Psychiatry and Wellness, Behavioral Medicine Associates, Atlanta and Alpharetta
Contact UsPrivacyDisclaimerSite MapAddress & DirectionsSitemapFeedback

Eating Disorder
Illicit Drugs
Perscription Drugs
Sex & Relationships
  Prescription Drug Abuse
Floyd P. Garrett, M.D.


I. Physical Dependence, Dependence, Addiction and Abuse

The first thing to get straight is the distinction between physical dependence, dependence and abuse in regard to substance use. The phenomenon of addiction is baffling enough in its own right without the added confusions resulting from the imprecise and undefined usage of terms. But there are other words which also require clarification: addiction, psychological dependence and substance dependence. All of these concepts are widely and sometimes carelessly used, reminding one of Humpty Dumpty's unique approach to language:

"When I use a word," Humpty Dumpty said in a rather a scornful tone, "it means just what I choose it to mean -- neither more nor less.
"The question is," said Alice, "whether you can make words mean different things."
"The question is," said Humpty Dumpty, "which is to be master -- that's all."
Alice was too much puzzled to say anything, so after a minute Humpty Dumpty began again.
"They've a temper, some of them -- particularly verbs, they're the proudest -- adjectives you can do anything with, but not verbs -- however, I can manage the whole lot! Impenetrability! That's what I say!"
Through the Looking-Glass and What Alice Found There. Lewis Carroll.

Physical dependence is a normal and universal result of the sustained consumption of alcohol and certain other drugs. After a certain period of time everyone who takes the drug in a sufficient dose will experience a withdrawal syndrome characteristic of the particular drug if intake is suddenly stopped or markedly diminished. Drugs that cause definite physical dependence include:

  • Alcohol
  • Barbiturates
  • Benzodiazepines
  • Caffeine
  • Nicotine
  • Opioids

The nature and severity of withdrawal symptoms from drugs that cause physical dependence vary according to the specific drug,  the dose and duration of its usage, and the specific characteristics of the user.

Physical dependence is not addiction. Everyone who ingests enough of a substance that causes physical dependence will develop such physical dependence, i.e. a withdrawal syndrome if the substance is suddenly stopped or markedly decreased. But only a minority of individuals who develop such physical dependence will go on to become addicted to the substance. Addiction is not physical dependence - though many of the drugs to which people can become addicted are capable of causing physical dependence.

Cocaine induces in some individuals one of the most powerful and difficult to treat addictions of all - but cocaine does not cause physical dependence in its users.

The confusion of physical dependence(= causes a withdrawal syndrome in everyone who takes enough of the substance for a long enough time) with addiction(= a behavioral syndrome characterized by prolonged excessive and harmful use of the substance) is one of the commonest and most harmful errors of understanding in this area. The majority of laypersons as well as a substantial number of physicians believe that "addictiveness" resides in certain substances rather than in the vulnerabilities of individuals exposed to those substances. But in fact only a minority of persons exposed to drugs that cause physical dependence(= withdrawal or discontinuation syndrome) go on to develop the behavioral syndrome of addiction.

It is obvious that the vast majority of people who consume alcohol, benzodiazepine tranquilizers(Valium like drugs) and opioids(narcotics) do not become addicts. Yet all of these substances are capable of causing definite and sometimes severe withdrawal syndromes.

Physical dependence simply means that if the substance being used  is suddenly stopped or markedly reduced, the user develops certain specific withdrawal or discontinuation symptoms in a pattern and course characteristic of that substance.

Addiction refers to a complex behavioral syndrome that includes pathological salience(=abnormal importance of the substance), obsession with obtaining and using the drug, excessive, prolonged and harmful use despite adverse consequences, and the mental defense mechanisms of denial, rationalization, minimization and justification. In the current official diagnostic systems the word dependence is used in place of addiction, further complicating and confusing the topic since this is by no means the same thing as the physical dependence described above.

Thus in the current diagnostic systems alcoholism(alcohol addiction) is called alcohol dependence. Benzodiazepine addiction is called benzodiazepine dependence. And opioid(narcotic) addiction is called opioid dependence. The general category for all of these is called substance dependence.

