What Does “Addiction” Mean, in Your Opinion?

[Koldo]

Well, what about the case where a person needs (or believes he needs) one pill every 4 hours in order to avoid having pain, and a few days later needs 2 such pills every 4 hours in order to avoid having pain, and a few days after that needs 3 pills every 4 hours in order to avoid having pain, etc., etc.?

Why does this person believe he needs to keep increasing the number of pills on a daily basis ?

If it is because the pain keeps increasing then I wouldn't call it an addiction.

 

[Nous]

Why does this person believe he needs to keep increasing the number of pills on a daily basis ?

If it is because the pain keeps increasing then I wouldn't call it an addiction.

How would you determine why the person is increasing his dosage of pain pills?

 

[Koldo]

How would you determine why the person is increasing his dosage of pain pills?

Has this person been diagnosed with a physical condition that is compatible with this ever increasing pain ?

Has this person been diagnosed with OCD or any other mental condition that could explain what's going on ?

Those are the two factors I would take into consideration.

 

[Nous]

Has this person been diagnosed with a physical condition that is compatible with this ever increasing pain ?

Has this person been diagnosed with OCD or any other mental condition that could explain what's going on ?

Those are the two factors I would take into consideration.

Let's say the person has been diagnosed with arthritis. This condition can become worse, and a person can experience greater pain some days than on others. A person can also experience greater or less pain depending on other factors such as what a person does or doesn't do--getting inadequate sleep, not getting regular exercise or exercising so as to put greater stress on joints, gaining weight or being overweight--as well as depend on psychological factors such as stress or pessimism.

So how do you determine why the person is increasing his dosage of pain pills?

 

[Koldo]

Let's say the person has been diagnosed with arthritis. This condition can become worse, and a person can experience greater pain some days than on others. A person can also experience greater or less pain depending on other factors such as what a person does or doesn't do--getting inadequate sleep, not getting regular exercise or exercising so as to put greater stress on joints, gaining weight or being overweight--as well as depend on psychological factors such as stress or pessimism.

So how do you determine why the person is increasing his dosage of pain pills?

If the person in question keeps increasing, and never decreasing, how many pills he takes on a daily basis, then this increase can't be explained by the arthritis. That is not compatible with arthritis. Arthritis isn't the sort of condition that keeps getting worse every day indefinitely at a pace that would justify this behavior. It is probably an addiction, although further diagnosis would be required to determine if the proper label for his mental condition would be something else.

 

[Nous]

If the person in question keeps increasing, and never decreasing, how many pills he takes on a daily basis, then this increase can't be explained by the arthritis. That is not compatible with arthritis. Arthritis isn't the sort of condition that keeps getting worse every day indefinitely at a pace that would justify this behavior. It is probably an addiction, although further diagnosis would be required to determine if the proper label for his mental condition would be something else.

I didn't intend for you to take my description of a person increasing the dosage of pain pills quite so literally or unrealistically. I only meant to use a concrete example of incrementally increasing dosage.

Consider the more more realistic hypothetical example of a person taking x mg. of analgesic y on day 1, x+1 mg. on day 10, x+2 mg. on day 20, x+3 mg. on day 30, and x+4 mg. on day 40. Does this person have an addiction on day 40? How do you determine that? How do you determine why this person has incrementally increased his dosage?

 

[Jainarayan]

I have a somewhat biased view about addiction v. dependence. I have been taking Percocet (oxycodone & acetaminophen) for three years steady this past Nov. 9 for a lumbar fusion in 2015 that was not entirely successful. I see a pain management MD every four weeks who monitors and prescribes the medication. I pee in a cup, he counts the pills I have left, I have to sign papers about opioid compliance. It's the same dosage I started with, though the effects don't last as long. I won't ask him to increase the dosage knowing the possible effect.

That said, do I think I'm addicted? No. I don't get 'high'. Though I still don't understand why people take them for that. It's a mild buzz or euphoria (at my dosage anyway, 10 mg) that makes me goofier than I usually am. But when it wears off, I don't crave another dose. If I don't get pain I don't think about them. I took a dose at 6:30 this morning. Right now, at 10:45 by my clock, I'm beginning to get some discomfort in my back and legs (that may be alleviated if I get up off my *** and walk around the office ), but I will hold out taking another dose until 1:30 - 2:00 pm. I will most likely need it for the pain, but I may not. No pain, no dose.

