Drug dependence: what is it, how does it arise and what symptoms does it produce?

Drugs that began to be used in a treatment can end up creating dependence.

The use of drugs in the particular field of mental health is one of the tools, together with psychotherapy, available to us to deal with the emotional disorders that we are all susceptible to suffer throughout life.

These are drugs whose use is widespread in Western society, which has led to a great deal of reflection on their use.This has given rise to numerous reflections on the intolerance of psychological pain and the refusal to go through difficult moments that are also part of one's own existence.

What is certain, however, is that they can sometimes be exceptional therapeutic allies; since in certain health conditions their use is unavoidable (at least during part of the process). It is therefore essential to know their most important side effects.

In this article we will focus only on their addictive properties, if they exist, or on related phenomena, if they are applicable. This reality has been given the name of pharmacodependenceand it is key especially in the anxiolytics.

What is drug dependence?

It is understood by drug dependence that situation in which the administration of some medicine has derived in the articulation of a search and consumption behavior that is not in accordance with therapeutic dosesand which ends up causing serious harm to the life of the person and his or her environment. This is, in general, a special situation, since the most common is that the beginning of the problem had its root in a therapeutic use of the compound (which ended up deriving in a pathological one).

Although these are substances that seek to prevent, alleviate or cure one of the many disorders that can affect people's mental health, it should not be forgotten that this is a pharmacological group that is particularly sensitive to this issue, since their action deliberately pursues a psychotropic effect (modulating how internal experiences are manifested). Dependence on such drugs is a complex pathology, and one of which we are increasingly aware. of which we are becoming increasingly aware.

When considering dependence on psychotropic drugs, it is necessary to take into account three different dimensions: the individual (biological particularity, life experiences, personality traits, etc.), the environment (social network, spaces in which daily life takes place, etc.) and the compound itself (pharmacokinetics/dynamics, effects on the mental sphere, etc.). In this text the emphasis will be precisely on the last of these, assessing what the literature tells us about the different psychotropic drugs.

Can psychotropic drugs generate dependence?

Psychotropic drugs are, without any doubt, the family of drugs with the greatest capacity to generate dependence of all those that are administered today for the purpose of regaining health. Of all of them, those that have received most attention are the anxiolytics (especially the benzodiazepines). (especially benzodiazepines, which are practically the only ones still in use), since they are administered on a massive scale to a society that has recently been facing very difficult situations (economic crisis, unemployment, etc.).

When we speak of dependence we refer to three different phenomena, more specifically: tolerance (the need to use an increasingly higher dose of the drug to obtain the effect that was achieved at the beginning), withdrawal syndrome (unpleasant sensations that occur when its administration is interrupted) and addictive behavior (the belief that the drug is required to be well or to feel safe, together with the anxious search for it).

Because the actions of each of the psychotropic drugs on the brain are distinctIn this article we will review the evidence currently available regarding the addictive potential of the three most commonly used: antidepressants, antipsychotics and anxiolytics (benzodiazepines). The first piece of advice that can be given in this text is, however, that doses and times should always be adjusted to the physician's indication, otherwise the risk of dependence will increase dramatically.

1. Antidepressants

Antidepressants are a group of drugs that are used for the treatment of all mood disorders and also for many of those that fall into the general category of anxiety, so their effects are not only euptimizing. With regard to the latter, they are particularly useful in cases in which there are cognitive components, such as social phobia, social anxiety and anxiety.such as social phobia or Generalized Anxiety Disorder. Of all those in use today, none of them merits a significant risk of addiction.

Selective MAOIs (which inhibit the action of monoamine oxidase A/B), which at present are rarely prescribed for depression (except in cases where other alternatives fail to improve), have never been considered addictive substances, and there are only a few documented cases in the literature in which they were abused. Nevertheless, in both the old and the new MAOIs, the main prevention is usually done with respect to dietary factors, since the intake of foods rich in thiamine can lead to a hypertensive crisis.

The same can be said for tricyclic antidepressants, for which almost no cases of addiction have been described in the literature. These drugs inhibit the reuptake of serotonin and noradrenalinand block a constellation of receptors (muscarinic, alpha adrenergic, etc.), promoting a cascade of side effects of diverse nature. This is the main reason why, at present, it is preferred to administer drugs with a safer profile of side effects; although in global terms they are the ones that have the most beneficial effect on depressive symptoms.

Finally, SSRIs (selective serotonin reuptake inhibitors), which are undoubtedly the most prescribed for depression and anxiety, do not have addictive properties either. However, it has been estimated that up to 20% of those who take them for six months or more may suffer from discontinuation syndrome when they abruptly stop taking them. The symptoms, very similar to those that could be expected in a withdrawal syndrome, involve: pseudo-flu, insomnia, imbalance, Nausea and headache. They are usually mild and resolve when the drug is reintroduced or gradually withdrawn.

In the case of SSRIs, the possibility has also been described that, in a small percentage of cases, a tolerance effect may occur. In this case, the continued use of the SSRI would imply a reduction of the effects of an identical dose, altering its efficacy and the way in which it should be administered. In this sense, it may also happen that the symptoms of depression increase during this period, so that the physician will have to adjust the dosage of the SSRI. the physician will have to adjust the regimen to the person's new needs..