The word dependence is thus being used in two distinct ways:

1. In the sense of physical dependence(= capable of causing a withdrawal syndrome) as described above; and

2. In the sense of addiction(=behavioral syndrome of sustained, excessive and harmful use of a substance).

It is easy to see how confusion results from such dual but distinct meanings of the same word, dependence. The matter is even more complex because most of the drugs that are involved in the behavioral syndrome of addiction(= substance dependence) are in fact capable of causing the condition known as physical dependence(= capable of causing withdrawal syndrome).

Diagnostic Criteria for Substance Dependence

The DSM-IV("Diagnostic and Statistical Manual, Fourth Edition") of the American Psychiatric Association is the current universally accepted reference for standardized diagnosis in the United States. The DSM-IV definition of substance dependence(=addiction) is:

A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  • Substance is often taken in larger amounts or over longer period than intended
  • Persistent desire or unsuccessful efforts to cut down or control substance use
  • A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain smoking), or recover from its effects
  • Important social, occupational, or recreational activities given up or reduced because of substance abuse
  • Continued substance use despite knowledge of having a persistent or recurrent psychological, or physical problem that is caused or exacerbated by use of the substance
  • Tolerance, as defined by either:
    1. need for increased amounts of the substance in order to achieve intoxication or desired effect; or
    2. markedly diminished effect with continued use of the same amount
  • Withdrawal, as manifested by either:
    1. characteristic withdrawal syndrome for the substance; or
    2. the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms

The ICD-10("International Classification of Disease," edition 10) criteria for substance dependence:

Three or more of the following must have been experienced or exhibited at some time during the previous year:

  • Difficulties in controlling substance-taking behavior in terms of its onset, termination, or levels of use
  • A strong desire or sense of compulsion to take the substance
  • Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects
  • Persisting with substance use despite clear evidence of overtly harmful consequences, depressive mood states consequent to heavy use, or drug related impairment of cognitive functioning
  • Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses
  • A physiological withdrawal state when substance use has ceased or been reduced, as evidence by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms

Examination of the above diagnostic criteria for substance dependence(addiction) discloses the complex nature of the behavioral syndrome of addiction and easily distinguishes it from the far simpler phenomenon of physical dependence,  which is merely an occasional component of the addictive syndrome.

The diagnostic criteria for substance dependence(= addiction) are generally the same for all substances except for specific differences in the nature of the withdrawal syndrome itself. 

In the context of the current diagnostic criteria the concept of substance abuse has a specific meaning, namely, a destructive pattern of substance use, leading to significant social, occupational, or medical impairment. Substance abuse may be thought of as problematic substance use that does not rise to the level of substance dependence(addiction). By definition, all substance dependence includes substance abuse. But substance abuse may and sometimes does occur without the presence of the full substance dependence(addiction) syndrome.

One final concept completes this complex and tangled forest of competing definitions and ideas: the notion of psychological dependence upon a substance. One may become psychologically dependent upon anything from a security blanket to another person to a pharmacologically inactive placebo(sugar pill). For whatever reason, the psychologically dependent person believes that he cannot do without whatever it is that he happens to be dependent upon. Thus any threat of loss or separation from the object of his dependence will arouse anxiety and trigger activity intended to prevent loss of the object. In this sense, substance dependence invariably includes psychological dependence upon the substance - but psychological dependence may be present without substance dependence or abuse.

II. Prescription Drug Abuse

Prescription drug abuse is the term commonly used to describe the excessive and harmful usage  problems that certain people have with prescription medications, usually of the sedative-hypnotic(tranquilizer and sleeping pill) class and the opioid(narcotic) class. Individuals who take too much of such medications are said to be abusing medications. They can be classified under the diagnostic criteria given above into substance abuse or substance dependence(addiction) patterns. The term prescription drug abuse commonly is used to refer to either or both groups and is thus still another opportunity for conceptual confusion.

