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Tolerance, physical dependence, and psychological dependence are related—but still distinct—conditions that are often confused with one another. Understanding the difference between these conditions is important because the treatment considerations can vary widely. Pain patients, in particular, may be interested to learn that the likelihood of their becoming opioid-dependent is relatively slim, even when opioid use leads to tolerance or physical dependence.
Opioid Tolerance
Physical Dependence on Opioids
Psychological Dependence on Opioids
Common Characteristics of Opioid Dependence
Opioid Tolerance
Over time, repeated use of an opioid causes certain receptors in the brain to become tolerant (ie, less responsive) to opioids—in other words, more of an opioid is needed to produce the same effect.1,2 The neurological changes that cause opioid tolerance are predictable and well understood. These changes appear to correct themselves within a period of weeks after opioid use stops.2 Although tolerance is one of the traits often seen in opioid-dependent patients (see Common Characteristics of Opioid Dependence), in the absence of other symptoms, tolerance is not evidence of opioid dependence or misuse.1
Physical Dependence on Opioids
A physical dependence on opioids means that the brain has made so many changes in response to repeated opioid stimulation that it now actually needs opioids to function "normally."2
Pain medicine and addiction medicine specialists agree that most patients treated with opioids for long periods of time become physically dependent on them.1
If opioid use suddenly stops, patients who are physically dependent will experience withdrawal symptoms. Avoiding this withdrawal is the main reason behind the drug seeking and drug use of someone who is physically dependent on opioids.
(NOTE: SUBOXONE is not indicated for pain management. Patients with a clinical need for pain management should not be transferred to a SUBOXONE regimen, even if they are physically dependent on opioids.)
The neurological changes associated with physical dependence on opioids are predictable and well understood. These changes appear to correct themselves within a period of weeks after opioid use stops.2
Physical dependence on opioids almost always precedes opioid dependence (see Common Characteristics of Opioid Dependence). However, unless other symptoms of opioid dependence are present, physical dependence should not be viewed as "proof" of opioid misuse.
Psychological Dependence on Opioids3-5
Psychological dependence involves continued drug use for reasons other than tolerance and withdrawal, such as a desire to experience a drug's pleasurable effects. The hallmark of psychological dependence—compulsive drug seeking and use—stems in large part from intense opioid cravings caused by complex neurological changes.6
An individual is generally considered psychologically dependent when his or her opioid use continues in spite of its negative effect on the individual's life. For example, people who are opioid-dependent feel a need to keep using opioids even if it hurts their health, job, finances, or family.7
SUBOXONE is appropriate for the treatment of people who have become physically dependent or psychologically dependent on opioids AND who are not in need of opioids for pain management. SUBOXONE is not indicated for treating pain.
See the Dependence Identifier for a list of questions that can help identify possible opioid dependence, in yourself or someone you are close to.
| 1. | American Pain Society. Advocacy & Policy: Definitions Related to the Use of Opioids for the Treatment of Pain. American Pain Society website. Available at: http://www.ampainsoc.org/advocacy/opioids2.htm. Accessed September 21, 2004. |
| 2. | Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002;1:13-20. |
| 3. | Lintzeris N, Clark N, Muhleisen P, et al. National clinical guidelines and procedures for the use of buprenorphine in the treatment of heroin dependence. March 2001. Publication Number 2873. |
| 4. | National Institute on Drug Abuse. Research Report series: prescription drug abuse and addiction. Printed July 2001. NIH Publication Number 01-4881. |
| 5. | O'Brien CP. Drug addiction and drug abuse. In: Molinoff PB, Ruddon RW, eds. The Pharmacological Basis of Therapeutics, 9th ed. New York, NY:McGraw-Hill; 1996:557-577. |
| 6. | Camí J, Farré M. Mechanisms of disease: drug addiction. N Engl J Med. 2003;349:975-986. |
| 7. | World Health Organization. Lexicon of alcohol and drug terms published by World Health Organization. Available at: http://www.who.int/substance_abuse/terminology/who_lexicon/en/. Accessed April 21, 2005. |
| 8. | American Psychiatric Association. DSM-IV Criteria for substance dependence and abuse. In: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th edition. Text Revision. Washington, DC: American Psychiatric Association, 2000. |
