obsession, addictionIt is important to understand the difference between physical dependence and addiction, two phrases that are sometimes used interchangably but that may or may not refer to the same thing, depending on the context.

Tolerance and withdrawal are signs of ‘physical dependence’ on a substance.  Addiction, on the other hand, is a complicated term that has different meanings in different contexts, but generally refers to an obsession or attachment to a behavior, person, or substance.

Many people mistakenly consider physical dependence and addiction to be the same thing. To illustrate the difference, there are many medications that cause ‘physical dependence’ that are not addictive.  Effexor and Paxil, two common antidepressants, cause physical dependence and have very uncomfortable withdrawal symptoms.  Physical dependence occurs in non-psychiatry-related medications as well; suddenly stopping some blood pressure medications will cause a spike upward in blood pressure.  Most people are aware of the withdrawal from missing their morning dose of coffee.  Steroids must be tapered when they are discontinued to avoid the risk of hypotension or even shock.

So what is addiction?  Addiction can be seen in different ways depending on who is looking.  From my perspective (as a psychiatrist), opioid addiction is the mental obsession for opioids.  Addiction is the relationship that the addict has with the drug.

Most people associate ‘addiction’ with a person using large amounts of the substance, but when addiction is understood to be not the taking of the drug itself, but rather the obsession, it is clear that addiction does not require the presence of the substance to be active.  In fact, addiction is in some ways most active when the substance is NOT present.

I have heard patients say ‘I’m not an alcoholic– I haven’t had a drink in weeks.’  But in AA there is recognition of a condition known as a ‘dry drunk,’ where a person who loves alcohol is not consuming alcohol, but is consciously or unconsciously thirsting like crazy for a drink!  Similarly, an opioid addict may be free of opioids for several days, but will be so obsessed with finding opioids that there is little ability to think about anything else.  So treating addiction requires much more than keeping the person from using drugs; successful treatment involves removing the mental obsession for the substance, and removing the relationship with the substance.

I sometimes refer to addiction to a drug as similar to having an unstable boyfriend or girlfriend.  When the realization is finally made that the relationship is ‘toxic,’ it isn’t enough to stop dating– the phone calls and text messages have to end as well.

I keep hinting at a discussion about a new treatment for opioid dependence, namely buprenorphine, or brand name ‘Suboxone.’  I don’t mean to drag things out forever.  I find it difficult to jump into a discussion of buprenorphine without first laying some groundwork, and the ground seems to gain an acre each time I write!  I will continue to explain the background concepts a little at a time, and at the same time say a word or two about buprenorphine.

I have made the point that even though opioid dependence has long been called a disease, the treatment community has treated the disease by focusing on defects of character and/or deficiencies of spirituality. This approach has worked for some addictions, but yields lousy results when treating opioid addicts, for reasons that are not entirely clear—but that I suspect have to do with the young age of addicts who seek treatment and the intense reinforcing properties of opioids.

So along comes buprenorphine.  Buprenorphine is a medication that has ‘double actions’ at opioid receptors in the brain.  I will eventually explain the mechanism, but for now understand that buprenorphine has some properties similar to pain medications, and other properties similar to opioid blocking medications.  The result is that buprenorphine almost completely eliminates the opioid addict’s obsession for opioids.  As I wrote at the start of this post, obsession is the essence of addiction!

Traditional AODA counselors cry foul, saying that without addressing character defects, the treatment is incomplete—merely a substitution of one drug for another.  But those people miss the point of buprenorphine’s actions.  They do not realize that actively using opioid addicts once had personalities and characters that were just fine—until their obsession to use opioids replaced that character.  I have found something amazing while treating several hundred patients using buprenorphine over the years;  the obsession that destroyed a person’s character is removed, that character comes back!!

I cannot stress this issue strongly enough, as it is one of the bases for the new paradigm of treatment for opioid dependence.  To summarize, by the old paradigm, addicts develop character defects from using, and treatment relies on the intensive repair of these character defects—a process that at best occurs over months, costs tens of thousands of dollars, requires active reinforcement in the form of NA for the rest of the addicts’ lives… and has a success rate in the single digits.

By the new paradigm, opioid dependence is a disease with the core problem of obsession for opioids– an obsession that crowds out personality traits and intimate relationships and destroys character. Buprenorphine is a medication with unique properties that result in the profound elimination of the obsession for opioids, and over time, once the obsession is removed, interests and relationships return, and character defects heal.

The healing of character defects does not require attendance at 12-step meetings– at least not as a prerequisite to sobriety– because a reduction in character defects is a direct outcome of the elimination of obsession for opioids.  Allowing one’s good character to return is a far more reliable proposition than trying to force-feed character to an addict in treatment!

Some studies show success rates, by the new paradigm, of around 80%.  My own numbers are certainly in that ballpark.