In outpatient clinics, it's common to hear patients ask:
"Doctor, will I become dependent on this medication?"
So, what exactly is drug dependence?
From a medical diagnostic standpoint:
Drug dependence falls under the category of Substance Use Disorder (SUD).
The American Psychiatric Association defines SUD as the presence of two or more of the following symptoms occurring within a 12-month period, including:
taking more substance than intended, unsuccessful efforts to cut down, significant time spent using or recovering from the substance, craving, failure to perform major role obligations, continued use despite interference with social/occupational/recreational activities, use in hazardous situations, use despite significant negative impact on health, tolerance, and withdrawal.
The severity of SUD varies:
According to the DSM-5, there are 11 diagnostic criteria.
Depending on the number of symptoms present within a 12-month period, SUD is classified as:
1. Mild (2–3 symptoms)
2. Moderate (4–5 symptoms)
3. Severe (6 or more symptoms)
The 11 diagnostic criteria are:
1. Often taken in larger amounts or over a longer period than was intended.
2. A persistent desire or unsuccessful efforts to cut down or control use.
3. A great deal of time is spent in activities necessary to obtain, use, or recover from the substance’s effects.
4. Craving or a strong desire or urge to use the substance.
5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by its effects.
7. Important social, occupational, or recreational activities are given up or reduced because of use.
8. Recurrent use in situations in which it is physically hazardous.
9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Tolerance.
11. Withdrawal.
Notes:
• Criteria 10 and 11 (tolerance and withdrawal) are not counted if they result solely from appropriate use of prescribed medications.
• In this context, “substance” includes both medications and chemical substances.
After reading this far, you may realize:
Most medications prescribed legally by doctors do not lead to SUD.
That’s because substances more likely to cause SUD typically include:
• Caffeine, tobacco/nicotine, alcohol
• Prescription drug misuse — such as opioids, sedatives/hypnotics, and stimulants
• Marijuana
• Illicit drugs — such as stimulants (including cocaine), opioids (including heroin), hallucinogens, and inhalants
Most medications taken by the general population don’t fall into these categories, or they are used within medically appropriate guidelines.
Therefore, medications legally obtained through proper medical channels usually do not cause dependence!
Additional clarification:
Some patients with chronic conditions require long-term medication use.
This should not be mistaken for dependence — it is simply a medical necessity.
In other words, for certain patients, these medications are as essential as food and water.
It is not dependence.
After all, we don’t consider ourselves addicted to food or water just because we need them every day — right?
References:
UpToDate:
• Substance use disorders: Clinical assessment
• Substance use disorders in physicians
Wikipedia:
Note 1:
Several studies have shown that alcohol is the most concerning substance among physicians, followed by prescription opioids.
For example, a retrospective study analyzing 3,604 physician health program (PHP) medical records reported the following “drug of choice” distribution:
• Alcohol – 25%
• Opioids – 25%
• Cannabis – 12%
• Cocaine – 11%
• Sedatives – 10%
• Amphetamines – 4%
• Inhalants – 1%
• Other – 8%
Note 2:
According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the risk thresholds for alcohol in the U.S. are:
• Men under 65:
≥5 standard drinks in a day, or >14 drinks per week on average
• Women and men over 65:
≥4 standard drinks in a day, or >7 drinks per week on average
One standard drink contains ~12g of ethanol (e.g., 1.5 oz of 80-proof liquor, 5 oz of wine, or 12 oz of beer).
For gender minority populations, no formal risk thresholds have been established yet.
There is also no universally agreed definition of unhealthy use for substances other than alcohol.
For some substances, any use at all (e.g., cocaine or methamphetamine) is considered unhealthy, as even occasional useincreases risks such as heart disease.
