Episode 2 – What Is Addiction?
Dr. Ashish Bhatt ❘
What is addiction? Breaking down our brain’s behaviors.
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Hayley: Hey, everyone. My name is Hayley, and this is Straight Talk With The Doc: a podcast with expert insight on addiction, mental health, and treatment. Our expert is addiction medicine specialist, Dr. Bhatt. How are you doing today?
Dr. Bhatt: I’m good, Hayley. How are you?
Hayley: I’m doing great, thank you. On this episode, we are going to talk about addiction versus dependency, as well as the drugs of today and what effects they have on the user. Using certain drugs, even exactly as prescribed, can still result in the development of a physical dependency, and one of those drugs of today is Opioids. Over the last 30 years, rates of Opioid abuse and overdose have risen drastically. Dr. Bhatt, are you seeing a lot of people entering treatment for Opioid abuse?
Dr. Bhatt: I think this has been a persistent theme of any talk that I’ve given or even in our podcast episodes. We know that even if you’re not in the healthcare field, even if you’re not even knowing somebody who’s addicted, it’s just so prevalent right now that not only are we seeing it of course in treatment, but we’re seeing it in the news. We’re seeing it all over the place. It’s a constant battle. There’s a rise, especially since the pandemic started or during that I think that was even a highlighted issue that Opioid abuse, dependency, whatever you want to call it, overdoses. It’s a huge problem here in America and in other parts of the world.
Hayley: What are the risks of taking drugs like Opioids, even if someone’s taking it exactly how it’s prescribed?
Dr. Bhatt: With this whole, we need to prescribe pain medications for people suffering from pain, that whole act in the best interest of the patient was pushed many, many years ago as an additional vital sign that we needed to recognize. And I know that led to a lot of overprescribing and a lot of marketing endeavors by pharmaceutical companies. This confluence of things that came together of why there were so many Opioids that were not only being used, but then were being diverted and sent out on the street on the black market. As we fast forward now where people maybe historically started experimenting with cannabis or alcohol, there’s been a bit of uptake in people who are now using Opioids, pills, or whatever. Not necessarily jumping into Heroin as a first line drug of abuse, but even just experimenting with it. The key here though, is with Opioids, the mechanism of action, and I’m talking straight pills here. I’m not talking about Heroin, I’m talking about pills that are made by pharmaceutical companies. These inherently, due to the mechanism of action and the pharmaceutic dynamics we call that, or the effect the drug has on the body, they can make you physically dependent even at therapeutic dosages. One I guess factoid, or one thing that has been highlighted, is that 50% of the average population, even if given a prescribed therapeutic dosage, could be physically dependent in as little as 2 weeks. One of the dangers here is that even though these medications have a proper medical usage they can and will over time, depending on the human being and the duration taken, will end up causing some level of physical dependency. Now again, does this mean addiction? No. But there you go, you’re going to have a risk if you don’t slowly come off of it. You’re going to have some sort of withdrawal. This right there is a huge risk factor for somebody who may be going from a usage to a dependency, and a dependency to an addiction. And I think people who are miss-using it don’t realize this.
Hayley: There’s a big difference between experimenting with opioids, and experimenting with alcohol or something like Marijuana.
Dr. Bhatt: Yeah, and again, there are risk factors here. And I’m not going to say that alcohol usage, abuse, and dependency, alcohol use disorders in general, they’re one of the biggest problems we have worldwide. But, there’s a different way that alcohol works on the body and the brain, and the different mechanism of its action, where Opioids have a different way of making somebody tolerant and needing to use more to get this desired effect. And even if that effect is not a misused effect of euphoria or some alternative sensation to legitimately take away your pain. The fact is that just by the nature of how it works, it will cause a physical dependency a lot quicker than most other drugs we have out there, including alcohol.
Hayley: Can you explain what the difference is between physical dependency and addiction?
Dr. Bhatt: Physical dependency is exactly kind of what it sounds- it’s somebody whose body has adapted to needing that drug or that agent to the point where if you take it away, you’re going to feel it. You’re going to feel it physically and possibly psychologically. But the physical dependency is what we’re highlighting here, is that your body becomes accustomed and tolerated to taking something and it needs to slowly wean itself off to not have a withdrawal effect. And that could often be very negative. But, an addiction is a whole constellation of symptoms, where it’s affecting not only your neurobiology, but then your psychology. It’s affecting why you’re pursuing something and are you pursuing something despite its detrimental effects and consequences in your personal life and your professional life, and your educational life, and your life in general in any domain and all domains. And where you can abstain, or you have behavioral losses of control, you crave it, or you can’t recognize negative- there’s a pothole in front of you. Don’t step in it- emotional dysregulation. This whole motivation, memory, altered brain circuitry, the pursuit of an alternative reward that goes in a cycle where you psychologically need it, physically need it. And you’re doing it despite all these negative factors. That’s addiction, where, what I said before- physical dependency does not include all of that. Addiction does often have physical dependency as a part of it, but just because somebody’s physically dependent on something doesn’t mean they’re addicted to it.
