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A wide range of drugs whilst not causing a true physical dependence can still cause ] symptoms or ] during dosage reduction or especially abrupt or rapid withdrawal.<ref>{{cite journal |author=Heh CW, Sramek J, Herrera J, Costa J |title=Exacerbation of psychosis after discontinuation of carbamazepine treatment |journal=Am J Psychiatry |volume=145 |issue=7 |pages=878–9 |date=July 1988 |pmid=2898213 |doi= |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=2898213}}</ref> These can include ],<ref name="pmid2262896">{{cite journal |author=Griffiths RR, Evans SM, Heishman SJ, et al. |title=Low-dose caffeine physical dependence in humans |journal=J. Pharmacol. Exp. Ther. |volume=255 |issue=3 |pages=1123–32 |date=December 1990 |pmid=2262896 |doi= |url=http://jpet.aspetjournals.org/cgi/pmidlookup?view=long&pmid=2262896}}</ref> stimulants,<ref>{{cite journal |author=Lake CR, Quirk RS |title=CNS stimulants and the look-alike drugs |journal=Psychiatr. Clin. North Am. |volume=7 |issue=4 |pages=689–701 |date=December 1984 |pmid=6151645 |doi= |url=}}</ref><ref>{{cite journal |author=Sarampote CS, Efron LA, Robb AS, Pearl PL, Stein MA |title=Can stimulant rebound mimic pediatric bipolar disorder? |journal=J Child Adolesc Psychopharmacol |volume=12 |issue=1 |pages=63–7 |year=2002 |pmid=12014597 |doi=10.1089/10445460252943588}}</ref><ref>{{cite journal |author=Danke F |title= |language=German |journal=Psychiatr Clin (Basel) |volume=8 |issue=4 |pages=201–11 |year=1975 |pmid=1208893 |doi= |url=}}</ref><ref>{{cite journal |author=Cohen D, Leo J, Stanton T, et al. |title=A boy who stops taking stimulants for "ADHD": commentaries on a Pediatrics case study |journal=Ethical Hum Sci Serv |volume=4 |issue=3 |pages=189–209 |year=2002 |pmid=15278983 |doi= |url=}}</ref> ] drugs and ] drugs.<ref>{{cite journal |author=Chichmanian RM, Gustovic P, Spreux A, Baldin B |title= |language=French |journal=Therapie |volume=48 |issue=5 |pages=415–9 |year=1993 |pmid=8146817 |doi= |url=}}</ref> It is debated if the entire ] drug class causes true physical dependency, if only a subset does, or if none does,<ref name="isbn0-07-149430-8">{{cite book |author=Tierney, Lawrence M.; McPhee, Stephen J.; Papadakis, Maxine A. |title=Current medical diagnosis & treatment, 2008 |publisher=McGraw-Hill Medical |location= |year=2008 |page=916 |isbn=0-07-149430-8 |oclc= |doi= |accessdate=}}</ref> but all, if discontinued too rapidly, cause an acute withdrawal syndrome.<ref>{{cite web | url = http://www.bnf.org/bnf/bnf/56/3209.htm | title = Antipsychotic drugs | accessdate = 22 December 2008 | author = BNF | authorlink = British National Formulary |author2=British Medical Journal | year = 2008 | publisher = British National Formulary | location = UK}}</ref> When talking about illicit drugs rebound withdrawal is, especially with stimulants, sometimes referred to as "coming down" or "crashing". A wide range of drugs whilst not causing a true physical dependence can still cause ] symptoms or ] during dosage reduction or especially abrupt or rapid withdrawal.<ref>{{cite journal |author=Heh CW, Sramek J, Herrera J, Costa J |title=Exacerbation of psychosis after discontinuation of carbamazepine treatment |journal=Am J Psychiatry |volume=145 |issue=7 |pages=878–9 |date=July 1988 |pmid=2898213 |doi= |url=http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=2898213}}</ref> These can include ],<ref name="pmid2262896">{{cite journal |author=Griffiths RR, Evans SM, Heishman SJ, et al. |title=Low-dose caffeine physical dependence in humans |journal=J. Pharmacol. Exp. Ther. |volume=255 |issue=3 |pages=1123–32 |date=December 1990 |pmid=2262896 |doi= |url=http://jpet.aspetjournals.org/cgi/pmidlookup?view=long&pmid=2262896}}</ref> stimulants,<ref>{{cite journal |author=Lake CR, Quirk RS |title=CNS stimulants and the look-alike drugs |journal=Psychiatr. Clin. North Am. |volume=7 |issue=4 |pages=689–701 |date=December 1984 |pmid=6151645 |doi= |url=}}</ref><ref>{{cite journal |author=Sarampote CS, Efron LA, Robb AS, Pearl PL, Stein MA |title=Can stimulant rebound mimic pediatric bipolar disorder? |journal=J Child Adolesc Psychopharmacol |volume=12 |issue=1 |pages=63–7 |year=2002 |pmid=12014597 |doi=10.1089/10445460252943588}}</ref><ref>{{cite journal |author=Danke F |title= |language=German |journal=Psychiatr Clin (Basel) |volume=8 |issue=4 |pages=201–11 |year=1975 |pmid=1208893 |doi= |url=}}</ref><ref>{{cite journal |author=Cohen D, Leo J, Stanton T, et al. |title=A boy who stops taking stimulants for "ADHD": commentaries on a Pediatrics case study |journal=Ethical Hum Sci Serv |volume=4 |issue=3 |pages=189–209 |year=2002 |pmid=15278983 |doi= |url=}}</ref> ] drugs and ] drugs.<ref>{{cite journal |author=Chichmanian RM, Gustovic P, Spreux A, Baldin B |title= |language=French |journal=Therapie |volume=48 |issue=5 |pages=415–9 |year=1993 |pmid=8146817 |doi= |url=}}</ref> It is debated if the entire ] drug class causes true physical dependency, if only a subset does, or if none does,<ref name="isbn0-07-149430-8">{{cite book |author=Tierney, Lawrence M.; McPhee, Stephen J.; Papadakis, Maxine A. |title=Current medical diagnosis & treatment, 2008 |publisher=McGraw-Hill Medical |location= |year=2008 |page=916 |isbn=0-07-149430-8 |oclc= |doi= |accessdate=}}</ref> but all, if discontinued too rapidly, cause an acute withdrawal syndrome.<ref>{{cite web | url = http://www.bnf.org/bnf/bnf/56/3209.htm | title = Antipsychotic drugs | accessdate = 22 December 2008 | author = BNF | authorlink = British National Formulary |author2=British Medical Journal | year = 2008 | publisher = British National Formulary | location = UK}}</ref> When talking about illicit drugs rebound withdrawal is, especially with stimulants, sometimes referred to as "coming down" or "crashing".