Do I think I'm dependent? Most definitely. I'm dependent on them to take away the pain. I'm not dependent on them to function in my daily life. If I had another non-opioid pain reliever that worked (none do, except sometimes ibuprofen if I take 600-800 mg at once, but I can't count on it) I'd be happy to give up Percocet. It helps, of course, that I don't have an addictive personality to begin with. Though the existence of such a thing is up for debate.

Edit: my Apple watch just told me it's time to stand and walk around. Brb...

 

[Nous]

I have a somewhat biased view about addiction v. dependence. I have been taking Percocet (oxycodone & acetaminophen) for three years steady this past Nov. 9 for a lumbar fusion in 2015 that was not entirely successful. I see a pain management MD every four weeks who monitors and prescribes the medication. I pee in a cup, he counts the pills I have left, I have to sign papers about opioid compliance. It's the same dosage I started with, though the effects don't last as long. I won't ask him to increase the dosage knowing the possible effect.

That said, do I think I'm addicted? No. I don't get 'high'. Though I still don't understand why people take them for that. It's a mild buzz or euphoria (at my dosage anyway, 10 mg) that makes me goofier than I usually am. But when it wears off, I don't crave another dose. If I don't get pain I don't think about them. I took a dose at 6:30 this morning. Right now, at 10:45 by my clock, I'm beginning to get some discomfort in my back and legs (that may be alleviated if I get up off my *** and walk around the office ), but I will hold out taking another dose until 1:30 - 2:00 pm. I will most likely need it for the pain, but I may not. No pain, no dose.

Do I think I'm dependent? Most definitely. I'm dependent on them to take away the pain. I'm not dependent on them to function in my daily life. If I had another non-opioid pain reliever that worked (none do, except sometimes ibuprofen if I take 600-800 mg at once, but I can't count on it) I'd be happy to give up Percocet. It helps, of course, that I don't have an addictive personality to begin with. Though the existence of such a thing is up for debate.

Edit: my Apple watch just told me it's time to stand and walk around. Brb...

I take it you agree that you cannot objectively determine whether someone else has experienced a “high,” as you call it.

How do you respond the findings of this study:

Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain? The authors found:

Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.​

I've shown this study to a couple of people I know who take opioids chronically. These days they seem to be under constant stress about the possibility of their prescriptions being discontinued, being able to get only small quantities at a time and having to go to the doctor often to get their prescriptions renewed, and worried about the possibility of not being able to obtain enough opioids. In both cases, their responses to the findings of the study were something such as, “But [the opioids] work for me better than non-opioid drugs.” This is, of course, what someone experiencing the placebo effect would say.

Among the things I noticed in the Supplemental eTables 7 and 8 is that compared to the non-opioid group, a much larger percentage of subjects in the opioid group were from the beginning taking dosages greater than the mean dose of opioids, and a much larger percentage of the opioid group continually took dosages that were larger than the mean daily dosage. Mean daily dosage was “calculated as the total morphine-equivalent mg of all study-prescribed opioids (including tramadol) dispensed from VA outpatient pharmacies within the prior 90-day window, divided by 90 days.”

 

[Jainarayan]

I take it you agree that you cannot objectively determine whether someone else has experienced a “high,” as you call it.

I can tell when someone is high, stoned, drunk. What I was getting at is that relative to my reaction to opioids, I don't think they're all that for getting high. I don't see the attraction.I'd rather have a couple of beers. But that may just be me... I'm resistant to most medications, whether prescription or otc. When I get a cold, I have to tough it out because nothing works.

I had a cousin who died of opioid abuse. She pestered another cousin, an MD, for prescriptions. Of course he refused. She pestered my sister, calling her in the middle of the night to ask her to ask her doctor for a script. My niece's husband died of an opioid misuse. Apparently he had forgotten what he took and when he took it, took more (it can happen, they alter your perceptions), fell asleep on the sofa and never woke up, leaving a wife and pre-teen and teenage girls.

How do you respond the findings of this study:

Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain? The authors found:

Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.