Hayley: Is there a difference between psychological addiction and dependency, or is that the same thing?
Dr. Bhatt: With physical dependency, we’re talking about basically the physical symptoms that you’re going to feel when you’re coming off of something. If somebody is physically dependent on Opioids, they’re going to have a withdrawal effect that is going to be increased pain, nausea, diarrhea, vomiting, muscle aches, watery eyes. But, that could just be the physical dependence without thinking that, “Hey, now I’m super depressed and I’m miserable and now when I don’t have it and I’m not withdrawing, then I’m still craving to get the drug again or I’m thinking about it all the time.” Psychological craving and dependency, that is a part that often goes more towards the addiction constellation of symptoms. And most people who are physically dependent, taking something at therapeutic dosages or taking it because they’re prescribed and need to wean off properly, usually don’t have a psychological dependence as we see with somebody who suffers with addiction may have.
Hayley: I want to talk about people who actually seek out treatment. Maybe they started experimenting with Opioids and now they’re realizing that they can’t get off of them on their own. Do people end up in treatment who have a physical dependency, but not an addiction?
Dr. Bhatt: I’m going to be cautious in my answer here, because I want to say there’s a percentage that’s there. Most people that you do see ending up in treatment centers, rehabilitation, something’s gone wrong or something has happened in their lives that they’ve felt the need to cut down. It’s not the typical human being that is being prescribed medications by their doctor, taking it as prescribed for a legitimate pain condition and then all of a sudden, feels, “I need to stop.” Well, usually if they’ve done it with a doctor and the doctors done it properly, they can slowly titrate, meaning cut down on the dosages in a proper proportionate manner over a period of time while the pain condition is either resolved, or substitute with something else. And that can be done without seeking psychosocial or addiction treatment. Cutting to the point that you’re making- yeah, there are going to be many people, probably younger people, who have gotten involved in the drug of the day, which is Opioids or whatever kind of “codones” that are out there. And they started taking them and they’re probably taking them to have a good time and getting high. But because of like what I said earlier, the nature of that drug- you’re going to get high. You’re going to get physically dependent on it. And then you’re going to stop and you’re going to run out of that drug, and what are you doing to go? You’re going to start having a withdrawal, and then you’re going to need treatment for that. You’re going to need help for that. If you are doing this illicitly- if you’re getting it off the streets, doing it in a club while partying, often you’re going to be seeking help. And that cycle might play out for a little while, but that person might be just trying to continue to use now to just get rid of those negative physical withdrawal symptoms. And they might have no choice but to end up in treatment, because their family members recognize that they’re going through withdrawal. They might make a big mistake or make errors and they’re feeling so bad. They might end up saying, “I need help” and addiction treatment is where they go. But, does that in essence necessarily define that person as a full-blown substance use disorder addicted individual? I wouldn’t say so. I think that person is physically dependent and went through experimentation and now has gone through the cycle. But that’s a real small population, because I don’t want our listeners to hear that and think, “Hey, that’s what I am. Dr. Bhatt said that now because I’m physically dependent I don’t have a substance use disorder and I don’t suffer with addiction.” But I do believe and I do see it. And I think those people when the detoxification process takes place and the withdrawal is mitigated, they don’t stop, because there’s no motivation to stop because their psychological pursuit was still in that whole. “I want to go have fun. I want to get high and want to maybe smoke weed”, but it’s not because their life is totally consumed with it. I believe the highlight here is that the physical nature of the drug led them to early withdrawal, and the treatment was in an addiction center. But that doesn’t mean because we treat withdrawal we’re treating addiction, because withdrawal and addiction are not equal in definition.
Hayley: How can we give a better diagnosis to those people seeking treatment? How can we tell who only has a physical dependency, but not an addiction?
Dr. Bhatt: I think we see that evolution when you’ve gone away from the substance abuse and substance dependency definitions to substance use disorders. And we’ve also, for the clarified stuff that might be a substance dependency that might be a secondary to physical treatment or medication treatment prescribed by a doctor. There are ways that we can address physical withdrawal, even if it’s where the scope of expertise is in an addiction treatment center, and highlight and clarify that this is because of withdrawal of substance use or substance use disorder that that has been caused by or the result of some sort of medical treatment, and we’re able to clarify that. But, again, that’s a very small number that we end up seeing, at least in my experience and I’ve been doing this for quite a few years. We don’t see it that common. We often see it in private practice, that we see people who haven’t had their lives spiral out of control. And I think the key point here is that when it’s not an isolated incident, these people that I’m trying to describe that might just have pure physical dependency, maybe have intact areas of their lives otherwise. And their lives basically aren’t spiraling out of control. And again, these are degrees. I’m not trying to paint this broad picture of everybody because this is not a one size fits all condition. But the bottom line is that somebody that comes into treatment- we should as doctors, and as practitioners, help clarify if their physical dependency is strictly nature to treatment that we identify that properly. And we don’t call this an addiction, and we help this person seek alternative methods to cure whatever that they were using the medications for, alternative methodologies to treat. There are many. And especially because we are talking about pain medications here, involve specializations and specialties that focus on pain management. So, there are other avenues, but we do have a responsibility to highlight that and diagnose it accurately. We can’t just label everybody with the word addiction. We can clarify that.
