Antipsychotics and Addiction

Antipsychotics are the primary treatment for disorders involving psychosis, such as schizophrenia and schizoaffective disorder. These medications are effective in managing symptoms like hallucinations, delusions, disorganized thinking, and a distorted sense of reality.

While conventional wisdom suggests that antipsychotics are not addictive in the traditional sense, some newer medications in this class may carry a potential for misuse. Understanding the risks of misuse, dependence, and withdrawal is essential to ensure these medications are used safely and appropriately.

What Are Antipsychotics?

Antipsychotics are a class of medications used to treat conditions such as schizophrenia, schizoaffective disorder, bipolar disorder, and major depressive disorder. These medications specifically target the symptom of psychosis, which is characterized by delusions, hallucinations, disordered thinking, and a disconnect between the person and reality.

In addition to psychosis associated with conditions such as schizophrenia, antipsychotics may also be used to treat psychosis that is triggered by illicit drug use and alcohol withdrawal. 

Antipsychotic drugs relieve psychosis ^[1]. They do this by targeting chemical messengers in the brain known as neurotransmitters. More specifically, antipsychotics alter brain levels of the neurotransmitter dopamine, an overactivity of which can cause psychotic symptoms. Newer, second-generation antipsychotics also target the neurotransmitter serotonin, which impacts mood, memory, and cognitive function. This effect on serotonin helps prevent adverse side effects that are common with older, first-generation antipsychotics ^[2].

Antipsychotics and Addiction

Antipsychotics are not addictive medications in the classical sense, unlike opioids, benzodiazepines, or stimulants. Taken as prescribed, antipsychotics don’t create a feeling of euphoria, trigger cravings, or lead to a loss of control. People also do not typically experience the kinds of life disruptions that are common with addictive drugs, such as problems at work, home, or school ^[3]. In other words, antipsychotics do not meet the established criteria for addictive substances.

That said, some antipsychotics do have qualities similar to addictive drugs. They may require higher doses over time (known as tolerance), lead to physical dependence, and cause uncomfortable withdrawal symptoms when one stops the medication. 

However, this is not the same as being addicted to antipsychotics. Addiction is an unhealthy pattern of substance use that involves strong cravings, a compulsion to use, a lack of control over use, and continued use despite negative consequences ^[4]. Put another way, people use substances such as alcohol and drugs to escape reality; antipsychotics are prescribed to return people to reality. 

Some Antipsychotics Have Abuse Potential

While antipsychotics are not addictive drugs in the traditional sense, recent trends show that recreational use of second-generation antipsychotics is on the rise. Research indicates that the second-generation antipsychotics quetiapine, risperidone, aripiprazole, and olanzapine have the potential for misuse or abuse ^[5].

These medications alter the effects of dopamine and serotonin. Dopamine is involved with the brain’s reward system, while serotonin regulates mood, anxiety, and impulsivity ^[6]. When taken without an underlying psychiatric need, these drugs can cause euphoria, relaxation, and a false sense of well-being that is common in recreational drugs, as well as drugs of addiction.

It’s important to note that using antipsychotics recreationally or without medical supervision can potentially lead to antipsychotic overdose, which can cause cardiotoxicity, seizures, coma, or death ^[5].

What is Antipsychotic Dependence?

Antipsychotic dependence occurs when a person is unable to manage their symptoms, maintain stability, or function in their daily life without the continued use of antipsychotic medications ^[2].

With prolonged use, some people develop a tolerance to antipsychotic medications and require higher doses to control their symptoms. In essence, they become physically dependent on antipsychotics, which increases the risk of adverse side effects. 

Additionally, abruptly stopping antipsychotic medications, especially after long-term use, can lead to uncomfortable withdrawal symptoms and a return of psychotic symptoms. For this reason, it is important to keep appointments, refill prescriptions before running out, and discuss dose adjustments with one’s prescribing healthcare provider ^[7].

Antipsychotics and Withdrawal 

Stopping or quickly reducing the dose of antipsychotic medications can cause psychotic symptoms to return and trigger drug withdrawal ^[3]. Antipsychotic withdrawal symptoms can be uncomfortable and may include ^[7]:

• Gastrointestinal upset, nausea, vomiting, diarrhea, and abdominal pain
• Headache and muscle tension
• Anxiety, restlessness, and irritability
• Insomnia
• Rapid heartbeat
• Involuntary muscle movements
• Increased perspiration
• Vertigo

However, slowly tapering off the antipsychotics under the guidance of a healthcare provider can help prevent or minimize antipsychotic withdrawals. A gradual tapering schedule involves reducing the dose slowly over a period of time, usually several months. A standard formula is to reduce the dose by about 10% every two to three weeks ^[8].

During the process of tapering off the drug, one should closely monitor symptoms, communicate with one’s healthcare team, and keep all appointments. Reporting changes in one’s mood, mental state, symptoms, and side effects allows the prescriber to assess progress, adjust the tapering schedule, and provide support as needed ^[3].

Use of Antipsychotics in Addiction Treatment

Antipsychotic medications also have an important place in addiction treatment. They are highly effective at providing relief for psychotic episodes that can occur during acute alcohol withdrawal. They are also used to treat substance-induced mental health disorders ^[4].

Antipsychotics are used in addiction treatment in the following ways ^[4]:

• Acute Alcohol Withdrawal: First-generation antipsychotics are used to manage the acute alcohol withdrawal symptoms of extreme agitation, hallucinations, and delirium tremens, which includes shaking and confusion. These symptoms are called acute because they happen right after one stops drinking, typically within 24 to 72 hours.
• Post-Acute Withdrawal: Second-generation antipsychotics are often prescribed to manage post-acute withdrawal symptoms like insomnia. Post-acute symptoms can linger for up to 18 months after stopping alcohol or drugs. 

In addition to these uses of antipsychotics in cases of addiction, this class of drugs also treats psychosis that is caused by illicit or recreational drug use that does not resolve. For instance, hallucinogens such as LSD and PCP can cause residual psychosis and flashbacks that may persist indefinitely ^[4]. Marijuana use can cause a similar syndrome known as cannabis-associated psychosis (CAPS) ^[9]. Antipsychotics can be effective in treating these types of psychosis, whether they stem from recreational drug use, addiction to substances, or other causes.

Not Addictive, but Not Risk-Free

Antipsychotic medications are not addictive in the traditional sense, and when used as prescribed, they can be life-changing for those who experience psychosis as part of a mental health condition or substance withdrawal process. While some second-generation antipsychotics have the potential for misuse, increased awareness of this risk can help prevent harm and promote safe treatment.

Some people may become dependent on antipsychotics to manage mental health symptoms and can experience withdrawal, particularly if the medication is stopped too abruptly. However, this is not the same as addiction. Unlike addictive drugs, antipsychotics don’t cause cravings or a loss of control: people taking them as prescribed simply rely on them to help manage their mental health condition.

When taken correctly under medical supervision, these medications offer powerful relief from debilitating psychiatric symptoms. They enable many people to reduce their symptoms of hallucinations and delusions, and as an effect, increase their overall quality of life.