An exceptional case would be that of bupropion, which is used for depressive symptoms and for smoking, generating effects on the noradrenergic and dopaminergic systems. In this case, its use has been observed in elite athletes as a legal stimulant, which has led to its inclusion in the list of anti-doping agencies for exhaustive monitoring. The drug's potential addictive properties are due to its impact on the reward system. its impact on the reward systemThe potential addictive properties of the drug are due to its impact on the reward system, although in most of the cases reviewed it was administered via snorting (taking advantage of the dense vascularization of the area), which is not the conventional way for medical use. Despite the above, it is generally considered that their addictive potential is low.

In summary, antidepressants are safe drugs as far as their addictive properties are concerned, because they do not promote states of euphoria in healthy subjects and their effect is limited to the restoration of euthymia in those who are depressed (or to the regulation of the cognitive components that maintain an anxiety disorder).

2. Antipsychotics

Antipsychotic drugs, which act as dopamine antagonists in the different neurotransmitter pathways, lack addictive potential. However, it has been postulated that they might be somehow involved in the fact that a high percentage (47%) of the population with schizophrenia uses at least one drug, with tobacco being particularly relevant. Such a finding would be important, because it is one of the factors that most frequently interferes with the treatment administered to them and with their medium and long-term prognosis.

Addiction facilitated by antipsychotics would be indirect, with the use of the substance being explained by the presence of symptoms of the pathology or by the concurrence of the side effects associated with these drugs. In such a case it would be understood as self-medication in order to deal with the discomfort, as most patients point out when questioned about it. A common example could be the consumption of stimulants to combat negative symptoms, such as emotional flattening and/or abulia, from which it follows that this abuse is not done at random (but would depend on the subjective "complaints" of the person).

In this regard, hypotheses have been formulated in which the drug is excluded from the equation, such as that of neural substrate overlap: in such a case, it would be understood that the neurological alterations underlying schizophrenia (especially associated with the mesolimbic pathway and the connections between the nucleus accumbens and the prefrontal cortex) would form a common mechanism for addiction and psychosis. Thus, the very fact of suffering from such a problem would increase the risk of comorbidity. would increase the risk of comorbidity with addictive disorders.. This hypothesis, in which the participation of dopamine is inferred, is still tentative today.

Other authors have proposed the possibility that the prolonged use of antipsychotics would result in changes in the cerebral reward system, with an increase of receptors for D2 and D3 and their affinity in the putamen and nucleus accumbens. It would thus be a question of a hypersensitivity to dopamine itself and to its natural and/or chemical agonists, induced by the drug to which it is administered.induced by the drug over time.

This problem would be added to other known problems derived from its chronic use; especially motor, cognitive and endocrine (in the group of typical antipsychotics); and would contribute to the substance addiction that is so frequent in this population.

3. Anxiolytics

The anxiolytics (which have sedative as well as myorelaxant and hypnotic properties) in current use, and particularly the benzodiazepine group, have been the target of much criticism due to their known addictive potential. These are drugs that act on GABA, the main inhibitory neurotransmitter of the nervous system, and whose effects on the organism are almost immediate. Thus, physical sensations that accompany anxiety are relieved after only a few minutes, which contributes to "hooking" users. users.

The addictive potential of these compounds can be explained by three different dimensions: their half-life (the time it takes for 50% of their concentration in plasma to be eliminated), the time of consumption and the dose used. Thus, the greater the amount of anxiolytic consumed and the more prolonged its administration, the higher the risk of dependence. Dosage is also important, and intermittent use is recommended (use only when the need is perceived, within very strict limits, and not in a rigidly prescribed manner).

For anxiolytics, the appearance of tolerance (reduction of the sedative effect after the fourth month of use and the need to increase the dose to achieve the initial effect), withdrawal syndrome (sensations similar to the original anxiety that arise when use is interrupted) and addictive behavior (belief that one cannot live without the drug and reassurance that it is available at all times) have been described in detail. Rebound symptoms" have also been demonstrated upon abrupt cessation of use.The main symptoms are insomnia and excessive autonomic hyperactivation.

For all these reasons, prescribing physicians are advised to use the lowest effective doses for their patients as far as possible, and to keep in mind from the beginning of the treatment when it will be terminated, trying to adjust to temporary safety windows (since after four months there is an increasingly significant risk of dependence and the benefits of its use are minimized). It is essential to bear in mind that the addiction they cause is both physical and psychological.

The symptoms of dependence on anxiolytics are very varied and often precipitate among those who are dependent on them.The symptoms of dependence on anxiolytics are very varied, and often precipitate new consumption among those who suffer from them in order to reduce or alleviate them, which contributes to the establishment and reinforcement of the problem. These include: sadness, tremor, pain, sleep disturbances (both onset and maintenance and early awakening), headaches, sensation of unreality (depersonalization and derealization), tactile hypersensitivity and motor tics. Cases of memory problems of variable duration have also been observed, especially with regard to the ability to "store" new content.

It is important to consider the monitoring of the emotional state during the prolonged use of benzodiazepines, since in some cases an increase in depressive symptoms has been detected. It is essential to warn that the concomitant consumption of alcohol can potentiate the effect that these substances would have separately, entailing a risk of overdose whose consequences can be very serious (depression of the nerve centers that make breathing possible, coma and even death).