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Drug War Hurts Pain Sufferers
May 28, 2003
Maia Szalavitz
What the media doesn't tell you

Pain treatment should be worlds away from the war on illegal drugs. Few believe that denying the dying pain relief is moral or appropriate; and yet research finds that between 50-70% of those dying of cancer do not get needed medicine because of fears related to addiction and drug–law enforcement.

Doctors have been prosecuted for giving doses of drugs that pain experts say are perfectly appropriate to treat chronic pain; their colleagues cite fear of prosecution as the main reason they don't give high enough doses of opiate medications. The media madness over Oxycontin abuse has set back pain relief efforts even further.

One root of the problem is confusion over the definition of addiction. Drug warriors have defined addiction as a property of a drug - i.e., certain drugs cause addiction in anyone who takes them for long enough and in high enough doses. That is why such drugs must be banned or tightly controlled if needed for medical treatment.

But as a recent article from Reason looking at heroin shows,  addiction is not merely a matter of physical dependence. Physicians and addiction experts define addiction as compulsive use of a substance or activity despite on-going negative consequences. Physical dependence may be part of the problem, but it is neither necessary nor sufficient to define it.

The definition of addiction as compulsive use despite consequences developed as research made abundantly clear that physical withdrawal symptoms are not what keep addicts hooked. The psychological drive to get high has been found to be far more important. This is why cocaine is considered highly addictive even though addicts don't get physically ill when they stop taking it.

It's also why Mark Twain's line about quitting smoking has become a cliche: "Quitting is easy, I've done it a hundred times." The real problem is not getting through the initial withdrawal - it's not starting again later.

Furthermore, if physical dependence on a substance was all that were needed to define addiction, all humans would have to be labeled air, food, water and shelter addicts.

What this means for pain patients is that even if they develop a physical need for painkillers - even if they suffer nausea, shaking and vomiting if the drug is suddenly withdrawn - it doesn't necessarily make them addicts. In order to become addicted, the drug has to have negative consequences while the person takes it and they must be obsessed with the drug experience.

If a drug is simply allowing someone to function normally and improving their life by reducing pain, they are not an addict. Unfortunately, many pain patients aren't aware of this, and there have been news accounts of Oxycontin patients, who were doing well on the drug, stopping cold turkey because they'd read it would make them into junkies.

The notion that physical dependence isn't addiction also undermines the idea that particular drugs in and of themselves can cause addiction. This, in turn, causes ideological problems for those who want to tar certain drugs as always bad. It's hard to have a war on something that in certain circumstances for certain people works wonders. The medical marijuana debate is a case in point.

The confusion over the concept of addiction has also caused problems in the treatment of depression. It has become clear that certain antidepressants lead to physical dependence including withdrawal symptoms if they are suddenly stopped. Most notable amongst these is Paxil (paroxetine). A group of patients is now suing the manufacturer of the drug, claiming that it is addictive because they developed physical dependence.

Of course, by the standards of addiction experts, Paxil doesn’t meet the criteria simply by causing physical dependence. There are blood pressure medications that, if stopped suddenly, can cause withdrawal; yet no one craves them. The Paxil case is slightly more complex, because the drug is used to improve mood. Nevertheless, people don't sit around reminiscing about the Paxil high and they don't increase their dose over time to chase this. Instead, they find it uncomfortable when they try to stop. That itself may be a problem; but it's not addiction.

The last 30 years have brought about dramatic advances in addiction research and a remarkable improvement in medicine's ability to control pain and depression. The media's ideas about addiction need to catch up with the science and help inform the debate.



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