Drug dependence: what it is, how it arises and what symptoms it produces

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

These are drugs whose use is widespread in Western society, which has motivated numerous reflections regarding intolerance to psychological pain and the refusal to go through difficult moments that are also part of one's own existence.

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

In this article we will focus solely on its addictive properties, if such exist, or on phenomena related to this if they are appropriate. This reality has received the name of drug dependence, and it is key especially in anxiolytics.

• Related article: "Types of psychoactive drugs: uses and side effects"

What is drug dependence?

Drug dependence is understood as that situation in which the administration of a medication has resulted in the articulation of seek-and-use behavior that does not conform to therapeutic doses, and that ends up causing serious damage to the life of the person and their environment. It is, in general, a special situation, since the most common is that the beginning of the problem had its roots in a therapeutic use of the compound (which ended up deriving into a pathological one).

Despite the fact that these are substances that seek to prevent, alleviate or cure any of the multiple 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 its action deliberately pursues a psychotropic effect (modulating how experiences are manifested internal). Dependence on such drugs is a complex pathology and of which we have more knowledge every day.

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

Can psychotropic drugs generate dependency?

Psychotropic drugs are, without any doubt, the family of medications with the greatest capacity to generate dependency of all those that are administered today in order to regain health. Of all of them, the ones that have received the most attention are anxiolytics (especially the benzodiazepines, which are practically the only ones that continue to be used), since they are administered massively to a society that has recently faced very difficult situations (economic crisis, unemployment, etc.).

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

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

1. antidepressants

Antidepressants are a group of drugs used to treat all mood disorders and also for many of those that are included in the general category of anxiety, so its effects are not only softeners. Regarding the latter, are particularly useful in cases where there are cognitive componentshow could they be social phobia or the Generalized anxiety disorder. Among all those used today, none warrant 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 do not obtain improvement), they were never considered addictive substances, and there are only a few documented cases in the literature in which an abusive use was made of them. themselves. Despite this, both in the old and in 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 crisis hypertensive.

The same can be said of tricyclic antidepressants, for which almost no cases of addiction have been described in the literature. These medicines inhibit the reuptake of serotonin and norepinephrine, and 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 secondary profile; although in global terms they are the ones that have the most beneficial effect on depressive symptoms.

Finally, the SSRIs (selective serotonin reuptake inhibitors), which without They are undoubtedly the most prescribed for depression and anxiety, they do not have properties of type addictive. Of course, it has been estimated that up to 20% of those who consume them for six months or more may suffer from a discontinuation syndrome when they stop using them abruptly. The symptoms, very similar to those that could be expected in a withdrawal syndrome, include: flu-like symptoms, insomnia, imbalances, nausea and headache. They are usually mild and resolve when the drug is reintroduced or gradually withdrawn.

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

An exceptional case would be bupropion, which is used for depressive symptoms and for smoking, generating effects on the noradrenergic and dopaminergic systems. In this case, it has been possible to observe its use in elite athletes as a legal stimulant, which has motivated its inclusion in the list of anti-doping agencies for its submission to an exhaustive follow-up. The 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 by sniffing (taking advantage of the dense vascularity of the area), which is not the conventional way for medical use. It is usually considered, despite everything that has been reviewed, that its addictive potential is low.

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

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2. antipsychotics

Antipsychotic drugs, which act as dopamine antagonists in different neurotransmitter pathways, lack addictive potential. However, it has been postulated whether they might be somehow involved in the fact that a percentage high (47%) of the population with schizophrenia use at least one drug, the case of tobacco. 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 prognosis in the medium and long term.

The addiction facilitated by antipsychotics would be indirect, explaining the use of the substance by the presence of symptoms of the pathology or by the concurrence of the secondary effects that are associated with these medicines. In such a case, it would be understood as a self-medication to stop the discomfort, as the majority of patients point out when they are questioned about it. A common example could be the use of stimulants to combat negative symptoms, such as emotional flattening. and/or apathy, from which it can be deduced that this abuse is not carried out randomly (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 the overlapping of the substrate neural: in this case, it would be understood that the neurological alterations underlying schizophrenia (especially associated with the pathway mesolimbic and the connections between the nucleus accumbens and the prefrontal cortex) would form a common mechanism for addiction and addiction. psychosis. In this way, the very fact of suffering such a problem 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 prolonged use of antipsychotics would result in changes in the brain reward system, with an increase in receptors for D2 and D3 and their affinity in the putamen and nucleus accumbens. It would, therefore, be a hypersensitivity to dopamine itself and its natural and/or chemical agonists, drug-induced over time.

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

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3. Anxiolytics

Anxiolytics (which have both sedative, muscle-relaxing and hypnotic properties) in current use, and particularly the group of benzodiazepines, have been the target of many criticisms for their known potential addictive. These are drugs that act on GABA, the main inhibitory neurotransmitter of the nervous system, and whose effects on the body are almost immediate. So, relieves the physiological sensations that accompany anxiety after just a few minutes, helping to "hook" to the users.

The addictive potential of these compounds can be explained by three distinct dimensions: their half-life (time it takes to eliminate 50% of its concentration in the plasma), the time of consumption and the dose that be used. In this way, the greater the amount of anxiolytic that is consumed and the longer its administration, the higher the risk that will be assumed of suffering dependence. The dosage is also important, recommending an intermittent use (consume only if the need is perceived, under very strict limits, and not in a rigidly prescribed manner).

For anxiolytics, the appearance of tolerance has been described in detail (reduction of the sedative effect after the fourth month of consumption and need to increase the dose to achieve the effect of the beginning), of withdrawal syndrome (sensations similar to the original anxiety that arise discontinuing use) and addictive behavior (belief that one cannot live without the drug and reassurance that it is available at all moment). "Rebound symptoms" have also been shown upon abrupt cessation of use., especially insomnia and an overwhelming autonomic hyperarousal.

For all these reasons, physicians who prescribe it are recommended to resort to the lowest effective doses as far as possible for its patient, and that it be kept in mind from the beginning of the treatment at what moment it will be considered finished, trying to adjust to windows temporary security (since after four months there is an increasingly relevant risk of dependency and the benefits are minimized of its use). It is key to keep in mind that the addiction they promote is both physical and psychological.

The symptoms of dependence on anxiolytics are very varied., and frequently precipitate among those who suffer from them a new consumption in order to reduce or alleviate them, which contributes to the establishment and reinforcement of the problem. In this sense, the following stand out: sadness, tremor, pain, sleep disorders (both initial and maintenance and early awakening), headaches, feeling of unreality (depersonalization and derealization), tactile hypersensitivity, and tics engines. There have also been cases of variable-length memory issues, especially with regard to the ability to "store" new content.

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