8 Warning Signs That You're Becoming Addicted to a Prescription Drug

Most people don't realize that they are addicted to prescription benzodiazepines or opioids until it is too late; the addictive trap has already been sprung. Today, I decided to write about what slipping into addiction to a prescription substance feels like - the self-deceptions, rationalizations, and moving goalposts involved. It's a subtle, gradual, and insidious process, and if you find yourself identifying with any of the warning signs that I explore here, beware. Backing out while it's still possible might help you to avoid serious misery or even save your life.

Because sometimes, you have no clue which photo to use. In reality, I have a slew of old pictures of different controlled substance formulations from Chinese manufacturers on my phone / cloud, which I used while trawling pharmacies to see which ones carried my brands of choice and were amenable to bribery. However, I didn't want to tempt / provoke salivation from anyone who has a problem. I'm a great guy, I know.

Note: For today's discussion, "dependent" refers to needing a physically addictive medicine to function normally (physically and mentally). "Addicted" means continuing to use a substance despite substantial detriments to your wellness.

Doctors traditionally present these states as different, using the example of Type 1 diabetics who are dependent on insulin to regulate their blood sugar but who are not addicted to it - they don't crave it, escalate their use, obsess over it, or use it dangerously.

However, I believe that the cognitive and emotional shifts that characterize addiction are more or less inevitable with regular use of some physically addictive classes of mind-altering drugs, including opioids and benzos; as the body's physiology shifts to require more and more of the drug for normal operation, the mind's workings distort to encompass all manner of rationalizations / justifications for escalating use. Those cognitive changes, in turn, are an essential part of what we call addiction.

Red Flag 1: Your symptoms are getting worse. When you take benzos and opioids regularly, your body adapts to your intake of physiology-altering substances by trying to maintain physiologic balance (homeostasis). In the case of depressant drugs such as opioids and benzos, this involves downregulation (making less sensitive) the receptors that these drugs bind to. It is also accomplished by upregulation of substances and pathways that oppose the effects of the substance (for example, glutamate, an excitatory neurotransmitter).

When the depressant drug that you're taking wears off, you're left with an excess of excitatory neurotransmitters as well as underactive depressant / calming pathways, which increases pain (in the case of opioids) and insomnia / anxiety (in the case of benzos).

At this stage in the insidious process, you're likely to be thinking, "Wow, that Vicodin hits my back pain perfectly," or "Thank God for Xanax; I can breathe again." The medication seems like the solution when it is in fact driving the worsening symptoms.

This increase in symptoms is inescapable for either class of drugs if you're using them regularly; the only options are to increase your dose, switch to a more potent drug, or take a tolerance break. For this reason, benzos and opioids are not meant to be prescribed long-term unless they are being used as-needed (PRN) with substantial periods of time in between doses.

Feeling your underlying symptoms intensify is one warning sign that you're on the path to dependence and addiction.

How do you know that your pain or anxiety isn't worsening independent of the effects of the drug? One important clue is context. If you're experiencing heightened back pain and you've just moved a bunch of furniture, it makes sense that you might need your pain medicine more regularly for a couple of days afterward (likewise if a major project deadline is looming and you're feeling more anxious, which causes you to take an extra dose of Xanax on one or two occasions).

Most people who become addicted to benzos and opioids aren't consciously abusing them. They are impressed and relieved by how well these drugs work to assuage legitimate pain and anxiety, and - as the red flags mount months and years down the line - they use motivated reasoning to justify their continued use of these highly dangerous medications because they find it hard to think about coping with these symptoms without the most expedient option (because the solutions that are more effective and that work in the longer term for pain and anxiety require a lot of work, and - let's face it - they don't give the euphoric boost of opioids or benzos).

Red Flag 2: The medication doesn't last as long and / or you need to up your dose. As I mentioned in Red Flag One, neither benzos nor opioids is meant for regular, long-term use. They're not effective when used in this way*.

*With a few exceptions, such as opioid maintenance as an addiction treatment or buprenorphine treatment as a long-term pain management option for chronic pain that doesn't respond to primary or secondary agents and can't be addressed by targeting the source.

Again, using opioids regularly exacerbates pain, a phenomenon known as opioid-induced hyperalgesia (if you're interested in the physiology of opioids, I wrote a walkthrough of mu opioid receptor dynamics here, which explains concepts like full / partial agonism, antagonism, and receptor affinity). By a parallel mechanism that involves GABA system downregulation and glutamate upregulation, benzos increase anxiety and insomnia.

Depending on the half-life of the specific medication that you're taking, you're most likely to feel these effects as the medications wear off, which is referred to as inter-dose withdrawal. Once you're experiencing inter-dose withdrawal, you've reached some level of physical dependence. From there, you're at high risk of progressing to full-blown addiction.

