Why Medication for Opioid Use Disorder Is Not “Trading One Drug For Another”

Part 1: Defining Addiction

A 22 year old male is sitting in bed, pale and mildly short of breath. He is recovering from a surgery on his heart valve which was badly damaged by infection he developed from injecting drugs intravenously. His pain is being treated with a combination of medications including buprenorphine. He feels it is working well and he is not having any withdrawal which he considers a small miracle. However in discussing his ongoing healthcare, he notes that he does not want to continue on buprenorphine after this hospital stay because ‘he does not want to trade one drug for another’. He intends to stop his use because he has now had a wakeup call and does not believe he needs anything else. He has tried to stop in the past without success….but now he feels absolutely sure…he’s got this.

The above is a fictional example of real conversations I have had with innumerable patients. This phrase of ‘replacing one drug with another’ is a common refrain echoed by groups as variable as Uncle Joe at Thanksgiving, politicians, the NA meeting counselor in recovery, and those in active addiction seeking treatment. It is even uttered by physicians. And repetition of this inaccurate statement is deeply damaging. It prevents those seeking recovery from utilizing all of the tools available to them in their recovery…the very tools shown over and over again to be the most effective. And it makes my eye twitch with anger.

In order to understand why medications like methadone and buprenorphine used for the treatment of addiction are NOT just trading one drug for another, we must look closely at what addiction is and what the medications do.
Medical professionals use sets of symptoms to help diagnose substance use disorders. The most recent criteria are in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (aka the DSM-5) which came out in 2013. There are different entries for each substance including alcohol but if you look at the criteria for each substance…you will see that the criteria are essentially the same for each one. And that right there is our first clue that the drug alone is not what defines a substance use disorder. ‘Dependence’ alone is not what makes a substance use disorder.

To better understand, let’s look at some vocabulary:

Hazardous use: Using a drug (or drinking alcohol) in a pattern which increases the risk for health problems Harmful Use: The drug or drinking IS or HAS caused health problems Substance Use Disorder: Ranges from mild to severe based on how many of the symptoms (criteria) the person has. In simplified language the criteria are that in the last 12 months the individual has:

1. Used more of the drug or used over a longer period than was intended
2. Wants to or has tried to cut down/stop the drug and just can’t seem to
3. Spends a lot of time getting, using, or recovering from the drug
4. Craved the drug
5. Been unable to do what needs to be done at home, at work, and/or at school
6. Keeps using even when it keeps causing problems in relationships
7. Given up or lessened hobbies or social/job roles because of the drug use
8. Continued using the drug in hazardous situations
9. Continued using despite knowing of a health problem caused or worsened by the drug use 10.* Physical tolerance is present meaning more drug must be taken over time to get the same effect 11.* Withdrawal is present if one suddenly stops taking the drug

If you have 2-3 of these criteria it is consistent with mild opioid use disorder, 4-5 with moderate disorder, and 6 or more is consistent with severe opioid use disorder. Symptoms number 10 and 11 are sometimes referred to colloquially as ‘dependence’ but this term is no longer recommended. More importantly, symptoms number 10 and 11 don’t even COUNT for opioids if you are taking them under appropriate medical supervision and as prescribed. This is because even an 80 year old man taking 10mg of oxycodone a day for his arthritis pain who never misuses it, has no cravings, no signs of an addiction, will still likely need medication increases one day as the medication becomes less effective (Criteria 10) and will become suddenly ill and go into withdrawal if the medication is suddenly stopped (Criteria 11). Withdrawal IS NOT THE SAME AS ADDICTION.

The Opposite.

Part 2: How Opioid Treatment Medications Do not Meet Criteria for Addiction

So…. What if you are receiving a medication like buprenorphine or methadone from a physician and using it as intended for treatment of your opioid use disorder? How are we doing now on meeting those criteria above? Well you WILL experience withdrawal if you suddenly stop taking this medication (Criteria 11)… but as we just noted, tolerance and withdrawal don’t count when taking a medication as prescribed. So that’s out. Cravings for other drugs may be present but usually fade over time and generally it is not these medications that are craved but the heroin or opioids that originally caused the use disorder. And I guess if we wanted to be SUPER technical we could say some people might still fight with loved ones over using this medication…but now these fights are often because the loved ones question if the person ‘really needs’ the medication and says they are ‘just trading one drug for another’.

What about those other criteria. What we see that what people on these medications are doing is working on developing new and healthy coping skills. They reach back out to friends and family to repair relationships. They seek work and get jobs. They go back to school. They go to doctors’ visits and counseling visits and get healthier. THEY. STAY. ALIVE. The drugs being used in addiction take a person away from their interests, away from their values, away from their loved ones, away from themselves. The medications in treatment and recovery are helping to stabilize the changes in the brain so that they can return to these things, return to these people, return to themselves. THIS IS LITERALLY THE OPPOSITE OF ADDICTION.

These medications are not panaceas. They alone do not solve substance use disorders. But the evidence is VERY clear that for more severe addiction the medications are SIGNIFICANTLY more likely to keep someone in recovery, engaged in care, and alive. So our theoretical patient absolutely can decide he wants to stick with counseling and social programs alone. But if he decides not to be on medication it should be because he truly understands the risks and benefits of it and has decided it is not consistent with his goals, needs, or abilities…not because of a snappy catchphrase and fear of judgement from others.

Note to readers: A future post on cross-addiction (truly trading one drug for another) will eventually be coming