Some drugs, like ] and ], describe the drug category and not the mechanism. The individual agents and drug classes in the anticonvulsant drug category act at many different receptors and it is not possible to generalize their potential for physical dependence or incidence or severity of ] as a group so need to be looked at individually. ] as a group however are known to cause tolerance to the anti-seizure effect.<ref>{{cite journal |author=Wolfgang Löscher and Dieter Schmidt |title=Experimental and Clinical Evidence for Loss of Effect (Tolerance) during Prolonged Treatment with Antiepileptic Drugs|journal=Epilepsia|volume=47 |issue=8 |pages=1253–1284 |date=August 2006 | doi=10.1111/j.1528-1167.2006.00607.x |pmid=16922870}}</ref> ] drugs, which have an important use as antidepressants, are considered to cause physical dependence, although it is considered mild compared to drugs like opioids and GABA modulators, but they engender a ], which was originally called "SSRI withdrawal" until a 1997 symposium sponsored by ] and ] (the producers of several anti-depressants including ] and Effexor) was held, with the drug representative attendees concluding that "discontinuation syndrome" sounded less threatening than "withdrawal"; however, "SSRI discontinuation syndrome" is a withdrawal syndrome upon discontinuation of SSRI/SNRI drugs, just as "heroin discontinuation syndrome" is a synonym for "heroin withdrawal". Due to this, in Europe these drugs cannot be advertised as "non-habit forming".{{Citation needed|date=December 2008}} There have been case reports of dependence with ] (Effexor).<ref name="Quaglio G, Schifano F, Lugoboni F 2008 1572–4"/> Some drugs, like ] and ], describe the drug category and not the mechanism. The individual agents and drug classes in the anticonvulsant drug category act at many different receptors and it is not possible to generalize their potential for physical dependence or incidence or severity of ] as a group so need to be looked at individually. ] as a group however are known to cause tolerance to the anti-seizure effect.<ref>{{cite journal |author=Wolfgang Löscher and Dieter Schmidt |title=Experimental and Clinical Evidence for Loss of Effect (Tolerance) during Prolonged Treatment with Antiepileptic Drugs|journal=Epilepsia|volume=47 |issue=8 |pages=1253–1284 |date=August 2006 | doi=10.1111/j.1528-1167.2006.00607.x |pmid=16922870}}</ref> ] drugs, which have an important use as antidepressants, engender a ] that manifests with physical side effects. E.g., There have been case reports of a discontinuation syndrome with ] (Effexor).<ref name="Quaglio G, Schifano F, Lugoboni F 2008 1572–4"/>