It is unfortunate that the terms abuse and dependence possess a powerful moral resonance and also imply a specific set of sociocultural norms and expectations. Many people in Western culture have been brought up to believe that it is bad and weak to be dependent on anyone or anything  - period. The cultural ethos prizes and in some cases requires independence rather than dependence. And of course the term abuse suggests a variety of unprincipled, immoral and illegal behaviors. The very  language that is presently used to describe substance problems is thus saturated with values, judgments and theories about what such problems represent and what ought to be done about them.

A. Prescription medications prone to abuse

Medications commonly "abused" include narcotic pain relievers, tranquillizers, and sleeping pills.

Not all tranquillizers are candidates for "abuse." It is customary to divide modern tranquillizers into two groups: (1) major tranquillizers like Thorazine, Haldol, Risperdal, Zyprexa and many others, none of them subject to "abuse," and (2) minor tranquillizers like Valium, Xanax, Ativan, Tranxene and Klonopin, all of them potentially "abusable."

Commonly abused narcotic pain medications include those containing synthetic narcotics such as hydrocodone or oxycodone, e.g. Lortab and Lorcet, Percodan, Vicodin, Percocet, as well as Demerol, Dilaudid, codeine, methadone and Darvon-containing compounds. Morphine, while subject to the same potential for abuse as the others, is less commonly prescribed for routine outpatient use.

Sleeping pills(sedatives and hypnotics) that are sometimes abused include Dalmane, Restoril, and  Halcion. Older barbiturate sleeping pills such as Nembutal, Seconal, and Tuinal were both extremely dangerous in overdose and also highly prone to abuse, hence are seldom prescribed any longer.

Soma(carisoprodol, a relative of meprobamate, "Miltown" or "Equanil," the very first modern tranquillizer) is a widely used skeletal muscle relaxer that is not uncommonly abused, usually in conjunction with pain medications and/or tranquillizers.

Stimulants such as Ritalin and Dexedrine lend themselves to abuse by some individuals.

It is worth noting that antidepressant drugs (Prozac, Paxil, Zoloft and many others) are not liable to abuse. Despite their capacity to lift certain types of depression, they do not provide abnormal "highs" or euphoric experiences of the kind that abusable drugs often do.

B. The difference between normal and abusive use of medications.

All of the medications listed above can be useful and safe if used in the correct fashion. It is a mistake to condemn such medications or to avoid entirely their use in appropriate circumstances simply because a small minority of individuals become dependent upon them and abuse them.

It is also a mistake, though a psychologically important and revealing one, to confuse the normal or healthy requirement of a sick person for a medication to remain well with that of the unhealthy and abnormal dependence of the addict. A severe diabetic, for example, is unquestionably "dependent" upon insulin in order to maintain correct glucose metabolism; and an individual with congestive heart failure is certainly "dependent" upon digitalis and a diuretic("water pill") in order to maintain as much cardiac function and general physical function as possible. There are people who are in fact bothered by such types of "dependence" upon appropriate and necessary medications, but it is obvious that their difficulties derive from denial of their underlying medical condition and the reality of their impaired health rather than from any concern about medication per se. For such people, the need to take medication simply reinforces the unpleasant truth that they prefer not to think about, namely, that they suffer from a chronic condition.

The simplest and most reliable way to distinguish normal use of  medications from their abuse is to consider whether they are being used for a legitimate medical purpose in accordance with the directions of a competent and ethical treating physician. Patients who take such medications for the right reasons and in the right doses cannot be described as abusing medications. They may and frequently do develop the syndrome of physical dependence(= causes a withdrawal syndrome) on medications which are capable of causing this - but the likelihood of proceeding to substance dependence(= the behavioral syndrome of addiction) is small.

On the other hand, when prescription medications are obtained in non-medical ways(from friends, family, or from sellers), when they are taken for non-medical purposes, or when they are taken in a fashion or quantity not recommended by a treating physician, such use can be correctly classified as medication abuse. It is under these circumstances that the possibility of medication dependence(addiction) is greatly enhanced.

