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When I see reports in the media about the problems associated with opioid prescriptions I get a little concerned with the association put alongside the issues that patients invariably become addicted to them.

The question Why can’t painkillers be both safe and effective? here also mentions the "addictive and deadly" nature of opioids.

When looking at the difference between dependence and addiction you can see how the 2 terms can be mis-attributed in some cases. When patients are taking opioids for pain relief, the need to take another dose after a while, and sometimes a higher dose after a while is not necessarily addiction.

For clarity after re-reading the question and the sources

With this question, I am not talking about methadone dispensing prescriptions for heroin addiction. I am talking about morphine for example, for severe and chronic pain relief.

Dependence is not the same as addiction and the word addiction is synymous with being a junkie so opiod users have been referred to as opioid junkies.

What I have been questioning, and the question still stands — Are opioids just dependency inducing or are they actually addictive to a majority of patients?

If you follow the definitions in the link provided, the way I see it is that opioids make patients physically dependent on them, although it could be argued that it is the chronic pain if other analgesics are ineffective.

If the cause(s) of the chronic pain are removed and the patient is being weaned off the opioids, do the damaging behaviours associated with addiction appear in a large proportion of these patients?

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    I don't think the message is that people invariably get addicted to opioid pain medications, it is that if you prescribe them to a lot of people, invariably some people will get addicted. Opioids are definitely addictive, I'm surprised you are questioning that, so I suspect you may be after more nuance than is immediately clear. Maybe you can clarify a bit? Maybe you are asking whether it is possible to have opioid tolerance without also having an addiction? – Bryan Krause Sep 10 '20 at 13:53
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    They're physically addictive to all patients if taken long enough, so I don't understand your question. – Carey Gregory Sep 10 '20 at 16:08
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Regarding one of the topics of this subject: Why can’t painkillers be both safe and effective?

It should be duly noted that,

One of the most problematic conditions when using opioids in clinic is the respiratory depression that they can cause

The most common cause of opioid overdose and death is opioid-induced respiratory depression (OIRD)

essentially due to a neuronal malfunction at the brainstem level

Opioids such as morphine depress the hypoxic ventilatory response in the brainstem by affecting the chemosensitive cells that respond to changes in the partial pressures of carbon dioxide and oxygen in the blood

The difficulty to treat an overdose and the narrow therapeutic window that opioids are known for, make them drugs that need to be monitored very well and thus not much "safe"; although there are a lot being made to counter that effect with the new development of drugs, such as Fentanyl or Remifentanil

Conventional µ receptor opioids have a narrow therapeutic window in part because of their mechanism of action

The opioid receptor desensitization is also a problem, that diminish their effectiveness, being also a cause of dependency and overdose.

Now, regarding your question: Are opioids just dependency inducing or are they actually addictive to a majority of patients?

The answer is both. Opioids are in fact addictive to the majority of patients due to their ability to desensitize quickly.

Opioids are required in ever-increasing doses as you develop a tolerance to them. In other words, the dose you used to take to relive your pain will eventually not work as well, which means you’ll need more of the opioid to get the same effect

From a clinical standpoint, opioid withdrawal is one of the most powerful factors driving opioid dependence and addictive behaviors. Treatment of the patient’s withdrawal symptoms is based on understanding how withdrawal is related to the brain’s adjustment to opioids

From a psychological point of view

Other areas of the brain create a lasting record or memory that associates these good feelings with the circumstances and environment in which they occur. These memories, called conditioned associations, often lead to the craving for drugs when the abuser reencounters those persons, places, or things, and they drive abusers to seek out more drugs in spite of many obstacles

And also they induce dependency essentially with the release of endorphins. With the definition being stated on the article that you have provided such that Dependence is characterized by the symptoms of tolerance and withdrawal.

One of the brain circuits that is activated by opioids is the mesolimbic (midbrain) reward system. This system generates signals in a part of the brain called the ventral tegmental area (VTA) that result in the release of the chemical dopamine (DA) in another part of the brain, the nucleus accumbens (NAc). This release of DA into the NAc causes feelings of pleasure. Other areas of the brain create a lasting record or memory that associates these good feelings with the circumstances and environment in which they occur.

Two clinically important results of this alteration are opioid tolerance (the need to take higher and higher dosages of drugs to achieve the same opioid effect) and drug dependence (susceptibility to withdrawal symptoms).

By all those reasons chronic pain is thus a very difficult condition to treat and is usually regarded according to the principle of the gate control theory of pain which leads to a broad spectrum analgesia therapy.


Regarding the fact that If the cause(s) of the chronic pain are removed and the patient is being weaned off the opioids, do the damaging behaviours associated with addiction appear in a large proportion of these patients?

Naturally a high intake for a longer duration is associated with more severe withdrawal and to better grasp this concept there is a psychological scale that enable us to measure that (Clinical Opiate Withdrawal Scale - COWS) by quantifying the severity of opiate withdrawal symptoms,

article

Patients who score between 5-12 are classified as mild withdrawal, 13-24 as moderate, 25-36 as moderately severe, and over 36 as severe withdrawal

On the other hand, sometimes the chronic use of opioids can lead to brain abnormalities (dependce/addiction abnormalities) and here we have a clear difference about dependence and addiction, because it will lead to different ends.

The abnormalities that produce dependence, well understood by science, appear to resolve after detoxification, within days or weeks after opioid use stops.

The abnormalities that produce addiction, however, are more wide-ranging, complex, and long-lasting. [...] Such abnormalities can produce craving that leads to relapse months or years after the individual is no longer opioid dependent.

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  • If you follow the definitions in the link provided, the way I see it is that opioids make patients physically dependent on them, although it could be argued that it is the chronic pain if other analgesics are ineffective. If the cause(s) of the chronic pain are removed and the patient is being weaned off the opioids, do the damaging behaviours associated with addiction appear in a large proportion of these patients? – Chris Rogers Jan 15 at 9:12
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    and you're right, opioids make patients physically dependent on them, however there is a therapeutic protocol to be followed, to ensure that it does not happen and eventually if it has to happen, to be in the smallest scale possible. if the weaning protocol is carried out well, the reality of dependency is very small. (statistically, from all people who have been in surgery, practically none is a opioid dependent) nevertheless I will attach more information on psychological aspects of opioids that may be a factor of dependency – program Jan 15 at 9:36
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There is no "yes" or "no" answer to your question as far as the use of both terms are concerned.

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