A couple of weeks ago, when I learned that I would have the opportunity to interview Mark L. Kraus, M.D., FASAM*, one of the nation’s top thought leaders on addiction, I asked you to tell me what questions you wanted me to ask. I tried to incorporate most of your questions into our discussion.
Dr. Kraus is an addiction medicine specialist and a diplomat of the American Board of Addiction Medicine. He is also an internist in private practice and Assistant Clinical Professor of Medicine at Yale University School of Medicine.
Dependence or Addiction?
I began our discussion by asking Dr. Kraus if he differentiated between dependence and addiction. He responded, “Yes, I think that physiological dependence and addiction are different.” He went on to explain that opioids work by binding to a mu receptor site, causing a biophysical and biochemical reaction. The receptor sites become so sensitive, or up-regulated, to the opioid that they must continue to be bathed in the chemical or they will scream, “Give me more!” If they don't get enough, they will crash. This same physiological reaction occurs whether a person is taking opioids to relieve pain or is abusing them.
“Where addiction goes further,” Dr. Kraus said, “is when it causes dysfunction in the person's life – financial, personal, legal problems. When it starts to interfere with their very being, I think we're starting to talk about an addiction.” He described addiction as a chronic brain disorder whereby someone becomes so up-regulated that tapering them off or withdrawing them from the medication becomes a really big problem. It can be done, but it is very difficult.
On the other hand, the pain medicine patient who is taking the medication properly, as prescribed, can usually be tapered down and off with much fewer problems. He concluded, “So I think the difference is the behavioral aspect.”
Tolerance or Addiction?
Some of you asked how to tell if you've just built a tolerance to the medication or the dosage of the opioid you're taking, or if it has turned into an addiction problem.
Dr. Kraus began by saying that when a patient is being treated by a licensed professional, who is prescribing opioids for pain management, they have a relationship. Then he went on to explain, “We've learned that opioids cause a thing called tolerance. You need more of the drug to continue to get the effect you're seeking. That's something, unfortunately, that's inherent in that class of drugs. It may very well be that they'll need to go up on their dose when it's not doing what the doctor and the patient want it to do.
“Drug seeking, drug behavior, misusing and abusing the script is not happening with the pain management patient, who is responsible and taking what the doctor said. The problem with the addict is they start misusing, abusing and diverting in an effort to buy more. That becomes an issue. Then the issues with their financial, legal and personal life become very much out of control and there's a big change in their behavior.