C. Who gets into trouble with prescription medicines?

Individuals with pre-existing addictive disorders such as alcoholism(= alcohol dependence in the current diagnostic language) seem to be more prone to the abuse of prescription medications than others. Personal or social maladjustment, depression, personality disorder, or a family history of addictive problems may predispose somewhat to prescription medication abuse. Patients with chronic painful conditions such as recurrent headache or "bad backs" may be at somewhat greater risk, especially when other risk factors are also present. Individuals who normally experience a high level of stress or discomfort and who lack the self-care skills to relieve such stress may find quick and unanticipated relief in prescription medication originally given for a transient or minor medical condition and thus attempt to prolong and increase their usage of medication.

Among health care professionals such as physicians, nurses, dentists and veterinarians prescription medication abuse and dependence(=addiction) not uncommonly commences almost "by accident" as the stressed, distressed, tired, and often depressed clinician takes a dose of pain medicine or a tranquillizer to relieve a temporary physical discomfort and discovers that there is an unexpected "bonus effect" in the relief of mental and emotional tension, the soothing of depression, and the augmentation of energy and drive. This effect is then actively pursued by taking the no-longer-needed medication for a "non-medical" purpose, often with gradual increase in frequency of use and quantity of consumption until the full behavioral syndrome of addiction(= substance dependence) has set in and the person has become preoccupied with obtaining and using the medication in amounts far exceeding the normal dose and for reasons not related to the proper therapeutic usage of the drug.

The same scenario often occurs in patients prescribed medication by their physician for a legitimate medical purpose. The patient finds that the medication relieves not only the symptom(s) for which it was initially prescribed but also induces a desirable mood, level of energy, or other positive and mental effect which can be reproduced by additional doses of medicine even after the original legitimate medical reason for its use no longer exists. Some patients may then continue to request medications from their physician or from other physicians even though they no longer require them. Usually the dose is gradually increased to levels far in excess of those normally reached because the patient's system(principally the liver) becomes increasingly able to detoxify the medication and higher doses are therefore required to maintain the same effect. This escalating dosage effect is particularly pronounced in the case of the narcotic pain relievers, which routinely induce tolerance("immunity") to their effects with sustained and regular usage.

D. What are the warning signs of abuse and dependence?

The mental effects of prescription medications vary considerably from person to person. Some people, for example, find that narcotic pain relievers simply make them feel bad - so much so, at times, that they would rather put up with the pain than take the medication. There are innate differences in people as to how they are affected by such medications.

Some people, as described above, notice a pleasant, soothing, relaxing or at times energizing effect of prescription pain medications which tempts them to continue taking them long after the need for them has passed. Such people exaggerate or even fabricate pain in order to obtain more medications. They may begin going to multiple physicians to acquire enough medication to meet their usually increased needs, as the effect of tolerance means that higher and higher dosages are necessary to achieve the same effect.

From the physician's standpoint patients developing substance dependence fail to improve in the symptoms for which medications were first prescribed. Indeed, their symptoms may appear to become worse, thus necessitating higher and higher dosages of medication to control them. Nothing else seems to work or provide relief. Patients may begin to call in for refills early and to report prescriptions that have supposedly been lost or stolen.

Whenever prescription medications are taken frequently in excess of directions, when they are taken for reasons other than those for which they were intended and prescribed, and when the patient begins to be preoccupied with obtaining and consuming the medication, the likelihood of medication abuse of dependence(= addiction) is high. Obtaining medications by devious or unusual means is another indicator of serious difficulty. And dishonesty, secrecy, lying, stockpiling and manipulating(for example, exaggerating or inventing symptoms) to obtain medications are definite indicators of medication abuse and dependence at an advanced and dangerous stage.

By the time the full blown syndrome of medication dependence(=addiction) has set in the patient has often tried unsuccessfully to cut back or stop using the drug altogether. Repeated failures to attain these goals is one of the most reliable indicators of addiction. For as Mark Twain said about nicotine addiction, "It's easy to stop smoking. I've done it a hundred times."

