Drug Dependence Versus Physical Dependence

Substance use disorder is a mental disorder defined in the fourth revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000). It includes out-of-control drug use, use outside social and medical sanctions, continued use despite clear evidence of drug-caused problems, and a drug-centered lifestyle. Physical dependence (including withdrawal on discontinuation), in contrast to addiction, is a pharmacological phenomenon in which the user experiences a specific constellation of symptoms for a relatively short period when use of the substance is abruptly discontinued. Physical dependence may, but often does not, accompany sub stance use disorder (abuse or dependence). The appropriate treatment for addiction, or substance use disorder, is usually long-term, specialized additional treatment followed by prolonged participation in one of the 12-step programs and/or other ongoing support and care. The appropriate treatment for physical dependence, in clear contrast, is gradual dose reduction to permit biological adaptation to lower doses of the dependence-producing substance, leading to zero dosing.

A patient who seeks to continue using a medicine because it is helpful is no more demonstrating "drug-seeking behavior" than is a patient who finds eyeglasses helpful in the treatment of myopia demonstrating "glasses-seeking behavior" if deprived of a corrective lens. Drug abuse and drug dependence are characterized by use despite problems caused by that use (loss of control) and by denial (and dishonesty)—neither of which is seen in appropriate medical treatment (DuPont & Gold, 1995).

Precisely the same confusion of medically trivial physical dependence with serious substance use disorder (addiction) occurs in regard to the use of opiates in the treatment of severe pain. Many patients and many physicians undertreat severe pain, because they are unable to distinguish physical dependence, the benign pharmacological fact of neuroadaptation in medical patients, from the abuse of opiates by drug addicts, a malignant biobehavioral disorder (Savage, 2003).

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