Addiction vs Physical Dependence

Addiction and Physical Dependence Are Not Synonyms

Benzodiazepine withdrawal syndrome from therapeutic use of benzodiazepines is a physical problem, not an addiction problem.

Making the distinction between addiction and physical dependence is important because the two issues are treated differently medically. For example, one wouldn’t treat an infant for addiction/drug abuse if the infant were born with a physical dependence.

A drug insert which accompanied a clonazepam prescription in the U.S.

Most Prescribed Benzodiazepine Patients Experiencing Withdrawal are NOT Struggling with Addiction

It is widely recognized in the existing medical literature that physical dependence can develop with the chronic use of many classes of medications. These include beta blockers, alpha-2 adrenergic agents, corticosteroids, proton pump inhibitors, antidepressants, and other drugs that are not associated with addictive “disorders.” While physical dependence and tolerance may be present in individuals with addiction (simply by way of taking the drug regularly), it is important to note that a person’s body may develop a physical or physiological dependence (and/or tolerance) to the presence of a chronically administered medication, without being an addict or having a substance abuse disorder. This phenomenon can happen to someone on heart medication or psychiatric medication, including benzodiazepines, when taken exactly as prescribed. The body’s acclimation to the chronic presence of the medication results in neuroadaptations and, ultimately, a dependency on the medication.

Physical Dependence is an Expected Outcome

According to The Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Benzodiazepine Risks Outweigh Benefits, physical dependence is an expected outcome associated with benzodiazepine prescription and is distinct from benzodiazepine use disorder. It states that physical dependence can develop within weeks and is heterogeneous across patients.

Between 20-100% of people taking benzodiazepines therapeutically/as prescribed long term will develop a physical dependence and/or adverse effects. This may include tolerance and withdrawal symptoms between doses (interdose withdrawal) which can look like addiction, but it’s not. Until further research is conducted in managing the problem, the most widely accepted approach to reverse a physical prescribed dependence to benzodiazepines is a slow taper to minimize the risk of a severe—sometimes lasting years— benzodiazepine withdrawal syndrome. Physical dependence occurs even if the medication in question is within the FDA approved dose range.

Why is this a problem?

The importance of distinguishing dependency from addiction is profound, because addiction protocols and “detoxes,” especially in the U.S., are not typically safe nor are they effective for people who are merely dependent on a benzodiazepine without a substance use disorder. While dependency can co-exist with addiction, most people experiencing benzodiazepine withdrawal do not have a substance abuse disorder, and therefore may be further harmed if the physical dependence is managed with the addiction model.

Patients who are not addicts are being treated for addiction – and that’s why addiction treatment doesn’t work for these patients.
This common misunderstanding is a primary reason why the epidemic with benzodiazepine withdrawal syndrome has gone on so long.

Definitions

In the U.S., a consensus statement released by The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine sought to define the terminology and recommended their definitions for use. The definitions presented in the consensus statement are as follows:

Addiction

Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

Physical dependence

Physical dependence is a state that develops as a result of physiological adaptation in
response to repeated drug use, manifested by withdrawal signs and symptoms after abrupt
discontinuation or a significant dose reduction of a drug.

Tolerance

Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.

The consensus statement goes on to explain the reasoning for defining and distinguishing the terms:

Physical dependence, tolerance and addiction are discrete and different phenomena that are often confused. Since their clinical implications and management differ markedly, it is important that uniform definitions, based on current scientific and clinical understanding, be established in order to promote better care of patients…

Clear terminology is necessary for effective communication regarding medical issues. Scientists, clinicians, regulators and the lay public use disparate definitions of terms related to addiction. These disparities contribute to a misunderstanding of the nature of addiction and the risk of addiction. Confusion…results in unnecessary suffering, economic burdens to society, and inappropriate adverse actions against patients and professionals

According to the FDA, who in their 2019 industry guidance, provided clarification of these terms:

Physical dependence is not synonymous with addiction; a patient may be physically dependent on a drug without having an addiction to the drug. Tolerance, physical dependence, and withdrawal are all expected biological phenomena that are the consequences of chronic treatment with certain drugs. These phenomena by themselves do not indicate a state of addiction.

Drug addiction is a cluster of behavioral, cognitive, and physiological phenomena that may include a strong desire to take the drug, difficulties in controlling drug use (e.g., continuing drug use despite harmful consequences, giving a higher priority to drug use than other activities and obligations), and possible tolerance or physical dependence.

The American Psychiatric Association also weighed in with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The DSM explains:

“Dependence” has been easily confused with the term “addiction” when, in fact, the tolerance and withdrawal that previously defined dependence are actually very normal responses to prescribed medications that affect the central nervous system and do not necessarily indicate the presence of an addiction.

Confusing Language

Because BIC’s focus is centered around raising awareness about prescribed benzodiazepine harm, please note and consider the following terms instead of addiction:

Iatrogenic/iatrogenesis (relating to illness caused by medical examination or treatment)
Prescribed dose/medication/drug dependence
As prescribed/doctor-prescribed/taken-as-directed
Therapeutic doses/use
Benzodiazepine-induced neurological dysfunction (BIND)
(Doctor/Treatment) induced (physical dependence/harm/injury) etc.
Damage/Neurotoxicity
Brain and central nervous system changes/disruption
Physical illness

And try to avoid words associated with substance abuse, like:

Addiction, addicted, hooked, high
Addicts, users, abusers, etc
Misuse, abuse, using, etc
Clean, sober, detox, overdose, kicked, recovery
Street drug nicknames for benzodiazepines such as “xanny bars,” etc.