Is physical dependence the same thing as addiction?
Is a person who takes a benzodiazepine every day, exactly as prescribed, addicted to it? If they get sick when they try to stop, does that prove it? And, if it is not addiction, why does everyone keep suggesting rehab?
Physical dependence is not addiction. They are two different conditions, and they can exist apart or together. In fact, a person can be physically dependent on Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam), or Valium (diazepam) and have no addiction at all.
I hosted a show about addiction treatment for years, and the focus of this show has since moved to deprescribing, the slow and careful work of coming off of a medication. The confusion between these two words is a big part of the reason. So, why does it matter which word we use?
What is physical dependence?
Physical dependence is the body adapting to a medication. Benzodiazepines, or benzos, act on receptors for gamma-aminobutyric acid, or GABA, the main calming signal in the brain. When a drug does that calming work every day, the brain adjusts by turning down its own system.
That adjustment is not a behavior, and it is not a choice. It can happen to anyone who takes the medication long enough, at the dose the doctor wrote on the prescription. When the dose drops too quickly, the brain is left short of its calming signal, and the result is withdrawal.
In September 2020, the US Food and Drug Administration, or FDA, updated the boxed warning on all benzodiazepines. The warning lists addiction and physical dependence as separate risks. It also says that stopping abruptly, or reducing the dose too fast, can cause withdrawal reactions that may be life-threatening, and it tells doctors to taper gradually.
Benzos are not the only example. Antidepressants and gabapentinoids, such as gabapentin and pregabalin, can also cause physical dependence, which is why the Maudsley Deprescribing Guidelines cover them alongside benzodiazepines. Few people would say that a person tapering off of an antidepressant is addicted to it.
What is addiction, then?
Addiction is a pattern of compulsive use that continues despite harm. There is craving, there is loss of control, and life begins to narrow around the drug. It is defined by behavior, not by what the body does when the drug is taken away.
I want to be careful here. Addiction is a medical condition too, and a person with an addiction deserves respect and real medical treatment. I am not drawing this line so that one group of patients can look down on another.
Twelve-step meetings help some people, and that choice is theirs. Still, they are not the only path, and they are not medical care. For opioid and alcohol problems, there are medical treatments that work, and what the good ones have in common is that they do not depend on stopping everything in one day and hoping for the best.
Why does a rehab stop the medication so fast?
Unfortunately, the detox and rehab industry is built around one goal, which is to have the person substance free by discharge. The length of the stay is usually set by insurance coverage, not by the nervous system. That might be seven days, or ten, or thirty.
Patients have described the same scene to me many times. They took a medication as prescribed for years, a worried family member found a program, and the intake paperwork asked for their “drug of choice.” They did not choose it. Their doctor did.
Then come the group circles, the meetings, and a curriculum written for a condition the patient does not have. The medication is cut quickly, because the calendar says so. Yet, a benzodiazepine taper done properly often takes many months, and for some people it takes more than a year.
Sending a dependent patient to detox is like calling the fire department for frozen pipes.
An analogy might help. Imagine that your pipes freeze in January, you call for help, and a fire truck pulls up. The crew is trained, well equipped, and completely sincere.
They break down the door and flood the house. The pipes burst anyway. On the bright side, the house is no longer at risk of fire.
While this is not a perfect analogy, and I am not convinced that the fire crew always does so well with fires either, the point holds. Frozen pipes are not a fire, and the tools made for one make the other worse. Frozen pipes are thawed slowly.
What does a fast taper do to a person who is physically dependent?
It can do real harm. A rapid taper, or quitting cold turkey, can cause severe withdrawal, and with benzodiazepines that includes the risk of seizures. That is never something to wait out at home.
Call 911 or go to an emergency department if there is a seizure, confusion or hallucinations, or thoughts of self-harm. For thoughts of suicide or any mental health crisis, you can also call or text the 988 Suicide and Crisis Lifeline.
There is also a longer problem. Some people who come off too fast develop protracted withdrawal, also known as benzodiazepine-induced neurological dysfunction, or BIND, with symptoms that come and go for months or longer. It is not well understood why one person is hit so much harder than another at the same dose.
Then the patient goes home, feels terrible, and is told that the old anxiety is back, or that this is a relapse. It is neither. It is what happens when a drug that the brain has adapted to is pulled away too quickly.
Fortunately, there is a right tool, and it is slow.
You may not be inclined to take a doctor’s word for any of this, and I understand. A doctor’s prescription, along with an assurance that the medication was safe to take long term, is how most people got here. So, look at the sources for yourself.
The Ashton Manual, written by the late Professor C. Heather Ashton, describes a gradual taper, often with a crossover taper to a longer-acting benzodiazepine such as diazepam. The Maudsley Deprescribing Guidelines describe hyperbolic tapering, meaning that the reductions get smaller as the dose gets lower. I am partial to Professor Ashton’s approach, yet it is not the only safe method, and any careful, gradual plan that you work out with your prescriber deserves respect.
What these methods share matters more than where they differ. The reductions are small, the body gets time to adjust between them, and a flare of symptoms is treated as information. Holding a dose for a while is not weakness.
Who decides how fast the taper goes?
You do, together with your doctor. If the taper is too fast, the doctor must help by slowing it down. If it feels too slow, patient and doctor may agree to go a bit faster, as tolerated.
That is the opposite of a discharge date. Barbara Connolly, PhD, joined me on the show for a conversation about safe benzodiazepine tapering and the Benzo Warrior community, and it is a good next listen if this is your situation.
What if there is addiction and physical dependence at the same time?
This is a good question, because it does happen. Just because someone has misused a benzodiazepine does not mean that the physical dependence can be ignored. The brain has adapted all the same.
In that case, both conditions deserve treatment, and the dependence is still treated with a gradual, medically supervised taper. Suffering through cold turkey withdrawal is not a lesson that anyone needs to learn. It is an injury.
You have a medical condition, and it has a medical solution.
If you took your medication the way your doctor told you to, and now you cannot stop without getting sick, your body has done what bodies do. While the way down may take longer than anyone would like, the brain does readjust when it is given time.
Do not stop on your own, and do not let anyone rush you. Find a prescriber who will go at your pace, and bring the FDA label along if you have to. The way down is slow, and it is yours.
Readers who want to work with Dr. Leeds can use the contact page.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.