Hayley: Besides pain management, how is the treatment approach different for someone with just a dependency?
Dr. Bhatt: I think that whole psychosocial component to rehabilitation, which is so profound with somebody who suffers with addiction- and when I say profound, meaning we have to emphasize that. Addiction is a result of your environment, your genetics, your underlying medical conditions, your usage of drugs- how often you use it, when you first starting using it, and this, again, influence on the relationship between your brain and neurobiology, your psychology, all of this stuff together. So that when you walk out of treatment or walk away from acute treatment that you know that you have built some level of resources within yourself that you can tap into. So you’re not going to get provoked by or around the same environmental cues, or social triggers, or psychological stressors that led you to use. Where somebody with physical dependency, usually like I said is circumscribed, hopefully it was done just to treat something legitimate and they developed a physical dependency as a result, then hopefully that, one- Opioids are usually used for short-term conditions. They’re not meant for long-term pain except for certain chronic conditions. But I don’t want to highlight that they’re opposed to the fact, to answer your question, is that we can again, hopefully alleviate them, treat them with proper medications to help taper them off, and help them get into the proper medical follow-up and the medical treatments that can now be hopefully be helpful because that acute situation has resolved. Because often times, it’s not as much as they became psychologically addicted in this small population that we’re talking about. We’re talking about they don’t know how to get off of it because they don’t want to go through that withdrawal that’s so painful. Once you get that slow taper and you titrate them off properly in a controlled environment, then you can hopefully have this person set up to either resolve themselves- because by nature of this distinguishment that we’re making here, they’re not suffering with addiction. They should be able to go on their way with that education that they’ve given during that detoxification period and set up with a proper aftercare to address any other residual issues. Where addiction has a whole constellation and chronic follow-up, those who have suffered, hopefully from just a dependency caused by not knowing or being on something a long time, if the offending issue has been resolved and then the detoxification has been done properly and they don’t have any substance withdrawal, hopefully they can go on with their lives in a healthy manner.
Hayley: Dr. Bhatt, as an addiction specialist, what do you think people should understand about the relationship between addiction and the drugs that cause physical dependency?
Dr. Bhatt: You’re just adding a huge risk factor to develop addiction, because, remember, addiction is the result of a multitude of things on top of your genetic make-up. And we’re not talking about genetics just as inheritance, again, I’ve talked about this before. It’s just a construction of your body on a microscopic level. Nobody knows exactly beforehand what relationship you’re going to have with substance before you use it, until you use it. Now, once that gets conditioned either through positive or negative reinforcement, and your environment, and other reasons of why somebody might continue to use. When you add the fact that a drug by virtue of its rapidity to develop some sort of physical withdrawal if you go to stop it, well, there you just added a risk factor to have to need it again. And so, for those who are listening, when you are going to go out there and use something, not just Opioids- Benzodiazepines are like this, alcohol is like this- by not including another array of drugs I’m not condoning them directly. I’m just saying there are certain drugs like Opioids, like Benzo’s, like alcohol, that cause physical dependency and cause it quicker than other drugs that don’t. And that then will increase your risk factor to develop because again. We don’t know how things are going to play out. But if at that time somebody’s also depressed or anxious, or gets rewarded somehow by continuing to use it, or escapes from their pain by continuing to use it, well, right there, those are additional risk factors to continue to develop an addiction. Anything that can cause physical dependency quicker has a risk.
Hayley: Is there anything else on this topic that you think people should know?
Dr. Bhatt: I think our last question kind of did highlight it, that Opioids are dangerous because of, again, if used properly for short-term legitimate reasons they have tremendous utility. They’re there. We wouldn’t be able to get through so many of our medical issues without these medications. But at the same time, for those who are new or using early in life and they have no real issue other than they want to just have a good time, they have to know that this drug is super dangerous. And it can cause physical dependency so quickly that even though you go to put it down, you’re not going to be able to because you’re going to be in a tremendous amount of pain once that physical withdrawal sets in. And it sets in super early. I mean, I can’t highlight that enough. One thing that we always talk about with this whole Opioid epidemic is it being caused by over-prescribing. We don’t want to see that again in a different way by us trying to patchwork and use other medications either, or over-treat with medication assisted therapies that can also cause dependency without people knowing about that, too. Without going into a whole separate topic, my point is that Opioids cause physical dependency very, very quickly and it’s just going to increase your risk for a lot of pain in your life if you’re doing it for non-legitimate reasons.
Hayley: Thanks for breaking that down, Dr. Bhatt. It’s important to spread awareness on the risks of using any drugs or alcohol. I don’t think anyone goes into it with the intention of becoming dependent on a substance but unfortunately, that is the reality for a lot of people. And it’s also important to reiterate that no matter what stage of addiction someone is in, there are options for help and intervention. You can learn more about that at addictioncenter.com, as well as listen to more of our podcast episodes there. Thank you for listening to this episode of Straight Talk With The Doc.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.