Last week we discussed the process of developing tolerance to medication. Whereas tolerance involves a state of adaptation to a medication that results in a change to some aspect of the impact of the substance, the term “physical dependence” refers to a state where a person has adjusted to a substance to the extent that they experience withdrawal symptoms when they discontinue its use. Withdrawal symptoms are most extreme if the person abruptly stops taking a medication they have developed physical dependence to; doctors generally taper off the dose slowly in order to minimize these symptoms.
Withdrawal effects tend to resolve as the body adapts back to a state where it no longer needs to compensate for the substance but can be extremely distressing and unpleasant while the body is adjusting. Withdrawal is the reason daily coffee drinkers experience a headache if they skip their morning brew. It’s also the reason some users of prescription pain relievers eventually seek out heroin to get their fix when their prescriptions run out and severe withdrawal symptoms feel otherwise inescapable.
Many people develop tolerance and physical dependence on substances that do not carry a significant risk of addiction. A person who is tolerant to and dependent on an antidepressant, for example, may require a higher dose to continue achieving the same effect and may experience significant withdrawal effects if they discontinue abruptly, but unless they crave the medication or experience difficulty managing its use, the risk of addiction is quite low. Medications that do not have fast-acting, desirable effects are not considered “habit-forming” because they are unlikely to be craved, overused, and associated with negative consequences.
The majority of medications designed and prescribed for mental health conditions are not considered habit-forming; that is, they are unlikely to be abused and to develop into an addiction. In terms of medications prescribed for mental health conditions, habit-forming options are those with fast-acting, desirable effects. Of course, “desirable” is subjective and context-specific and medication effects are highly specific. Moreover, a person who genuinely needs a prescribed medication is much less likely to abuse it than someone who uses that substance for its recreational effects; therefore, stimulant medications such as Adderall can be habit-forming for some users and relatively safe for others (for more about Adderall and other ADHD medications, see this article).
While tolerance, dependence, and withdrawal are not necessarily signs of addiction, they can prompt behaviors that increase addiction risk, such as using more of the substance than prescribed or using it in situations that have adverse consequences. If the medication does not cause fast-acting and subjectively desirable effects, such as increased energy and focus in the case of stimulant medications (e.g., Adderall, Ritalin, Vyvanse, and Dexedrine), relaxation and anxiety relief in the case of anxiolytic medications (e.g., Xanax, Ativan, Klonopin, and Valium), and other effects such as ease in falling asleep (e.g., some sedating antidepressants and antipsychotics and sleep medications like Ambien), they are unlikely to be abused. These medications can also lead to psychological dependence, which reflects the belief that the person needs the medication to function optimally (whether that is accurate or not).
In essence, tolerance and physical dependence do not equate with addiction. Many medications, especially those taken daily, lead to tolerance and physical dependence but are not addictive. It all comes down to whether misuse of the medication leads to effects that are desired and craved by the individual, which differs from person to person. Some medications, such as those listed in the previous paragraph, tend to be associated with higher risks of abuse because many people enjoy the way the medications make them feel and begin to depend on the relief or support they provide. Of course, each individual is also not equal in terms of their risk of addiction; there are many other factors, including genetic predispositions, life experiences, social connections, and a variety of psychological and sociological variables that contribute to the risk of addiction to prescribed medications for mental health conditions that should be taken into consideration by a trained psychiatrist when determining the appropriate medication intervention for each individual.