The use of the term substance dependence or drug dependence has taken on different meanings at different time periods, and this has led to some confusion regarding the use of the term dependence in the context of addictive behavior, particularly the abuse of drugs and alcohol. Initially, the state of substance or drug dependence was described as the state that occurs when a person could only function normally when they had a specific level of a certain drug in their system. If the levels of the drug declined due to normal metabolic functions, the person would display withdrawal symptoms. Thus, withdrawal was an essential component of the diagnosis of addictive behavior.
According to this classic type of definition, substance or drug dependence only occurred when the person experienced a withdrawal syndrome once they had stopped using the drug or as a result of reducing the amount of the drug they normally used. Drug dependence was associated with a physical addiction to a substance, and the terms drugdependence and drug addiction were used interchangeably.
However, as clinicians began to struggle with treating individuals who had been diagnosed with addictive behaviors as a result of drug abuse, they observed that even though many individuals with significant substance abuse problems did not display overt physical withdrawal symptoms once they stopped using their drug of choice, they still experienced high rates of relapse, significant difficulty not using their substance of choice, and were just as hard to treat as individuals who had developed significant physical dependence on drugs. The American Psychiatric Association (APA) eventually altered the diagnostic criteria for addictive behaviors such that the development of physical dependence on a substance was not an essential part of the diagnosis of substance dependence (addictive behavior).
Substance dependence was reconceptualized as a form of addictive behavior where an individual demonstrated issues with controlling their use of a drug, experienced significant distress associated with the consequences of their drug use, and demonstrated other issues that led to dysfunctional behaviors associated with their drug use. Demonstrating a withdrawal syndrome was part of the diagnostic criteria for substance dependence; however, it was neither necessary nor was it sufficient to receive a diagnosis of substance dependence. The clinical difference between substance abuse and substance dependence became a matter of the number and types of symptoms that were met by the individual according to APA’s diagnostic criteria. However, APA changed this diagnostic approach in its latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
In 2013, APA reclassified and restructured its diagnostic approach to substance abuse issues and withdrew the terms substance abuse and substance dependence altogether. Now, the clinical term for syndromes once described as “addictions,” “substance abuse,” or “substance dependence” is a substance use disorder. This term incorporates the older notions of substance abuse and substance dependence into one general clinical description that views addictive behaviors as lying on a continuum of severity as opposed to being discrete categories of abuse and dependence. Moreover, it is quite possible to develop a level of physical dependence on a medication that is only taken for medicinal reasons under the supervision of a physician, and such use would not qualify for a diagnosis of a substance use disorder (e.g., someone who is prescribed antidepressant medications or a person who is prescribed opiate drugs for the control of chronic pain).
These days, when clinicians use the term dependence, they most often use it in the context of the development of physical dependence on a substance and not specifically to describe a syndrome of abuse or addictive/compulsive behavior. Instead, physical dependence is comprised of two separate syndromes: tolerance and withdrawal.
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The current clinical meaning associated with the term dependence is reserved for individuals who develop a syndrome of tolerance and withdrawal associated with their drug use (physical dependence). The development of withdrawal symptoms to a drug is always preceded by the development of some level of tolerance to the drug; therefore, if a person demonstrates a withdrawal syndrome, they must have developed some level of tolerance to the drug. However, one can develop tolerance to a drug without withdrawal.
A person can be diagnosed with a stimulant use disorder as a result of abusing cocaine and not demonstrate significant issues with withdrawal. Thus, the terms dependence (or physical dependence) and addiction (or a substance use disorder) are no longer interchangeable. Nonetheless, many nonclinical sources still refer to dependence as a syndrome of drug abuse that leads to significant dysfunction in the person, including issues with controlling their use of the drug. This article maintains the clinical view that a substance use disorder and physical dependence (or dependence) represent different concepts even though many people with substance use disorders have also developed physical dependence as part of their disorder.
The issues that many people experience with controlling their use of a drug are not always related to the development of withdrawal symptoms. Instead, they represent very complex physical and psychological mechanisms that result in a person having difficulty stopping use of the drug even if they do not experience significant withdrawal issues.
Nonetheless, APA also specifies diagnostic criteria that can be used to assess and diagnose the development of a withdrawal syndrome in an individual who has abused cocaine. Thus, in clinical terms, a person would be diagnosed with a substance use disorder (e.g., a stimulant use disorder as a result of cocaine abuse) and stimulant withdrawal according to very different sets of diagnostic criteria.
Chronic use of cocaine can result in the development of both tolerance, which develops very rapidly, and a withdrawal syndrome, which is primarily composed of emotional factors that are driven by imbalances in hormones and neurotransmitters. The major symptoms of withdrawal associated with cocaine are changes in mood, cravings for cocaine, appetite increase, lethargy or sleepiness, and physical symptoms, such as changes in heart rate, increased sweating, jitteriness, etc.
There are numerous risk factors associated with the development of physical dependence (again tolerance and withdrawal) to cocaine. It should be understood that having one or more of the risk factors associated with the development of any condition does not guarantee that one will develop the condition; it only results in an increased probability that one mightdevelop the condition. Risk factors are additive, such that a person with more risk factors is at a higher probability to develop the condition in question.
The risk factors for the development of physical dependence on stimulant drugs like cocaine, as outlined by APA and The Substance Abuse and Mental Health Services Administration (SAMHSA), include:
- The length of time an individual has regularly been using cocaine
- The amount of cocaine an individual typically uses
- Sex (Males are more likely to develop physical dependence on cocaine than females, most likely because they use it in greater amounts than females; however, there is some research that suggests that women may be more likely to develop physical dependence on cocaine.)
- Age, with individuals between the ages of 18 and 25 being at higher risk overall
- A family history of individuals who have developed physical dependence on drugs
- The age at the person started using cocaine, with younger users being more likely to develop dependence (One study found that people who begin using the drug at an early age, such as 12 or 13, were far more likely to develop physical dependence on it than individuals who started using the drug at 18-20 years of age.)
- Having some other mental health disorder
- A history of a substance use disorder or some other psychological disorder in the individual’s family (People who have first-degree relatives with either of these diagnoses are at a greater risk.)
- Individual differences in metabolism
- The manner by which the person typically takes the drug (Users who inject or smoke the drug are more likely to develop physical dependence than people who snort it.)
- Other social factors that can include social economic status, a history of trauma or stress, a history of abuse, other drug use, etc.
- Certain personality factors that may be associated with an increased risk to develop physical dependence on drugs or alcohol
Finally, the ability of the person to control their use of the drug, such as limiting their use to specific situations and being able to limit their use to only small amounts at a time is associated with a decreased risk to develop significant tolerance and withdrawal symptoms (physical dependence) as well as a decreased risk for being diagnosed with a substance use disorder. Thus, individuals who have issues with controlling their use of cocaine also appear to be at an increased risk for the development of physical dependence on cocaine.
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