The other half of this Red Flag, namely, needing to increase your dose, becomes relevant as your tolerance builds due to physiologic adaptations that are a universal response to regular intake of opioids or benzos. As these changes occur, you're going to need an increase in dose (or to be switched to a more potent agent, if you're taking an opioid and this is possible).

The reason that I classify this as a red flag is because - given that neither class of medication is meant to be used long-term unless it is being used very sporadically under PRN dosing, in which case a dose increase should not be necessary - I can't think of a reason to continue using the medication at this point that isn't suspect.

With benzos, you might use them short-term for severe anxiety and insomnia while you're starting a non-addictive medication that takes a few weeks to kick in (for example, an SSRI like Lexapro or an NDRI like Wellbutrin). You should also be working with Cognitive Behavioral Therapy techniques, mindfulness exercises, and other non-pharmacologic tools - in the long term, these are both the safest and the most effective solutions; medications are just a support to use as you develop these more sustainable management tools.

For pain, opioids work very well for acute, short-term pain such as pain arising from a muscular injury or post-operative pain.* If you're taking opioids regularly for more than 4-6 weeks, at which point you are absolutely going to develop a physical dependence on whatever medication you're ingesting, you should be focused on treating the source of the pain rather than just masking it with a highly addictive, ineffective (in the long term) substance.

*Although NSAIDs are often equally or more effective and opioids are often prescribed unnecessarily after minor operations in the U.S.

What procedures are available to decrease your pain by targeting its source - for example, cortisone shots for knee pain or selective spinal nerve blocks for back pain? What less-addictive medications are available - for example, prescription NSAIDS like Sulindac for inflammation-related pain or gabapentin / Lyrica for neuropathic pain? Have you tried mindfulness and Cognitive Behavioral Therapy, hydrotherapy, and / or Complementary and Alternative treatments such as acupuncture?

If you're not addicted or heading in that direction, then why are you choosing to up the dose of a medication that will inevitably intensify your symptoms when used regularly? Again, if you're using a PRN medication as sparingly as you should be, then you should not need a dose increase at all.

I'm not saying that any of these red flags has 100% applicability. It's not inconceivable that increasing the dose of a benzo or an opioid might be clinically reasonable as a one-time measure while a long-term, primary strategy is being implemented / gaining efficacy. However, the need to increase your dose should be viewed with the highest suspicion because it likely indicates tolerance, which almost certainly reflects some degree of physiologic dependence. Your body is operating differently than it used to or else you would have the same response to the same dose of the medication. If you understand what's at stake, this should worry you.

You say: "My doctor will be aware of all of this and let me know if I'm throwing up red flags for addiction, right?"

Absolutely, emphatically not. Although it's a sad testament to overwork, unethical practice, and the abandonment of benevolent paternalism in medicine, the testimony of hundreds of thousands of addicted patients shows that - especially in the U.S. - you cannot trust your physician to properly monitor dependence and addiction or even to warn you that they might occur.

It is so easy for your physician to sign off on a refill rather than exploring more complex, sustainable options, but it can be hell on Earth to come off of these drugs (even if you are the fabled dependent but not addicted person, and even if you taper low and slow, as you're encouraged to [although your physician probably won't know to do that]). Most physicians won't raise the uncomfortable specter of addiction until something obvious happens - such as requesting early refills or claiming that you lost your script.

Red Flag 3: You're taking the medication earlier and / or thinking about it more often. This is where self-honesty can spare you a world of hurt. Although any addict will tell you that the ability to discern one's true thoughts and emotions is eroded by addiction as denial, rationalization, and other maladaptive coping mechanisms evolve, the truth is that, deep down in the core of my being, I always knew that I was in danger of becoming addicted and then, later on, that I was addicted.

You've got to be honest with yourself about how much you're looking forward to that Ativan or Vicodin and about the motives behind that anticipation. Are you thinking, "Two more hours until I can take my Vicodin and get some relief?" Are you spending all day looking forward to that nighttime Xanax, motivating yourself to get through some extra work or exercise because you know that it's waiting for you at the end of it?

Perseveration about a drug is, in my opinion, the key sign that you're becoming addicted to it. After all, no one thinks longingly about when they can inject their pre-prandial insulin.

Scheduling activities around medication is a huge (bright?) red flag. These will be thoughts like: "I'll watch that show later, after I take my Xanny and I'm more relaxed," or "I've got a [insert stressful family / work event] coming up; better make sure that I take my Xanax beforehand."

If you ever move up a scheduled (non-PRN) dose, that, too, is a massive red flag. If you're supposed to take an Ativan at bedtime, but you enjoy the relaxation so much that you start having it right after dinner, you're already well on your way to addiction.

Red Flag 4: Something embarrassing happens while you're on the medication, but you continue to take it.