Yeah, I've seen this sort of report before. It's bollocks when the pain is severe. I do not wish chronic back pain on anyone. It's incapacitating. I've taken ibuprofen in doses of 800 mg, which is the prescription dose, and they did little to nothing for my pain. I took them as my oxy was wearing off, not wanting to take another oxy until at least 6-7 hours. I do tough it out, but the pain is not lessened with the ibuprofen.

I've shown this study to a couple of people I know who take opioids chronically. These days they seem to be under constant stress about the possibility of their prescriptions being discontinued, being able to get only small quantities at a time and having to go to the doctor often to get their prescriptions renewed, and worried about the possibility of not being able to obtain enough opioids. In both cases, their responses to the findings of the study were something such as, “But [the opioids] work for me better than non-opioid drugs.” This is, of course, what someone experiencing the placebo effect would say.

Well yes, there are a lot of people freaking out over this. I haven't run into it. My pain specialist is an MD who follows all the protocols for reporting and monitoring. In three years the subject of discontinuing my treatment has never come up. Doctors can make a good case for their course of treatment. I really don't believe it will come to a virtual ban on opioids.

What is in effect and is true is:

• Monthly (or 4 week/28 days) med. check/office visit.
• Counting the remaining pills. Must bring the original bottle each visit. They calculate how many there should be based on the current date,, the date of prescribing, how many are dispensed. I get 90/month, prescribed for 3x/day as needed (I usually do take them, 6-8 hours apart). This is to make sure I'm not selling them or overusing them. If I run out, I cannot get a refill (which is not a refill, it's a new prescription) until I see the doc, but no sooner than 4 weeks/28 days.
• Urine test every 4 weeks.
• Must use the same pharmacy each time. If I change pharmacies I have to let the doctor know, and why.
• Pharmacies "talk" to each other via the shared network and database. If they look up your name or SS# or insurance plan or some other identification, they can see immediately when the last prescription was filled and picked up.

If I violate any of those or don't follow them, the doctor has no choice but to refuse to treat me. I suspect many people want what they want, when they want, how they want. And I do remember the days, just a few years ago, when the surgeon or pain specialist would call in or fax a script to the pharmacy for an opioid; or you could pick up the paper script at the doctor's front desk; or s/he would refill if you ran out before the time you should have; or you didn't need the surgeon or a PM specialist... your family doctor would just write the script.

Addiction, abuse and misuse are a real problem because of those lax procedures... if you want to call them procedures. Believe you me, between my husband and me with all the Handy Dandy Slice 'N Dice we've been through, and the resulting meds, I'm no stranger to these procedures. Quite honestly, as much of a pain in the *** as it is to take a morning off from work every 4 weeks, and know that if I've taken all I am allotted for a day and I get severe pain again, I have to tough it out, it's really for my and my doctor's protection.

 

[Nous]

I can tell when someone is high, stoned, drunk.

By what method? What objective measurements do you perform in order to determine that another person “is high, stoned, drunk”? I take it that you can only determine that someone is currently “high, stoned, drunk,” not whether they were, say, an hour earlier, or the day before. Right?

What I was getting at is that relative to my reaction to opioids,

If you notice in the OP, my first question is: Does “addiction” exist in some objective sense, or is that term (and/or the concept of “to be 'addicted' to”) ultimately subjective and/or undefinable? That's my primary question here. I'm not sure how you answer that question.

If the term “addiction” or “to be addicted to” cannot be defined and determined by an objective method, then it seems we should consider it a subjective phenomenon.



I don't think they're all that for getting high. I don't see the attraction.I'd rather have a couple of beers. But that may just be me... I'm resistant to most medications, whether prescription or otc. When I get a cold, I have to tough it out because nothing works.

Yeah, I've seen this sort of report before.

Actually it seems that was the first long-term study of the effectiveness of opioid vs. non-opioid analgesics for moderate and severe pain.

It's bollocks when the pain is severe.

Obviously that isn't what the study found. What is the basis of your claim?

I've taken ibuprofen in doses of 800 mg, which is the prescription dose

Actually, the maximum daily dosage for ibuprofen is 3200 mg. When I had oral surgery a while back, I noticed that it was best for me to take enough Ibuprofen to knock the pain out completely, then I only needed, at most, 2 doses per day, but oftentimes just one dose. That was just my experience, not advice for anyone else.