E. What are the negative consequences of medication abuse and dependence?

The medication dependent(=addicted) individual is frequently like the character in "Alice in Wonderland" who had to run as fast as he could just to stay in the same place. When addiction is firmly established the chief job of the person is to meet the requirements of the addiction for whatever substance is involved. Failure to meet these requirements is met with the severe punishment of mental and physical withdrawal. It is no longer so much a case of attaining positive results by taking medication as it has become of avoiding negative results by making certain that the medication is always available. Particularly in the case of prescription drugs, to which easy access is restricted by the requirement for a physician's prescription, the addicted individual may have to spend an amazing amount of time and energy simply ensuring that he does not run out of medication. This often involves multiple doctor visits, visits to emergency rooms, and even phoning in illegal prescriptions or forging or altering prescriptions.

Medication dependent(=addicted) persons invariably experience and almost always manifest impairments in their thinking, feeling and actions. Intermittent confusion, memory loss, impaired judgment, personality change, emotional disturbance(depression, mood instability, irritability), social withdrawal and physical incoordination and sluggishness leading to falls, accidents and injuries are common. As time goes on the person becomes less and less like their normal "pre-addiction" self and more and more akin to the stereotypical substance addict. Ethical deterioration in the form of dishonesty, secrecy, manipulation, lying and even stealing is a frequent accompaniment of many advanced addictions. These behaviors contradict the basic pre-addictive value structure of the individual and therefore cause great inner conflict, dissonance, shame and guilt - all of which serve to fuel the addictive process by increasing mental distress and the need for chemical relief of suffering. A vicious circle is established from which the addict finds it exceedingly difficult, sometimes impossible to break free without outside assistance.

F. The common withdrawal syndromes.

1. Opioids(narcotics)

Narcotic pain relievers, taken in sufficient dose for a sufficient period of time, all cause a specific opioid withdrawal syndrome manifested by:l

  • Chills
  • Sweating
  • Runny nose and eyes
  • Abdominal cramps
  • Muscle pains
  • Insomnia
  • Nausea
  • Diarrhea
  • Insomnia
  • Anxiety and restlessness
  • Yawning
  • Drug craving
  • Fatigue
  • Dysphoria (unpleasant, painful mental state)

Despite its well-earned reputation for extreme discomfort("cold turkey"), the pure opioid withdrawal syndrome, unlike some cases of sedative/tranquillizer/alcohol withdrawal,  is never a life-threatening condition. Opioid withdrawal does not result in seizures. The withdrawal syndrome resolves spontaneously without treatment in 1 - 2 weeks in most cases, although brief and progressively diminishing recurrences of some symptoms are occasionally observed for some time afterwards before finally ceasing entirely.

2. Sedatives/Tranquillizers

Virtually all of the sedatives and tranquillizers in common use today are members of the benzodiazepine family of drugs which includes Valium, Xanax, Ativan, Klonopin, Tranxene, Dalmane, Restoril and Halcion. The barbiturate family, because of its overdose lethality as well as its proneness to abuse and dependence, is today far less widely used for routine outpatient sedation and tranquillization than it was before the introduction of the benzodiazepines. Barbiturates, benzodiazepines and alcohol all behave similarly in their effects on the central nervous system and in the kinds of withdrawal syndromes they produce. Any member of any class will substitute for any member of another class in preventing its withdrawal syndrome when the primary drug is halted. Thus Valium can substitute for phenobarbital which can substitute for alcohol.

The sedative/tranquillizer/alcohol withdrawal syndrome consists of:

  • Anxiety and restlessness
  • Insomnia
  • Elevated pulse, temperature and blood pressure
  • Visual and tactile hallucinations
  • Confusion and disorientation (delirium tremens, D.T.'s)
  • Grand mal convulsions

Under typical circumstances only a minority of sedative dependent individuals will develop the full blown withdrawal syndrome, which, however,  is occasionally fatal. In general, the higher the dose and the longer the use of the substance, the more likely the withdrawal syndrome is to be severe and possibly dangerous. All symptoms are promptly suppressed by an adequate dose of a benzodiazepine tranquillizer, which is the standard detoxification treatment for such conditions. Decreasing doses of medication are used when necessary and then discontinued as symptoms abate. The acute withdrawal is usually complete in a week or less, but anxiety, insomnia, and mood instability, although with drug craving and heightened risk of relapse may persist for weeks or months afterward, gradually diminishing in most cases until the individual is restored to his normal pre-addictive state.