Maybe you take a Xanax on an empty stomach before a business meeting and get a little loopy / goofy.*

*I have stories for days, unfortunately. Other people noticing that you're under the influence of a benzo or opioid is often an excellent sign that your body is responding to the medication in a way that indicates heightened risk of addiction; this is because the people who are most affected by a substance's intoxicating effects are more likely to seek out these effects again. And again. And again.

Maybe you combine that Xanax with a glass of red wine before a family function and can't remember half of the "great conversations" that other attendees recall having with you that night. Maybe you eat a bunch of food or order a bunch of stuff on Amazon that you don't remember eating / ordering (Ambien shopping hauls that you have no recollection of are so common that there are various slang terms for them - I call them Blackout Fridays).*

*Appallingly, it is quite common to get behind the wheel while on Ambien (a z-drug used as a sleeping medication, which acts at the same receptor as benzodiazepines). Most people who this happens to, including at least one U.S. Senator, are mistaken as drunk and cannot recall why they went out for a drive. There is even an "Ambien defense" to murder and other serious crimes that has been used in several countries; this is especially convenient because all benzos / z-drugs are amnesic, meaning that your client can conveniently forget or have spotty recollection of whatever crime he or she is accused of.

With opioid painkillers, perhaps you get into a fender-bender and are lucky enough that no one recognizes your pinpoint pupils. Maybe you didn't sleep well and end up nodding off a little at work after you take your morning dose.

All medications cause side effects, of course, and if the net benefit of the medication is great enough, then the side effects are worth putting up with (or even trying to rid yourself of with other medications).

However, getting to the point where your behavior is impaired and / or embarrassing is a serious red flag because the vast majority of people would discontinue a non-essential medication that was causing them to behave this way - especially when there are non-addictive alternatives and even non-pharmacologic solutions that are as effective as the medications.

If you're continuing to use benzos or opioids despite impaired judgment / embarrassing or sloppy behavior while you're on them, you need to have an earnest talk with yourself or a therapist about why you're continuing to use them.

Red Flag 5: You're combining your medication with alcohol. Maybe you're like Lucille Bluth from Arrested Development and you mistake the drowsy eye on the "do not consume with alcohol" label for an encouraging, winky eye.

The warning labels on these medications instruct you to avoid alcohol while on them for a very good reason. The risk of almost every negative side effect, from impaired judgment to impaired breathing, increases not additively, but multiplicatively or even exponentially when you combine either drug class with alcohol.*

*Combining benzos and opioids is similarly dangerous; it carries a significant risk of overdose by respiratory depression (in fact, in 2021, 14 percent of fatal opioid overdoses involved benzos, and in 2020, 17.4 percent of fatal opioid overdoses involved alcohol). Prescription of opioids with benzos is done in some circumstances - such as in the context of end-of-life care or when treating severe pain with a muscular component. In these cases, however, the drugs are usually taken on an alternating schedule rather than at the same time, and blood oxygen levels are carefully monitored, as is respiratory rate.

If you are drinking alcohol with your medication to boost its effects, you are evidencing the distorted judgment that is a primary feature of addiction. Get out if / while you still can.

Red Flag 6: You're running out early. This is when your doctor is likely to start taking a keen interest in your controlled substance consumption - mainly because this is when he or she crosses a clear line into malpractice if the prescription is refilled early without evidence that it was lost or stolen.

If you need more of your medication, you need to okay that with your doctor preemptively, not after the fact. However, as I detailed in Red Flags 1 / 2, if you need more of a benzo or an opioid, you're already on the path to dependence and quite possibly addiction.

Running out early is a clear sign that you are already addicted; you're taking more of your medicine while ignoring or discounting the negative effects of going without it for a day or two (or more*).

*Like many benzo addicts, I often took a month's worth of my Xanax script in two to three days. No exaggeration. More on the self-deception / rationalization and teleporting internal goalposts that fueled my benzo addiction here.

My advice is to get help immediately through 12-Step* or SMART meetings, looking into opioid maintenance**, considering inpatient or outpatient rehab***, or by connecting with another resource.

*Info on how to find a 12-Step meeting near you here (bottom of article)

**Directories of providers for buprenorphine and methadone maintenance here (bottom of article)

***Tips on choosing a suitable inpatient rehab program here

Please believe me when I say that it only gets worse from here, and that, from the bottom of my heart, I wouldn't wish addiction on the world's worst person.

Red Flag 7: You're too afraid of withdrawal to taper off of your medication. Maybe you realize that one or more of the aforementioned red flags apply to you; this is good because it means that your self-honesty is intact. You realize that you probably need to taper off of the benzo or opioid that you're on, but you can't set a date to do so (or every time you start, the withdrawal symptoms are so severe that you back off immediately). Regrettably, many doctors will cosign this BS postponement of the inevitable.

You're already in a physiologic trap, and it will only get worse with time. The longer that you use benzos or opioids for, the more tolerant you'll become to them and the more dependent on them you will become.

