Iatrogenic Addictions

Q:  What are the two key features of addiction?

A: Continued use despite negative consequences & dishonesty.

Q: What is the difference between addiction and physical dependence?

A: Addiction is a complex biopsychosocial disease that is lifelong and potentially fatal. Physical dependence is a simple cellular adaptation to the presence of an external chemical.  Two other differences come to mind: relapse is common in addiction and never happens with physical dependence.  Treatment for physical dependence is gradual dose reduction, while treatment for addiction includes lifelong participation in a 12- step group.

Q: How can benzodiazepines be used appropriately in medical practice? 

A: Benzodiazepines are a controlled substance so they do have an abuse potential, but only for people with prior addiction to alcohol and other drugs.  Benzodiazepines can be used safely in persons without a history of alcohol and drug dependence.

Q: Why are prescription medications like oxycontin becoming important drugs of abuse?

A: They are becoming important drugs of abuse because they are so widely prescribed for outpatients.  This is a recent phenomenon…it has not happened in the last 80 years of medicine.  Because these drugs are so widely prescribed there is substantial diversion and addictive use.  

Q: Why is there an increase in oxycontin and methadone deaths?

A: Medical diversion is increasing and these drugs are lethal in naive individuals. When people take other people's benzodiazepines they usually do not end up in the emergency room or coroner's suite. With opiate drugs, death is always a possibility in the naive user. However, like benzodiazepines, these medications are very safe and effective when prescribed to the right patients and taken as prescribed. Pain is important to treat vigorously. There is no excuse for under-treatment of pain. So while pain medicines are very effective, they also can find their way on to the street as potent alternatives to heroin.

Q:  What can be done to increase the chances that a medicine will not become a drug of abuse?

A: First is not to prescribe controlled substances on an outpatient basis to people with a history of dependence.  Second is to educate patients who use controlled substances about their responsibility for the control of these medications.  Third is aggressive prosecution of people who divert these substances for non-medical reasons.

Q: How should pain clinics be organized to reduce drug diversion and drug dependence?

A: Most important, pain clinics need to be aware that diversion is a major problem that threatens the very existence of pain clinics.  They should also work closely with law enforcement agencies to prevent and prosecute diversion.

Q: Do you have a series of questions you would ask if you were a consultant asked to evaluate whether a pain medication or benzodiazepine is a drug of abuse or used appropriately as a medicine?

A:Well there are several things to look at:
a.    Is the medication effective? Is it usually effective at low and stable doses for people without addiction?
b.    Encourage pain specialists to communicate with family about the patient’s need for and response to medication.
c.    Be vigilant about honesty and dishonesty when dealing with patients, with honesty contingent for continued prescription
d.    Is the medication taken as prescribed?  Is it used to party or get high?  Is it mixed with alcohol or drugs of abuse?
e.    Is the patient honest about use, refills, MD prescribers and so on? 

Q: How do you distinguish medical from non-medical use of a prescribed drug?

A: There are several criteria to be evaluated. The first is intent; is the drug being used to treat a diagnosed illness or to party? The second is effect; does it improve or harm the user’s life? The third measure is pattern of use. Is the dose stable and sensible or chaotic and higher than necessary? Another indicator is control, is the use monitored by a physician or self-controlled? The final question is legality. Is the drug being used by the person as prescribed and is it prescribed in an appropriate dose?

Q: What are the factors that raise the risk of addiction?

A: Risk factors fall into two categories personal and environmental. The primary personal risk categories are: having an addicted parent or sibling, being impulsive and oriented to the present, having values that focus on personal feelings of pleasure or satisfaction rather than responsibilities to others, having no religious values, and being between 15 and 30 years old. Environmental risk categories are: being frequently exposed to alcohol or other addicting drugs, living in a family that tolerates drug use or excessive alcohol use, having a community that tolerates addiction and its consequences. 

Q: Is the drug problem becoming better or worse?

A: Illegal drug use has fallen in America from its peaks of the 1970’s and 1980’s. Infrequent drug use appears to be falling the most. Use of legal drugs, like alcohol and cigarettes, is falling more slowly. Drug-caused problems, both health problems and crime, are falling slowly if at all. Drug use, in the most heavily affected communities shows very little change. 

Robert DuPont, MD is a practicing psychiatrist specializing in the prevention and treatment of addiction for three decades. He was the first director of the National Institute on Drug Abuse (NIDA). Dr. DuPont was also the second "Drug Czar' (director of the White House office of drug abuse prevention). His second major area of progessional interest is anxiety disorders including obsessive-compulsive disorder and was the founding president of the Anxiety Disorders Association of America (ADAA). Dr. DuPont received his bachelor's degree from Emory University and his MD from Harvard Medical School. He did postgraduate training in psychiatry from both Harvard and the National Institutes of Health.