The opiate deficit

One of the ways to look at opiate dependency is to view the problem as an opiate deficiency. People aren’t born with this condition. The deficit develops as a result of using much larger amounts of drugs that act at opiate receptors than would naturally occur. Our brain normally has only small quantities of endorphins (naturally occurring opiates) present. The exposure to large quantities of a similar compound changes things.

In some ways this is similar to developing one type of diabetes. Type 2 diabetes may occur after long-term exposure to larger quantities of simple sugars and other carbohydrates than the body needs to fuel a particular level of activity. This results in several changes including a decreased sensitivity to insulin. This exposure changes things – these people now need more insulin. They have an insulin deficit.

The bottom line is opiate dependent people have developed a need for a certain amount of opiates just to function; people without this problem do not. 

We could imagine a small pit on the surface of their brain. If this is filled with opiates they feel normal. Too much and they feel high, none or not enough and they don’t function well. Only opiates will fill this deficit -other drugs and combinations have been tried but do not work. 

Methadone and Suboxone work because they are opiates – they fill the deficit. 

Dependency vs. addiction

Dependency is defined by tolerance to a substance and a recognized withdrawal syndrome when the substance is discontinued. Dependency is inconvenient at times but it is possible to lead a normal and fulfilling life dependent on a medication that is an effective treatment – again think diabetes. Consider the following:

A 65 year old widow lives next door to me. She has rheumatoid arthritis but between her immune modulating medications and taking long acting oxycodone twice per day she is able to garden, take care of her house, her grand kids a couple of days per week and bake pies with the church ladies. She is considered a great neighbor. She never takes more of her medication than she should, she doesn’t use it to get high or for emotional support if she has had a bad day and has not altered the route of administration of her opiate – she always takes a whole pill orally as directed. However, if her family doctor went out of town and her prescription was not refilled she would go into the same withdrawal that an opiate addict would. She is opiate dependent but has a productive and fulfilling life.

Addiction is different. Addicts have a dependency but also develop maladaptive behaviors – behaviors that are not good adaptations. The behaviors are based on two things – finding and acquiring the drugs and also hiding from people that they need the drugs.

At first they withdraw from things they used to like doing then they withdraw from friends and then family. They start spending time with new “friends”. They divert money from where it should be going and then they start doing things they would have never imagined like lying, cheating or stealing. Some engage in prostitution or get drugs from their drug-dealing “friend” as part of the arrangement – trading drugs for sex. Some start selling drugs to keep up with the cost of their habit. They may even try to recruit new people to drug use. Eventually they become alienated from their family and get in trouble with their boss or agencies like the police, Children’s Aid, Canadian Revenue Agency, Ontario Works etc. At some point they look in the mirror and ask “who am I”. Most try quitting at least a few times on their own but find they can’t function without the drugs. This is when they first think about coming to BMC.

What we do at BMC is help the motivated opiate addict by providing them the correct dose of the medication their brain needs to function. Once their brain is taken care of they usually take the opportunity and start changing their life – a process known as recovery.

In short, motivated opiate addicts gradually transition to being just opiate dependent. They lose their addictive behaviors and re-enter society. Being opiate dependent does not prevent one from having a happy productive and fulfilling life. Being an opiate addict most definitely does.

Is methadone and Suboxone maintenance just switching one drug for another?

Many opponents of methadone and Suboxone therapy suggest that our patients are just switching one drug for another. This is wrong – imagine an alcoholic telling you he got off the beer by drinking wine. Obviously, he is still drinking alcohol.

Anything that works at the opiate receptors can be considered an opiate. Our patients are still taking opiates because opiates are the only class of compounds that will fix the opiate deficit. Essentially they are still taking the same “drug”, they have not switched one for another.

The difference is, of course, that now the opiates are in the form of a prescribed medication which is closely monitored by a team of physicians, nurses, case mangers and pharmacists. The patients no longer have to pursue the illicitly acquired drug with all the associated risks and expenses of doing so. Finally, they are again free to make choices. Most make the right ones.