Understanding Dependence
Opioid dependence is a sensitive topic. But it is important to understand if you are taking opioids long-term.
Dependence is one of the most common side effects of opioids. It is not about character, lack of willpower, or moral weakness. Instead, it is the body’s natural response to opioids and can happen to anyone.
Our goal in this module is to help you feel less shame or judgement when considering how dependence on opioids may be affecting you. We also want to encourage you to reach out to your friends, family, and health care team if you think you might need help managing dependence.
Check Your Understanding
Here are a few questions for you to try answering. You won’t be graded on your answers. These are just for you to see what you already know about this topic.
Learn/Refresh
What is dependence?
Opioids change the body and brain in ways that almost always lead to physical dependence and may also lead to psychological dependence.
When someone is physically dependent on opioids, they get withdrawal symptoms if they abruptly stop taking the medication. These can include pain, nausea, and anxiety.
Some people also become psychologically dependent. This means that opioids become central to their thoughts, emotions, and activities — so much so that they have a strong desire for opioids (or craving), despite possible harm.
Sometimes, dependence leads to Opioid Use Disorder or OUD (what many people call addiction).Opioid use disorder is when someone keeps using opioids even though it causes serious problems in their life. They may struggle to stop, even if it harms their health, behavior, or thinking.
Dependence is not the result of misuse
Dependence is not a result of misusing opioids or not taking them as prescribed. It is simply a biological process of your body adjusting to opioid medications.
Most people who develop tolerance and withdrawal symptoms are not taking opioids to get "high" but are using them to relieve pain. However, they may be finding that their current dose does not last as long or work as well as when they first started.
We used to think opioid misuse was necessary for someone to develop opioid use disorder. But new research shows that up to 2 in every 3 people who develop mild opioid use disorder have no history of opioid misuse.
Signs you may be developing a dependence
There are many possible signs of opioid dependence. Here are some of the most common:
Pain that continues despite taking opioids
Difficulty reducing your dose (tapering)
Not believing that other approaches could help manage your pain
Increased anxiety
Changes in your social life or how you interact with other people
Persistent thoughts about opioids (for example, thoughts about your next dose and concerns about running out)
Depression or other emotional symptoms between doses or when trying to taper
Good News
The good news is that you can take steps to stop using opioids and end opioid dependence.
Many people stop using opioids by gradually reducing their dose (tapering). If you taper, you may find that you have the same pain as you did while taking opioids — or even less. Also, your ability to find pleasure in other activities and your overall health and daily life may improve, even if your pain stays the same.
If you have opioid use disorder, you can consider starting buprenorphine or another medication for pain that is safer than opioids. These medicines can give you relief from the tolerance and dependence opioids create. They may also help with depression.
Consider having a frank discussion with your doctor about what might be good options for you. This may open new possibilities for making the tapering process easier.
How dependence develops
Taking prescription opioid medication causes your body to make less of its own opioids. Natural opioids help regulate many different systems in your body, including:
Pain
Stress hormones
Feelings of pleasure and satisfaction (your body’s reward response)
Heart and circulation (cardiovascular) health
Protection from infection
And more
When you start taking opioids medications, your brain reduces its production of natural opioids to restore balance. When this happens, your body becomes dependent on opioid medications.
Physical dependence usually happens within a couple weeks of taking opioids. But it can be faster or slower for some people.
Some changes that lead to physical dependence can happen as early as the first dose.
As your body adjusts to an opioid medication, you can also experience increasing tolerance. This means you need more opioids to get the same effect.
Dependence and tolerance often result in increased pain, anxiety, loss of pleasure, and several other symptoms.
Some people also develop a psychological dependence — their desire for opioids becomes central to their thoughts, emotions, and activities.
If someone is physically and psychologically dependent on opioids, they may have opioid use disorder or OUD. Symptoms can include cravings, changes in how they interact with others, and the need for ever-increasing amounts of opioids to soothe their withdrawal symptoms.
Reflect
Prescription Opioid Dependence Assessment
This exercise has questions to help you think about how opioids are affecting you on a day-to-day basis. You don’t need to share your answers with anyone, so try to be as honest as possible. But if your answers surprise you, consider sharing them with your doctor or another member of your health care team. The answers may also help you consider what the next steps on your journey might be.
Click here to download the exercise worksheet
Consider these possible next steps:
Share one or more of the insights you gained from the exercise with your doctor or another member of your health care team.
Reflect on how tolerance, dependence and opioid use disorder may be affecting your life.
Resources
Information about OUD for patients
https://my.clevelandclinic.org/health/diseases/24257-opioid-use-disorder-oud
https://www.hopkinsmedicine.org/health/conditions-and-diseases/opioid-use-disorder
Information about OUD for doctors
Guide for Veteran’s Administration (VA) doctors on how to help patients with OUD
In Pain, by Travis Reader
In Pain is a memoir. It was written by a bioethicist (a person who helps doctors and researchers make ethical decisions in medicine.) The author personally struggled with opioid addiction and withdrawal. If you want to read it but don’t want to buy it, ask your local library if it’s available for checkout.
Description of the book from the publisher: https://www.harpercollins.com/products/in-pain-travis-rieder?variant=32207679684642
Selected scientific articles