Dependence vs Addiction

Updated: Jan 12

My recovery founder Deborah Levy examines the different theories on drug addiction

At a non-medical/diagnostic level just take a moment to think about the different perceptions that are created when you think of addiction – what do you see?

Think about dependence now…does it create a softer perhaps a more forgiving image?

Whilst the two words might conjure up different mental pictures, is there actually a difference in meaning? Also, how easy is it in a clinical setting to successfully diagnose a patient with either a dependence or an addiction?

What is certain is that there has been ongoing debate amongst medical professionals for many years when it comes to reaching consensus in the diagnosis of addiction vs dependence.

The principal framework used by specialists when diagnosing a substance misuse issue is the Diagnostic and Statistical Manual of Mental Disorders (the DSM), which is currently in its fifth edition.

DSM-IVTR was the first edition that distinguished between drug abuse and drug dependence.

Drug Abuse / Dependence Models

Looking at the wider picture, there are a variety of abuse/dependence models for consideration:

  1. The physical dependence model

  2. The positive reinforcement model

  3. The disease/medical model

The physical dependence model states that some drugs lead to physical dependence when taken, the body builds tolerance requiring more drug to maintain the same effect. Unpleasant withdrawal symptoms occur when the substance is not taken, these symptoms work as negative reinforcement. Abraham Wikler worked with heroin addicts and noted that if withdrawal symptoms occurred repeatedly in certain environments, then the responses also became classically conditioned.

O’Brien et al (1990) O'Brian et al (1990).pdf ( made headway in their study of conditioned cravings; Cocaine users reported a strong craving for cocaine whilst watching a cocaine related video. McHugh et al (2015), in a more recent study again showed how visual stimuli such as drug paraphernalia can elicit drug cravings in those who are dependent.

It is recognised that the dependence model has its limitations, it does not explain how the dependence started or deal with the reasons why someone relapses once the physical withdrawal has passed. Wikler explained relapse as a conditioned withdrawal symptom. Cravings, he concluded, were due to environmental stimuli associated with previous drug use.

With regard to the positive reinforcement model, the most popular contemporary view of why humans self-administer potentially lethal drugs is that these chemicals activate the reinforcement system in the brain (the dopaminergic mesolimbic system), it desensitizes the body’s natural production of dopamine (pleasure transmitter) which makes it difficult to experience pleasure. This model is based on the idea that drugs act as instrumental reinforcers and that drugs are proclaimed to increase the chances of responses that produce them (Heyman, 2009). (PDF) Resolving the contradictions of addiction (

Again, there are limitations of the positive reinforcement model; why do some people continue to take drugs despite its diminishing effects? Why do negative consequences of drug taking e.g. relationship or financial issues not inhibit its usage?

The Disease model is perhaps most widely accepted model of addiction, arose from early treatment programs for alcohol from the likes of Benjamin Rush who was the first medical professional to treat alcoholism as a disease.

The drug that the disease model is most commonly applied to is ethyl alcohol. This model describes addiction as a mental illness, on which the American Medical Association (AMA) agrees and defines alcoholism, as well as drug dependence, as diseases (Galanter & Kleber, 2011).

It is however not certain whether or not this model holds to its explanation that addicts are suffering from a disease. There must be some truth to this model’s concept being that this disease only attacks some individuals (Levinthal, 2010)?

The limitations of the disease model is that it does not address physical and psychological dependence issues.

Where are we at today?

Some of the key organisations such as The World Health Organisation and DSM have revised classifications of abuse and dependence into a diagnosis of "substance use disorder" (SUD)

To be diagnosed as a having an SUD, in addition to undertaking an initial consultation, a person needs to meet at least two of the 11 DSM-5 listed symptoms:

  • Repeated use, resulting in a failure to fulfil major role obligations

  • Repeated use in hazardous situations

  • Continued use despite social/interpersonal problems

  • Cravings

  • Tolerance

  • Withdrawal

  • Use for longer periods or in larger amounts than intended

  • Persistent desire or unsuccessful attempts to control the use

  • A great deal of time spent on activities related to the use

  • Reduced important social, occupational, or recreational activities

  • Continued use despite physical or psychological problems

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