You'll need more of your medication to function. However, even if your physician increases your dose, you will experience more intense side effects, continue to feel inter-dose withdrawal, and eventually max out the allowable dosage of whatever med you're on.

As discussed ad nauseum above, regular use of benzos increases insomnia / anxiety; regular opioid use increases pain. These are unavoidable consequences that occur for every patient eventually because they result from universal adaptations that the body uses to compensate for the presence of a drug that throws off its physiologic balance.

You need to get off of this stuff. Staying on these medications because you can't stand the effects of tapering off is a form of sunk cost fallacy.

You should plan on a long taper that ends at a very low dose of a suitable, preferably long-acting medicine (diazepam or Librium (chlordiazepoxide) are frequently used for benzo tapering; methadone or buprenorphine for opioid tapers).

You should enlist the help of a physician who will prescribe medicines to help with the process (gabapentin is a godsend for both forms of withdrawal, in my experience; my at-home opioid withdrawal protocol contains some other comfort medicine tips as well as non-pharmacologic suggestions).

Please be careful, especially with benzo withdrawal. I've had grand mal seizures from benzo withdrawal that have obliterated whole chunks of memory and permanently altered how I think and feel.

With proper guidance from a physician, with a low-and-slow taper assisted by comfort meds and mindfulness techniques, getting off these meds without horrific withdrawal symptoms is eminently doable. People are often shocked by how much of their pain, anxiety, insomnia, and weird miscellaneous symptoms* that appear unrelated to their medication regimen vanish after they get these drugs out of their systems.

*Benzo withdrawal in particular has been misdiagnosed as everything from autoimmune conditions to rare neurological disorders. They're funky drugs that put a damper on every aspect of perception, cognition, and emotion, and coming off of them sends all of your systems into overdrive. Frankly, it's a terrifying experience, and the dreadful anxiety as you taper off of benzos lends itself to morbid, hypochondriacal rumination.

Chronic pain patients who have been dependent on opioids for years often feel markedly better a month or two after they finish their tapers; the body regains its ability to self-soothe. Likewise, long-term benzo users who taper off frequently report markedly sharper memory and discover that their "Panic Disorder" or "Generalized Anxiety Disorder" either no longer exists or is substantially less severe after a year off of these drugs.

A note on long-term effects: You don't want to be on benzos long-term. They cause changes in mood and memory, including a significant increase in the risk of dementia. They impair your ability to think rationally and make you more likely to act impulsively. Withdrawal from them can take two whole years.

Opioids, which cause chronic, severe constipation alternating with periods of diarrhea (if it's a short-acting medication), have been implicated in the genesis of GI cancers. They, too, affect mood and memory; they also alter the endocrine syndrome (for example, by causing steep decreases in testosterone levels in many male patients). Some of these effects, too, are likely to be permanent.

Red Flag 8: You react in a defensive, dismissive, or otherwise negative manner to reading this article. Be honest with yourself: You know whether you have a problem. Chances are that a good portion of you who chose to click on this article are addicted to your opioid or benzo medication or are on your way there. None of these red flags in and of itself always signals addiction, but your attitude toward reasonable questioning of your use of these medications is extremely telling.

If you read my descriptions of why opioids and benzos aren't suitable for long-term, non-PRN use and reflexively thought "Yeah, but..." or "I really need them to get through X, though..." or "This doesn't apply to me," then you need to very rigorously examine why you're reacting so strongly and quickly.

Would you feel the same way if you were reading about the risks of a blood pressure medication that you were taking?

When in doubt, taper off. The only winning move against benzos and opioids is not to play. With regular use over an extended period, a high percentage of users will become dependent upon and addicted to these powerful, insidious drugs.

The risk of addiction is so high with benzos and opioids, and the negative effects of addiction to them so dire, that the benefits are simply not worth the risk. In many healthcare systems, opioids and benzos are virtually never prescribed outside of end-of-life and surgical care*.

* I'm not talking about underdeveloped systems, either. I have a physician friend who trained at the University of Queensland in Australia, who said that getting a prescription for opioids outside of very acute, short-term circumstances is essentially impossible; even after surgery, most patients aren't given opioids, and those few who are must take them while still under supervision in a surgical recovery unit in a hospital.

Please be honest with yourself and get out while you can. The longer addiction goes untreated - the longer you take a medication for and the higher your dosage goes - the lower the chance that you will recover.

If one single person reads this article and stops their opioid / benzo use before it becomes a problem - or more of a problem - then the hundreds of hours that I have put into the dozens of articles on this site have all been worth it.

Community input: Can anyone think of any warning signs that I missed? Is there any part of what I discussed that patients and / or providers disagree with?

This can be touchy stuff, I know. For clinicians, I know how tough it can be to approach a patient about a suspected addiction, but you must never forget that it is your duty to do so.

As always, thanks for reading. Be well.