One of the major criticisms I hear about treating opioid dependence with buprenorphine is the claim that maintaining patients on medication is just ‘trading one addiction for another’.
A few weeks ago I talked about the new ASAM definition of ‘addiction’, but there is another important distinction that needs to be drawn when it comes to opioid addiction before we can be really clear on what it means and how it affects the lives of patients.
There are two main parts to opioid addiction, a cause and an effect. The cause, the root of the disease, is activation of the brain’s reward system, which causes physical dependence. Dependence is the condition of the brain where it thinks that a massive dose of opiates is necessary to its survival, and lack of that dose causes withdrawal symptoms. The effect, the symptoms of the disease that we try to treat, is the addicted behavior — the stealing, lying, lack of interest, neglect, and other behavioral changes that cause a patient distress and lower the quality of their life. These addictive behaviors generally arise due to a patient needing to satisfy their physical dependence; there is no evidence to suggest that these behaviors are innately present in out patients as spiritual or emotional deficits of character.
You can see how, though dependence often causes these behaviors, the dependence and behaviors can also exist apart from each other. People can suffer the behavioral and emotional impacts of addiction without being physically dependent on opiates — they may be psychologically dependent, or they may be suffering from other stress factors that cause them to treat the substance as though it was necessary for survival.
The opposite situation is also true. Many patients who are treated for chronic pain are certainly physically dependent on opiates, but do not demonstrate addictive behaviors. The current state of our knowledge of the brain’s opiate system is that, when a patient has been physically dependent on opiates for a long time, the damage done to the reward pathways is most likely permanent. At our current level of understanding there is no way to reset these pathways; the patient will always be physically dependent on opiates.
But medication maintenance can help us separate the cause of the disease — the physical dependence — from the effects that cause the patients pain and distress. Physical dependence is never going to go away, so the goal of medication maintenance is physical dependence without painful addicted behavior. We accomplish this by using medications that eliminate a patient’s cravings and withdrawal symptoms, so they can go about their lives normally, as though their brains weren’t dependent on anything.
So it’s true that patients being maintained on medication have traded one dependence for another, because there’s no way to make the dependence go away. But their addiction, as expressed in their emotions and behavior, can be — and is — successfully treated. To reject the medication method of treatment, to criminalize it because it doesn’t manage to eliminate the underlying dependence along with the addicted behaviors, does nothing but harm those patients who could most benefit from this chance to regain their lives.