G. Treatment of Prescription Drug Dependence

The basic principles of substance dependence treatment apply to prescription drug dependence. These include:

  • Elimination of the offending substance(s)
  • Detoxification as required
  • Medical and psychiatric evaluation for associated conditions and complications
  • Education about addiction, self-care and recovery
  • Relief of stress and the development of a healthy lifestyle
  • Psychosocial treatment and support, including 12 Step groups when appropriate

Simply discontinuing the substance(s), with or without a brief period of medical detoxification, is often, though not always, ineffective. The "stop-and-start" recurrent nature of the underlying addictive process means that unless the addiction itself receives attention and treatment it may well reassert itself again after a brief interval of abstinence in which all superficially appears to be going well. The need for such ongoing "recovery therapy" is especially pronounced in individuals with a past or family history of substance dependence, and in those whose addiction has progressed to an advanced stage characterized by elaborate and often illegal drug-seeking behavior.

When substance dependence(= the behavioral syndrome of addiction) appears within the context of a chronic psychiatric or medical condition for which the offending drugs were originally indicated and useful before addiction set in, medical management of such symptoms as remain is obviously important and can sometimes be challenging. In many though unfortunately not in all cases, relief of the addictive disorder actually results in a diminution or disappearance of symptoms(chronic pain, intractable headaches, anxiety, insomnia) for which the medications may have originally been prescribed. When symptoms persist and require treatment it is important to devise a plan that offers the maximum possible relief with the minimum risk of relapse into addiction. Neglect of legitimate symptoms can predispose to relapse if the affected individual feels there is no alternative but to return to the drug(s) which first provided some relief.

A very high percentage(up to half in some studies) of individuals developing substance dependence disorders also manifest one or more psychiatric conditions, of which depression and anxiety disorders are by far the commonest. Adult attention deficit disorder has recently been recognized as a condition that may predispose to substance dependence.  In many cases the resort to prescription drugs actually began as an unwitting attempt to "self-medicate" and relieve the symptoms of such pre-existing conditions. Temporary relief of such psychiatric symptoms was indeed obtained with narcotics and/or sedatives, but with the onset of substance dependence(= the behavioral syndrome of addiction) these initial gains were lost and were replaced by increased symptoms resulting from an escalating negative interaction between the addictive and the psychiatric disorders.

Appropriate treatment of such "co-morbid" or "dual diagnosis" psychiatric conditions as depression, attention deficit hyperactivity disorder(ADD, ADHD),  and clinically significant anxiety(panic disorder, agoraphobia, social anxiety disorder, obsessive-compulsive disorder) greatly improves the likelihood of lasting recovery from substance dependence.


Chemically Dependent Anonymous

Criteria for Substance Dependence Diagnosis

Drugs of Abuse

Facts about Opiates

Lycos News: Pharmaceuticals
This site offers the latest news and information on the use and misuse of pharmaceuticals.

Narcotics Anonymous

Opioid Dependence

Pills Anonymous
On-line support
Comprehensive site

Prescription Drugs
Boston University Medical Center

Prescription Drug Use and Abuse
National Institute on Drug Abuse

Prescription Medications

Substance Abuse Resource Guide
Many good links

Original Papers

The Addict's Dilemna

Addiction, Lies and Relationships

Addiction and the Mechanisms of Defense

Alcohol Addiction

Drug Therapy of Alcohol Dependence

Excuses Alcoholics Make

The Female Partner of the Male Alcoholic

Getting Away With Addiction? 

Intervention for Alcohol and Drug Dependence

Obstacles to Recovery from Addiction

Prescription Drug Abuse

Prolegomenon to the Metaphysics of Recovery

What is Recovery?

Why is Recovery So Hard?

Worried Sick About His Drinking?

Your First AA Meeting: An Unofficial Guide for the Perplexed