 

[Jainarayan]

By what method? What objective measurements do you perform in order to determine that another person “is high, stoned, drunk”? I take it that you can only determine that someone is currently “high, stoned, drunk,” not whether they were, say, an hour earlier, or the day before. Right?

Appearance, behavior. It's pretty easy to tell if someone is drunk. Being stoned on coke or weed is also easy to tell (seen it, never done it). I have no window into the past.

If you notice in the OP, my first question is: Does “addiction” exist in some objective sense, or is that term (and/or the concept of “to be 'addicted' to”) ultimately subjective and/or undefinable? That's my primary question here. I'm not sure how you answer that question.

Objective as in "applicable to all"? No.

If the term “addiction” or “to be addicted to” cannot be defined and determined by an objective method, then it seems we should consider it a subjective phenomenon.

I think the terms “addiction” or “to be addicted to” are subjective. I don't think it's a one size fits all.

Obviously that isn't what the study found. What is the basis of your claim?

Real world, talking to other people with chronic pain who were not part of that study. I don't trust studies. The JAMA is not the be-all end-all. 240 "randomized patients" is in no way a true sample of the population dealing with chronic pain. Not with a population of 300 million, and roughly 10% reporting some form of back pain. Even if 1% of that 30 million has chronic back pain that is still 3 million people. Visit any chronic pain management forum, or survey pain management specialists. So, I don't trust a study that talks about 240 patients.

Actually, the maximum daily dosage for ibuprofen is 3200 mg. When I had oral surgery a while back, I noticed that it was best for me to take enough Ibuprofen to knock the pain out completely, then I only needed, at most, 2 doses per day, but oftentimes just one dose. That was just my experience, not advice for anyone else.

I know. 800mg is what's prescribed per dose, up to 4x/day and no more than 3200 mg/day.

I had oral surgery in 1978, Four wisdom teeth out at the same time, general anesthesia. It hurt. Not to minimize your experience, but after a few days the pain goes away. Otc NSAIDS are usually enough. After 2 weeks of Vicodin for sleep apnea and sinus surgery I tossed them and took ibuprofen (acetaminophen does next to nothing for me). I didn't need the Vicodin. But oral surgery and sleep apnea surgery pain are not even on the same planet as pain from back surgery and its effects. Look up 'failed back syndrome'. Failed back syndrome - Wikipedia It's pretty common.

 

[Jainarayan]

I might add, since I don't think I saw it in here except something I briefly mentioned, otc NSAIDS generally don't require larger and larger doses to get the same effect or result. Opioids require higher dosages as time goes on to get the same effect or result. They do create a tolerance.

Not a bad description:

What is opioid tolerance and addiction?

What is opioid tolerance and addiction?
ANSWER

After taking opioid pain medication for a while, you might find that you need more and more of the drug to achieve the same effect in reducing pain. This is called tolerance. It's not the same as addiction, which involves a compulsive use of and a dependence on a drug. People who are addicted to opioids compulsively seek out the pain medications. They typically have behaviors that lead to negative consequences in their personal lives or workplace.

 

[Koldo]

I didn't intend for you to take my description of a person increasing the dosage of pain pills quite so literally or unrealistically. I only meant to use a concrete example of incrementally increasing dosage.

Consider the more more realistic hypothetical example of a person taking x mg. of analgesic y on day 1, x+1 mg. on day 10, x+2 mg. on day 20, x+3 mg. on day 30, and x+4 mg. on day 40. Does this person have an addiction on day 40? How do you determine that? How do you determine why this person has incrementally increased his dosage?

The answer would be the same. But let me fix your question to retain its spirit: How do you determine whether someone is addicted to something if they behave, and have a surrounding history, in a way that resembles that of a person that is not addicted ?

I can't. At that point I would have to ask the person in question and then try to figure out whether they are telling the truth.

 

[Nous]

I think the terms “addiction” or “to be addicted to” are subjective.

I think so,too. And I think it's misleading and causes (and is based upon) a lot of confusion to use those terms as though they do refer to some objective state.

I think the same the same is true of the APA's concept of "substance dependence" (or, as it is now designated, "substance use disorder"). Obviously the diagnostic criteria for this alleged "mental disorder" does not include even one "symptom" that is quantifiable or able to be determined by some objective method.