==See also== ==See also==

Revision as of 07:36, 19 February 2015

Addiction and dependence glossary
  • addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences
  • addictive drug – psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug's effect on brain reward systems
  • dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
  • drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
  • drug withdrawal – symptoms that occur upon cessation of repeated drug use
  • physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
  • psychological dependence – dependence socially seen as being extremely mild compared to physical dependence (e.g., with enough willpower it could be overcome)
  • reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
  • rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
  • sensitization – an amplified response to a stimulus resulting from repeated exposure to it
  • substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
  • tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

Physical dependence refers to a state resulting from chronic use of a drug that has produced tolerance and where negative physical symptoms of withdrawal result from abrupt discontinuation or dosage reduction. Physical dependence can develop from low-dose therapeutic use of certain medications such as benzodiazepines, opioids, antiepileptics and antidepressants, as well as misuse of recreational drugs such as alcohol, opioids, and benzodiazepines. The higher the dose used, the greater the duration of use, and the earlier age use began are predictive of worsened physical dependence and thus more severe withdrawal syndromes. Acute withdrawal syndromes can last days, weeks or months, and protracted withdrawal syndrome, also known as "post-acute withdrawal syndrome" or "PAWS" - a low-grade continuation of some of the symptoms of acute withdrawal, typically in a remitting-relapsing pattern, that often results in relapse into active addiction and prolonged disability of a degree to preclude the possibility of lawful employment - can last for months, years, or, in relatively common to extremely rare cases, depending on individual factors, indefinitely. Protracted withdrawal syndrome is noted to be most often caused by benzodiazepines, but is also present in a majority of cases of alcohol and opioid addiction, especially that of a long-term, high-dose, adolescent-beginning, or chronic-relapsing nature (viz. a second or third addiction after withdrawal from the self-same substance of dependence). Withdrawal response will vary according to the dose used, the type of drug used, the duration of use, the age of the patient, the age of first use, and the individual person.

Symptoms

Physical dependence can manifest itself in the appearance of both physical and psychological symptoms which are caused by physiological adaptions in the central nervous system and the brain due to chronic exposure to a substance. Symptoms which may be experienced during withdrawal or reduction in dosage include increased heart rate and/or blood pressure, sweating, and tremors. More serious withdrawal symptoms such as confusion, seizures, and visual hallucinations indicate a serious emergency and the need for immediate medical care. Sedative hypnotic drugs such as alcohol, benzodiazepines, and barbiturates are the only commonly available substances that can be fatal in withdrawal due to their propensity to induce withdrawal convulsions. Abrupt withdrawal from other drugs, such as opioids can cause an extremely physiologically and psychologically painful withdrawal that is very rarely fatal in patients of general good health and with medical treatment, but is more often fatal in patients with weakened cardiovascular systems; toxicity is generally caused by the often-extreme increases in heart rate and blood pressure (which can be treated with clonidine), or due to arrhythmia due to electrolyte imbalance caused by the inability to eat, and constant diarrhea and vomiting (which can be treated with loperamide and ondansetron respectively) associated with acute opioid withdrawal, especially in longer-acting substances where the diarrhea and emesis can continue unabated for weeks, although life-threatening complications are extremely rare, and nearly non-existent with proper medical management. Dependence itself and chronic intoxication on psychostimulants can cause mild-to-moderate neurotoxic effects due to hyperthermia and generation of free radicals. This is treated with discontinuation; life-threatening complications are nonexistent.

Treatment

Treatment for physical dependence depends upon the drug being withdrawn and often includes administration of another drug, especially for substances that can be dangerous when abruptly discontinued. Physical dependence is usually managed by a slow dose reduction over a period of weeks, months or sometimes longer depending on the drug, dose and the individual. A physical dependence on alcohol is often managed with a cross tolerant drug, such as long acting benzodiazepines to manage the alcohol withdrawal symptoms.

Drugs that cause physical dependence

Rebound syndrome

Main article: Rebound effect

A wide range of drugs whilst not causing a true physical dependence can still cause withdrawal symptoms or rebound effects during dosage reduction or especially abrupt or rapid withdrawal. These can include caffeine, stimulants, steroidal drugs and antiparkinsonian drugs. It is debated if the entire antipsychotic drug class causes true physical dependency, if only a subset does, or if none does, but all, if discontinued too rapidly, cause an acute withdrawal syndrome. When talking about illicit drugs rebound withdrawal is, especially with stimulants, sometimes referred to as "coming down" or "crashing".

Some drugs, like anticonvulsants and antidepressants, describe the drug category and not the mechanism. The individual agents and drug classes in the anticonvulsant drug category act at many different receptors and it is not possible to generalize their potential for physical dependence or incidence or severity of rebound syndrome as a group so need to be looked at individually. Anticonvulsants as a group however are known to cause tolerance to the anti-seizure effect. SSRI drugs, which have an important use as antidepressants, engender a discontinuation syndrome that manifests with physical side effects. E.g., There have been case reports of a discontinuation syndrome with venlafaxine (Effexor).

See also

References

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