pain patients but not actually all that great at the goal of relieving pain in the long run.
posted by fshgrl at 9:35 PM on August 31, 2018
Then read this one. Pain medication has many other harmful side effects and pain patients are far more likely to experience those than addiction. It's also fairly well sourced and has a completely different editorial slant. Interesting to read both!
Basically everything you've been told about pain medication by the media, your friends, movies and your doctor is probably wrong. It's effective and rarely abused by chronic pain patients but not actually all that great at the goal of relieving pain in the long run.
posted by fshgrl at 9:35 PM on August 31, 2018
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posted by leesh at 10:53 AM on August 31, 2018