A person using pain medication can be mischaracterized as having addiction by concerned family members, legal representatives; or even themselves. Misguided perceptions may further extend to co-workers, sway a juror’s perception in a legal judgment, or turn a random traffic stop into a question of DUI. Pain medication dependence or addiction can easily complicate a divorce proceeding. Understanding whether they have dependence, addiction or both is important if experts will be involved. Many persons who use pain medications long term do in fact meet criteria for addiction, yet costly misjudgment can occur when the patient shows strong signs of dependence in the absence of addiction per se. I am going to describes some examples from my patients, as well as legal cases I have been asked to review; to illustrate the hazards of jumping ahead by lumping these together.
Why dependent persons may conclude they “are addicted”
First, lets define these concepts a little further. Physical dependence is just that; prolonged exposure to the drug yields some withdrawal symptoms within hours upon discontinuation, or even in the low “trough” level between dosages. In the case of pain medication like oxycodone, hydrocodone, methadone, fentanyl, hydromorphone or dilaudid; this can be severe. A person may experience severe sweats, limb jerking that interferes with sleep, pain all over, runny nose, shakes; it can be quite awful and can last for days. It is not uncommon for patient has become dependent after consistently taking 1 hydrocodone every 6 hours for weeks or months. Several hours after a given dose, they may experience onset of these withdrawal symptoms, because the drug is being cleared from their body at a rate that is sooner than their dosing schedule and the symptoms are relieved by taking another dose. This see-saw roller coaster pattern can easily lead the person experiencing this pattern to conclude “I am addicted to these painkillers”. The central nervous system adapts strongly in the face of repeated exposure, yielding dependence, and in some cases addiction. But when family members notice the sweats, the anxiety related to the predictable onset of withdrawal, and associated irritability, they may prematurely conclude “He has become addicted to the painkillers”.
Who cares what we call it?
When the stakes are high, such as custody litigation, medical standard of care determination, and other legal matters, the distinction of addiction versus dependence may have very large implications. If an expert were asked to opine, they may more may not draw the same conclusion as above.
In the case of custody proceedings, a spouse seeking custody may be acutely aware of the pain medication use of the other, and bring this up as a primary issue “They are addicted, and therefore should be in treatment for addiction, and have zero custody”. In this example, the person using the pain medication has become dependent, a natural consequence of prolonged repeated exposure to the drugs. If the expert reviewing the case didn’t see evidence of compulsive use, escalating the dose beyond the prescriber’s instructions, illicit use or supplementing with other pain drugs not prescribed by the physician, or behaviors related to the medications otherwise inconsistent with their personality such as lying to the physician; the expert may conclude this person has dependence but not addiction.
Addiction and Opioid Use Disorder
To diagnosis addiction, or what is more recently called “opioid use disorder”, we need to examine the impact of the drug exposure to the person’s behavior, thoughts, and priorities. Addiction is a condition where there is an intensity of motivation towards obtaining and experiencing the substance (or in some cases a behavior such as gambling or porn). Consumption of medications (in this case) becomes a highly prioritized need, that is disproportionate to existing or former priorities. In other words, the pills are, more or less, a preoccupation.
In one recent case, a common progression is prolonged treatment of an injury (in this case a car accident in a college student), and upon discontinuation of the pain medication the young woman began using heroin, dropped out of college and was living on the street. The case against the auto insurance company to consider the addiction as a consequence of the pain treatment both increased the monetary value of the claim, yet it requires a great deal of finesse to help a random jury understand the exposure to medications was not a deliberate shameful act, and the progression beyond dependence to addiction is largely driven by genetic factors, coupled with lifetime emotional trauma.
Another case, a prominent physician was writing prescriptions for Oxycontin in exchange for sexual favors. After he lost his license, a civil claim was brought against the physician by the patient for further enabling an opioid addiction, where the patient otherwise needed to be referred to treatment, not exploited for sex.
When a person has dependence, what are signs they also have addiction?
There are some behaviors that accompany both addiction and dependence, such as a dose escalation. Pain medication tends to wane in effectiveness with prolonged use. A person’s expectations related to the effectiveness may be poorly matched with their experience so they take more, or are asked to take more. This could be considered dependence, especially where poor boundaries exist with their prescriber around how much to take, or whether they can take more if needed. However, when a person can’t overcome an impulse to take more medication, especially where that impulse is driven by a desire to achieve mood effects or euphoria, this is a feature of addiction. Incidentally, not all persons will endorse a mood effect or euphoria as a impact of pain medication, but those that do are much more likely to end up with addiction and dependence.
In summary, if a person takes pain medication long enough (consistently, every day for weeks or months), the development of dependence is highly likely. When a person develops dependence without signs of addiction, this distinction may help overcome stigma or worse; because not all patients who are dependent meet criteria for addiction. The former is characterized by physical withdrawal symptoms, the latter by a negative behavioral transformation of the individual attributable to the drug.
For more information on expert services related to addiction and pain management, see ALM directory.
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