A few months ago, a physician and good friend, Dr. Jennifer Schneider, called me out for inadvertently conflating physical dependence with addiction. What I have realized since then is many (maybe most) clinicians, not to mention the general public, have little to no idea that physical dependence and substance addiction are not synonymous. Hence, this article.
- Physical dependence is a property (a side effect, so to speak) of certain drugs. Physical dependence occurs because your body has adapted physically when you take a certain medication for more than a short time. Physical dependency can happen with or without addiction. It is defined by the presence of a withdrawal syndrome (a combination of symptoms) if the drug is stopped suddenly. Generally, withdrawal can be prevented in part or totally if the dose is gradually reduced.
- Addiction is a maladaptive coping mechanism that people use to avoid feeling stress, anxiety, depression, loneliness, boredom, and other forms of emotional discomfort. Addiction occurs because you are trying to escape from life. Addiction is defined using the following criteria: preoccupation to the point of obsession with obtaining, using, and recovering from the effects of the substance (or behavior), loss of control over use (often evidenced by failed attempts to quit or cut back), and related negative consequences. Addiction can occur with or without physical dependence. Either way, recovering from an addiction is difficult; typically, it is a two steps forward, one step backward process.
Physical dependence is common when people take Beta blockers (like Inderal), certain antidepressants (like Paxil), and corticosteroids (like Prednisone) for a month or two (or longer). With physical dependence, if you take a particular medication for a month or two (or longer) and then abruptly stop, you are likely to experience a specific combination of symptoms of withdrawal—which, depending on the drug, may include headaches, fever, nausea, diarrhea, sweats, chills, restlessness, irritability, sleeplessness, trouble waking up, etc.
Dr. Schneider actually provided me with some terrific examples of this phenomenon, telling me: “If a person who’s been taking Paxil for depression stops suddenly, that person is likely to experience flu-like symptoms. If someone with heart disease on a drug like Inderal stops suddenly, there is a risk of a heart attack. And if someone on a high dose of prednisone (say for asthma or an autoimmune disease) stops suddenly, that person can DIE. In fact, when I was a young medical resident, a chronically ill patient I was asked to see had chosen to stop his prednisone because he no longer wanted to live. A psychiatrist then evaluated him and decided that this man had the right to make that decision. A few days later the man died.”
Those examples sound nothing at all like addiction, do they?
The confusion (for me, when I’m not paying very close attention to what I write and say) stems from the fact that physical dependence can also occur with certain addictive drugs—like opioids, benzodiazepines, alcohol, etc. People can use these drugs as a form of emotional escape and numbing, becoming emotionally and psychologically addicted while also becoming physically dependent. This is why addiction rehabs often treat heroin addicts, for example, with titrated (gradually reduced) amounts of lesser opiates. Essentially, these addicts are weaned off their drug of choice over the course of a week or two as a way of reducing the potentially drastic symptoms of physical dependence withdrawal.
Another significant difference between physical dependence and substance addiction is that a person who is physically dependent but not addicted, once he or she been weaned off the medication, with or without withdrawal symptoms, will usually not crave that particular drug, whereas an addict, because he or she is emotionally and psychologically hooked on the substance and its effects, will crave it. And that craving may continue for years after quitting.
Consider, for example, my research assistant Scott. Scott is in recovery for alcoholism and marijuana addiction, and he also deals with occasional bouts of anxiety and depression. He says that when he first quit drinking and using pot, his depression and anxiety worsened, and his psychiatrist prescribed Paxil. After about 18 months on Paxil, he and his doctor agreed that he no longer needed it. Over the course of a month, he took smaller and smaller (titrated) doses. During that timeframe and for about two weeks afterward he had headaches (that gradually lessened and then disappeared entirely). In the almost 15 years since quitting Paxil, he has not once craved either the drug or its effects. Conversely, he thinks about having a cocktail or smoking a joint every time he has a bad day.
Put simply, Scott was physically dependent on Paxil but not addicted to it. When he quit using Paxil, he had symptoms of physical withdrawal that eventually went away, and he has not been tempted by it since. Meanwhile, his cravings for alcohol and marijuana—substances to which he is addicted—have never completely dissipated, and it’s possible they never will. No, he is not tempted to “pick up” nearly as often or as strongly as when he first started recovery, but the desire is still occasionally there. For him, physical dependency with Paxil was a short-term problem, while his addiction to alcohol and pot is a lifelong issue.
Special thanks are owed to Dr. Jennifer Schneider for her assistance with this article.