Maria is a refugee from the Balkans and is being treated with venlafaxine for post-traumatic stress disorder and major depression. Over a holiday, she runs out of the medication and experiences a withdrawal reaction that she finds very frightening. Maria refuses to restart the antidepressant because she feels she’s able to “beat the addiction.” Paul had his hand mangled in a machine at work and has gone on to develop what appears to be reflex sympathetic dystrophy, which has been increasingly painful. His family physician is reluctant to renew his prescription of narcotic analgesics, fearing that he’s “becoming dependent,” especially since he reported a withdrawal reaction after running out of meds one weekend.
Finally, John is a 42-year-old businessman who fractured his cervical spine while snowboarding. He was in pain for more than a year and took oxycodone for pain relief. Two years later, he’s still taking the narcotics, although he admits to friends that his pain is almost completely gone. He says he finds it difficult to stop and has begun to seek prescriptions from other doctors. John’s also cut back his work and now arranges all his business meetings to take place in the afternoon because he’s irritable and anxious until his first dose of the day.
Wrestling with words
All of the above patients had a withdrawal reaction to medication. Only one, John, is addicted to his meds. Unfortunately, there’s widespread confusion about these terms today, possibly related to the particular wording of the definitions of substance abuse as established in DSM-IV. When the DSM committee developed the diagnostic criteria for “addiction,” there was an argument over the actual use of the word. A slim majority felt that the term was too pejorative, and so the more neutral word “dependence” was adopted instead. According to a group of addiction experts in a recent article (Am J Psychiatry 2006;163: 764-5), this was a mistake.
Previously, the term “dependence” referred to physical dependence, which causes withdrawal symptoms when a drug is discontinued — classic examples are alcohol and heroin. With alcohol, a certain threshold of dose must be exceeded before withdrawal is seen, which has perhaps led to the notion that withdrawal reactions are an indication of excessive dose. Physical dependence is also seen with some antidepressants and beta-blockers. The adaptation that causes withdrawal symptoms is a normal physiologic response to certain medications, however, and is completely separate from the compulsive drug-seeking behaviour of addiction.
Loss of control
Replacing the term “addiction” with “dependence” in the DSM-IV has muddled the line between addiction and adaptation. Clinicians may now interpret withdrawal symptoms, which imply physical dependence, as an indication of addiction, leading them to withhold medications from individuals who badly need them. Yet addiction refers not to experiencing withdrawal, but to the loss of control over intense urges to take a drug, without regard of consequences.
Barry L. Gilbert, MD, CCFP, FRCPC is a psychiatrist, psychoanalyst and Assistant Professor of Psychiatry at the University of Toronto.