Real world, talking to other people with chronic pain who were not part of that study. I don't trust studies. The JAMA is not the be-all end-all. 240 "randomized patients" is in no way a true sample of the population dealing with chronic pain.

Wow. Why do you consider it better to trust your "sample" of unscientific anecdotal claims?

Scientific studies employ methodologies so that the findings are repeatable, and confounding factors are eliminated (at least as far as possible).

 

[Nous]

I might add, since I don't think I saw it in here except something I briefly mentioned, otc NSAIDS generally don't require larger and larger doses to get the same effect or result. Opioids require higher dosages as time goes on to get the same effect or result. They do create a tolerance.

Not a bad description:

What is opioid tolerance and addiction?

What is opioid tolerance and addiction?
ANSWER

After taking opioid pain medication for a while, you might find that you need more and more of the drug to achieve the same effect in reducing pain. This is called tolerance. It's not the same as addiction, which involves a compulsive use of and a dependence on a drug. People who are addicted to opioids compulsively seek out the pain medications. They typically have behaviors that lead to negative consequences in their personal lives or workplace.

Yes, I was going to note in my post the other day that people who have developed tolerance to a psychoactive substance often do not experience a "high" or any other measurable effects of intoxication--which is one of the ways that tolerance is defined.

I think it is also noteworthy that in the Krebs et al. study that I linked to above, the opioid group had significantly more adverse drug-related symptoms.

 

[Nous]

The answer would be the same.

What is the basis for your claim that the pain of arthritis does not increase over time? I'm pretty sure that idea is utterly untrue.

But let me fix your question to retain its spirit: How do you determine whether someone is addicted to something if they behave, and have a surrounding history, in a way that resembles that of a person that is not addicted ?

But that revision seems to be based on the assumption that there is some objective difference between "someone [who] is addicted to something" and "a person that is not addicted". Does it not?

 

[Jainarayan]

Wow. Why do you consider it better to trust your "sample" of unscientific anecdotal claims?

Scientific studies employ methodologies so that the findings are repeatable, and confounding factors are eliminated (at least as far as possible).

I think 240 respondents is pitifully small, especially from a specific pool of patients: Patients were recruited from Veterans Affairs primary care clinics from June 2013 through December 2015. As far as I can see, that cannot possibly reflect the patient population at large... I was never surveyed, for example.

Prescription Opioid Data | Drug Overdose | CDC Injury Center

• More than 17% of Americans had at least one opioid prescription filled, with an average of 3.4 opioid prescriptions dispensed per patient.

That 3.4 prescriptions per patient is that high due to people (like me) who have chronic pain and have 12 prescriptions per year, 1 every 30 days. But 17% of Americans is 56 million. Did opioids work better than other pain meds. for all 56 million? I'm sure the answer is no. Still, out of 56 million Americans and that many prescriptions, 240 is 0.00043% of all opioid prescriptions. That's kind of small.

 

[Nous]

I think 240 respondents is pitifully small, especially from a specific pool of patients:

How many people were in your "sample" of anecdotal claims? Were they randomized. Did you you control for confounding factors?

Again, why do you consider it better to trust your "sample" of unscientific anecdotal claims?

 

[Jainarayan]

How many people were in your "sample" of anecdotal claims? Were they randomized. Did you you control for confounding factors?

Again, why do you consider it better to trust your "sample" of unscientific anecdotal claims?

Studies can be and are manipulated, and are subject to agendas. Whether it's real or manufactured, the so-called "opioid crisis" and "opioid epidemic" is a bandwagon that politicians and medical professionals, not to mention the media, are jumping on.

I gave you information based on personal, real life, real world experiences. So, if this is going to become a cross-examination with what I detect is a sarcastic tone, I'm out.

 

[Koldo]

What is the basis for your claim that the pain of arthritis does not increase over time? I'm pretty sure that idea is utterly untrue.

It increases over time, but you would see a fluctation in medication usage. There would be better days and worse days. And you wouldn't also see the increments happening in such a regular basis. Which is why your scenario wouldn't fit arthritis.

But that revision seems to be based on the assumption that there is some objective difference between "someone [who] is addicted to something" and "a person that is not addicted". Does it not?

Yes, behavior for instance.