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There are some stories American journalists don’t like to tell. One of them is about pain treatment: Virtually every single article about it in the mainstream media downplays the effectiveness of opioid treatment for pain, and massively hypes the risk of addiction.

Newsweek’s “The New War on Pain” cover story last week was a classic in the genre. Its first mention of opioids is in the context of addiction, citing new medications that “pack all the punch of narcotics with less of the specter of addiction.”

The article goes on to conflate addiction and dependence as it describes one of the new medications, saying that “Patients can still become dependent on a new form of the morphine derivative called Kadian, for instance, but if they crush one of the pills for snorting, its center explodes, releasing a substance that blocks the euphoric high.”

What this misses is that addiction is not the same thing as dependence. Addiction, according to the most widely used definition in psychiatry and addiction medicine, is essentially compulsive use of a drug despite repeated negative consequences. Physical dependence is needing a drug to get by.

We are all physically dependent on food, water and oxygen, but only people like those who binge on Big Macs until they reach 500 pounds and can’t lose weight can be considered “food addicts.” If addiction and dependence are the same thing, however, we’re all food, water and oxygen junkies.

This distinction matters, as STATS has noted previously here. It matters because if addiction is dependence, all pain patients who need opioids daily are addicts; and prescribing to them can then be considered illegal, as “maintaining an addict” (with some limited exceptions) is against the law.

It also matters because cocaine doesn’t produce physical dependence: you can stop taking it without getting sick (though you’ll surely crave it and feel low) and both scientists and lay people used to argue that this meant it wasn’t addictive. The 80’s cocaine epidemic fed on this myth.

Furthermore, addiction isn’t caused by simple exposure to “euphoria” from drugs; people who take Kadian as directed are just as likely to get euphoric as those who take non-abuse-resistant formula as directed. The abuse-resistant formulation makes the drug less attractive to pre-existing addicts who want to enhance their high by snorting or injecting – it doesn’t prevent physical dependence nor “euphoria” in patients.

Curiously, Newsweek goes on to describe how in clinical trials of these supposedly massively addictive drugs, one third of people drop out due to intolerable side effects. For a drug whose “euphoria” is allegedly irresistible, a drug that is supposed to make people into addicts upon exposure, that’s a remarkable fact.

The truth is, trials by the National Institute on Drug Abuse have found that most people actually don’t like the sensation addicts call the opioid “high;” they find it numbing and unpleasant. As a result, the risk of addiction is low.

And yet Newsweek claims that “Opioid users also run two parallel risks: that they will become addicted, and that they will suffer the stigma of addiction even if they're not abusing the drugs.” The risk of the latter is much higher than the former precisely because coverage like this does not distinguish between addiction and dependence.

Newsweek underplays the benefits of opioids in the same section, noting that less than a third of people in clinical trials find them beneficial. What it doesn’t mention is that clinical trials usually use standardized dosing and because of this, many people who would benefit from a higher or lower dose aren’t helped. The variability that makes some people find opioids blissful while others hate them also means that an effective dose for some will simply not even affect the pain of others.

The dosing problem plagues opioid treatment in the community as well: because doctors are frightened of being prosecuted for “over-prescribing,” they don’t keep increasing the dose until the patient reports relief. Instead, they try to prescribe the lowest possible dose for the shortest period of time – and then patients are surveyed about whether or not opioids help them and say “no” because they have never actually been treated with a therapeutic dose tailored to their needs.

The magazine also notes that the military wants to avoid an epidemic of addiction related to pain treatment, saying that “Addicted Vietnam vets still wander into VAs;” but it fails to mention that government-funded research found that while 50% of Vietnam veterans used heroin or opium recreationally while serving – and 20% used the drugs long enough to become physically dependent – within 8 months to a year of their return home, only 10% continued taking such drugs and just 1% were addicted.

In other words, even in the stressful situation of being a soldier in Vietnam, recreational users (not pain patients, who are at even less risk) did not face the monumental “specter” of addiction that the media attributes to these drugs.

And of course, the article fails to mention the prosecutions of doctors for “overprescribing” opioids and only touches on the difficulties patients have getting access to them.

While opioids do not help everyone, they are one of the best weapons we have in our existing arsenal to fight pain. Some evidence suggests that just like the nerve blocks touted in the article, high doses of opioids used early and titrated to a dose that gives full relief could, like the blocks, prevent acute pain from becoming chronic pain. Unlike the blocks, however, these are cheap, low-tech approaches that could be implemented widely immediately.

If only we would allow doctors to use these medications properly.

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