Physical Dependence and Addiction
An Important Distinction
The following is the single most important concept to understand when learning about addiction and evidence-based treatments. If you learn nothing else but this you will be in better shape than most and aspects about modern addiction treatment that baffle many will be clear to you. All modern evidence-based treatments are based off of understanding this important distinction. - See definitions from the medical field
In short a physical dependence to opioids means that the body relies on a external source of opioids to prevent withdrawal. Physical dependence is predictable, easily managed with medication, and is ultimately resolved with a slow taper off of the opioid.
Normally, the body is able to produce enough endogenous opioids (example: endorphins) to prevent withdrawal. But as tolerance increases, eventually the body's ability to maintain this equilibrium is exceeded and the body becomes dependent on that external source.
Many substances - such as caffeine, nicotine, sugar, anti-depressants, to name a few - can cause physical dependence, it is not a property unique to opioids. Physical dependence to opioids is normal and expected and a distraction from the real problem, addiction.
Physical dependence is sometimes simply called dependence, but this can lead to confusion because addiction is sometimes called dependence as well.
Unlike physical dependence addiction is abnormal and classified as a disease.
Addiction is a primary condition manifesting as uncontrollable cravings, inability to control drug use, compulsive drug use, and use despite doing harm to oneself or others.
Uncontrollable cravings prompt the destructive behaviors of addiction. There is no addiction without cravings.
Strong cravings are common to all addictions. These cravings are rooted in altered brain biology. Recovery is the process of reversing, to the extent possible, these brain changes. This is accomplished through therapy and replacing the addictive behaviors with healthy alternative behaviors.
Addiction is sometimes called; opioid dependence, substance dependence, and most recently opioid use disorder, but still too often simply dependence, which leads to confusion.
Addiction can occur without physical dependence; consider cocaine or methamphetamine both have little outwardly apparent withdrawal syndrome but addiction to either can devastate lives. Non-substance addictions such as gambling, sex or internet also have no physical dependence. What is common to all these addictions is the unnatural cravings that prompt the compulsive behaviors.
Physical dependence can occur without addiction; this is the common experience of most chronic pain patients who are able to take their opioid medication as prescribed for pain but don't develop the uncontrollable compulsion and loss of control. A desire to avoid withdrawal is not addiction.
Modern Addiction Treatment
Evidence-based addiction treatment is aimed at correcting the brain adaptations associated with addiction, not physical dependence. Because physical dependence is normal and reversed with a slow taper, treatment medications simply maintain some of the existing physical dependence in order to suppress symptoms of craving and withdrawal. This allows the patients to make behavioral changes that will rewire the brain reversing some of the changes of addiction. Once the slow and deliberate process of reversing destructive brain adaptations is significant, a slow taper resolves the remaining physical dependence. The Neurobiology of physical dependence and addiction