Addiction Addiction, Physical Dependence, and Tolerance to Pain Medication What's the difference? By Carol Eustice Carol Eustice Facebook Carol Eustice is a writer covering arthritis and chronic illness, who herself has been diagnosed with both rheumatoid arthritis and osteoarthritis. Learn about our editorial process Updated on December 01, 2020 Medically reviewed Verywell Mind articles are reviewed by board-certified physicians and mental healthcare professionals. Medical Reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. Content is reviewed before publication and upon substantial updates. Learn more. by John C. Umhau, MD, MPH, CPE Medically reviewed by John C. Umhau, MD, MPH, CPE John C. Umhau, MD, MPH, CPE is board-certified in addiction medicine and preventative medicine. He is the medical director at Alcohol Recovery Medicine. For over 20 years Dr. Umhau was a senior clinical investigator at the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIH). Learn about our Medical Review Board Print Daniel Sambraus / Photographer's Choice / Getty Images There is a difference between addiction, physical dependence, and tolerance to pain medication. It is imperative that each of us understands the difference. Many people with chronic pain conditions, including certain types of arthritis, are prescribed pain medication. Their medical condition dictates the need for such drugs—that's why it was prescribed as part of their treatment plan. Yet, if you pay attention to the news, people who are legitimately prescribed pain medication are being lumped in with the abusers. We can easily understand how that developed. After all, there is an epidemic of opioid abuse in the U.S. The drugs are said to be overprescribed. Add to that a celebrity dying from a drug overdose and the anti-drug campaigns hit a fever pitch. Each of the aforementioned problems is a legitimate concern. But, so is the disregard for people (e.g., chronic pain patients) who legitimately need pain medication to function and have some quality of life. Their plight cannot be minimized while the urgency of other matters is dealt with. This realization has largely been lost because too many people do not understand the difference between addiction, physical dependence, and tolerance. We cannot blur the lines between these three factors and expect to solve problems related to drug use and abuse. It is the first step we all must take—understanding the terminology. What Is Addiction? The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) recognize the following definition of addiction as it relates to the use of opioids for the treatment of pain: Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addiction is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. What Is Physical Dependence? The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) recognize the following definition of physical dependence: Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. What Is Tolerance? The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) recognize the following definition of tolerance: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution (i.e., diminishing or lessening) of one or more of the drug's effects over time. That said, most pain medicine and addiction specialists concur that chronic pain patients treated longterm with opioid drugs usually do develop physical dependence. Some patients will develop tolerance. But, usually, this group of patients does not develop an addiction. The actual risk of addiction is considered unknown and not predictable, but it is likely related to several factors, including genetic predisposition. Addiction itself is a primary chronic disease. Exposure to drugs is just one factor in its development. In fact, in most cases, exposure to drugs that can stimulate the brain's reward center do not produce addiction. Characteristic Features and Behaviors Impaired control, craving, and compulsive use of the drug, as well as continued use of the drug despite negative physical, mental, or social consequences, are considered characteristic features of addiction. But, it can be a bit more complicated than simply recognizing the presence of those features. The same features could be related to inadequate pain relief. A doctor must be able to exercise their judgment and to discern between addiction and another cause. There are specific behaviors that point to the possibility of addiction. Those behaviors include: Not adhering to the prescribed schedule for the drugTaking more than one dose at a timeRepeated reports of stolen or lost drugsDoctor shopping (getting the drug from more than one doctor)Isolation (wanting time alone)Additionally using non-prescribed psychoactive drugsUsing pain medications for sedation, intoxication, to boost energy, or to lower anxiety levelsRequesting certain formulations or routes of administration of the drugAvoidance of or disinterest in non-opioid treatment options Addiction clearly is associated with potentially serious, even fatal, consequences. On the other hand, physical dependence is considered a normal response by the body to the chronic or continued use of certain medications—and not only opioid pain medications. For example, physical dependence can occur with corticosteroids, antidepressants, beta-blockers, as well as other medications not considered addictive. If drugs that may be associated with physical dependence are to be discontinued, the drug should be tapered to avoid withdrawal symptoms (e.g., prednisone tapering). Tolerance is even a bit trickier to understand. Tolerance may occur to the desired effect of the drug, but it can also occur to the undesired effects. Tolerance is also variable, occurring at different rates for different effects. Using opioids as an example, tolerance to the analgesic effects occur more slowly than to respiratory depression. The Best Online Therapy Programs We've tried, tested and written unbiased reviews of the best online therapy programs including Talkspace, Betterhelp, and Regain. The Bottom Line Addiction is mostly a behavioral disorder, although it can overlap with physical dependence. Typically, addiction involves using the drug despite negative consequences, craving the drug even when not in physical pain, and using it for reasons other than the prescribed indication. Physical dependence is evident when someone develops a tolerance to a drug or if one would experience withdrawal symptoms from stopping the drug suddenly. Tolerance is present when the same dose does not garner the same result, thereby requiring higher doses to achieve the desired result. In and of itself, physical dependence does not mean that there is addiction, but it may accompany addiction when there is addiction. If you or a loved one are struggling with substance use or addiction, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area. For more mental health resources, see our National Helpline Database. 1 Source Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. A brief review of the genetics and pharmacogenetics of opioid use disorders. Dialogues Clin Neurosci. 2017;19(3):229-236. 10.31887/DCNS.2017.19.3/wberrettini Additional Reading Physical Dependence and Addiction - An Important Distinction. NAABT. Updated 03/12/2016. Definitions Related to the Use of Opioids for the Treatment of Pain: Consensus Statement of the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. ASAM. 2001. Drugs of Abuse. IV. Introduction to Drug Classes. 2011 Edition: A DEA Resource Guide. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). Is There a Difference Between Physical Dependence and Addiction? National Institute on Drug Abuse. December 2012. By Carol Eustice Carol Eustice is a writer covering arthritis and chronic illness, who herself has been diagnosed with both rheumatoid arthritis and osteoarthritis. See Our Editorial Process Meet Our Review Board Share Feedback Was this page helpful? Thanks for your feedback! What is your feedback? Other Helpful Report an Error Submit Get Treatment for Addiction Advertiser Disclosure × The offers that appear in this table are from partnerships from which Verywell Mind receives compensation.