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Regular use of an opioid for any reason rapidly induces physical dependence, characterized by a highly unpleasant withdrawal syndrome when the drug is discontinued or rapidly decreased in dosage, or when an antagonist is administered. The acute withdrawal syndrome generally consists of signs and symptoms opposite to those of the drug when initially administered: severe dysphoria, anxiety, eye tearing, a runny nose, goose bumps, cramps and deep pains are common.
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The speed and severity of withdrawal depends on the half-life of the opioid – heroin withdrawal occurs more quickly and is more severe than methadone withdrawal, but methadone withdrawal takes longer. The acute withdrawal phase is often followed by a protracted phase of depression and insomnia that can last for months.
Physical dependence is completely distinct from and does not imply psychological addiction, defined as uncontrolled drug use despite harm. However, physical dependence can certainly aggravate psychological addiction when it occurs. Withdrawal symptoms can be greatly lessened by slowly tapering the dose over days or weeks, sometimes after switching to a long-acting opioid such as methadone. The symptoms of opioid withdrawal can also be treated with other medications, such as clonidine for sympathetic hyperactivity and a benzodiazepine for anxiety and insomnia. “Rapid detox” is a relatively new technique that uses opioid antagonists to cause acute withdrawal while the patient is under general anesthesia to eliminate the otherwise extreme discomfort. This procedure has attracted considerable controversy due to its high cost and risk; several patients have died during the procedure.
Many pain specialists consider the procedure unnecessary, and addiction specialists criticize it for doing nothing to keep an addict from relapsing into opioid abuse after the procedure is complete. Rapid detox also does not alleviate the protracted withdrawal syndrome that lasts for weeks or months after the acute phase. Although physical dependence is nearly universal among those who use opioids regularly, true addiction is actually quite rare even when large amounts of opioids are used over long periods of time to treat chronic pain under the close supervision of a doctor. This is thought to be due to the rapid development of tolerance to the euphorigenic properties of opioids; without euphoria, only the unpleasant side effects (such as bowel dysfunction) remain so there is no motivation to take more than is needed to manage pain.
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