Written by Stephanie Garner
Reduce suffering. That is the goal most clinicians carry into practice. But sometimes the treatment itself turns into the problem — a patient walks into a clinic with a fracture and walks out, weeks later, unable to stop taking the opioid prescribed for post-surgical pain. Iatrogenic addiction is the clinical term for substance dependence or compulsive behavior that originates directly from medical treatment. Vowles et al. (2015) found wide variation in rates of problematic opioid use in chronic pain studies, largely because studies used different definitions of misuse, abuse, and addiction. Their weighted estimates placed addiction in the 8% to 12% range. Even the lower estimates remain clinically significant because they affect a large number of patients exposed to long-term opioid therapy.
What makes it worse? Many of these cases begin with textbook prescribing. A five-day course of hydrocodone after knee surgery. Lorazepam for acute panic attacks. Nothing reckless. The slide from therapeutic use into dependence happens quietly, and clinicians are often the last ones to notice — partly because medical training has long treated addiction as something that happens to other people’s patients.
The Broader Addiction Spectrum
Treatment-induced dependence does not develop in a vacuum. Genetic factors play a role. So do environmental stressors and psychiatric comorbidity. All of it feeds into whether a given patient crosses the line from use into disorder. The addictions most often seen in people today can be triggered by a variety of factors. A clinician trying to understand where iatrogenic cases fit has to look at the full picture — the most common types of addiction seen in clinical practice range from alcohol and opioid use disorders to behavioral patterns such as gambling and disordered eating.
Here is why that range matters: if you only screen for prior substance misuse, you will miss the patient who has never used recreationally but happens to carry an OPRM1 polymorphism. Variants in genes such as OPRM1 may influence opioid response and addiction vulnerability, but they are not reliable stand-alone predictors of who will develop opioid use disorder (Mistry et al., 2014).
On paper, that patient looks low-risk. In reality, biological vulnerability can complicate that picture. There is also a classification issue. The DSM-5 collapsed “abuse” and “dependence” into one spectrum — substance use disorder, mild through severe. Iatrogenic cases sit awkwardly inside that framework. The patient may meet DSM-5 criteria for substance use disorder, but the origin of that disorder is medical. It matters for treatment planning, for prognosis, and for how the patient sitting across from you processes what went wrong.
High-Risk Medication Classes
Some prescriptions carry far more risk of iatrogenic addiction than others. Knowing which ones is not optional — it is the baseline.
Opioid analgesics are the most studied example. The CDC’s 2022 guideline advises prescribing opioids at the lowest effective dose and for no longer than needed, with a tapering plan when opioids are used around the clock for more than a few days. Many post-surgical patients in some settings go home with enough pills for two weeks because the discharge paperwork was written before anyone stopped to ask whether acetaminophen and a nerve block might have been enough. Hospitals know alternatives exist. Actually rewriting the default order sets is a different story.
Benzodiazepines come next. Alprazolam, lorazepam, diazepam — effective for acute anxiety, but tolerance and physiologic dependence can develop with ongoing use. Withdrawal after prolonged use can mimic the original symptoms, trapping patients in a dose-escalation cycle they didn’t ask for. Some patients do not realize they are dependent until they try to stop.
And then there are gabapentinoids — pregabalin, gabapentin — which got positioned as the safer alternative to opioids around 2015 and never lost that reputation. Prescriptions went through the roof. Emerging data challenges that assumption (Evoy et al., 2021). Z-drugs and stimulants carry their own dependence curves. The common denominator? Neuroadaptation. The brain adjusts, and adjustment is where dependence starts.
Risk Factors and Vulnerable Populations
It would be convenient if prior substance use history were the only red flag. It is not. Not even close.
Depression, PTSD, and generalized anxiety — each one raises the risk substantially. Chronic pain also increases risk, even before prescribing patterns are considered. Imagine a scenario where two people walk out of the same pharmacy holding the same bottle of oxycodone 5 mg. One had an appendectomy last week — healthy, stable, good support at home. The other? Fibromyalgia for eight years. Depression that nobody has treated. No therapist, no psychiatrist, no safety net. Same prescription. Wildly different risk profiles.
Age complicates things further. Benzodiazepine clearance slows down as patients get older — a 78-year-old on lorazepam is not going to process it the way a 45-year-old does, and the sedation piles up in ways that increase fall risk significantly. Teenagers are a different problem entirely. Adolescents prescribed stimulants need careful monitoring because these medications are Schedule II and have misuse potential, but appropriate ADHD treatment does not clearly increase later substance use disorder risk.
And across every demographic, fragmented care makes things worse. Three specialists, no shared chart, nobody coordinating. The orthopedist writes hydrocodone, the psychiatrist writes clonazepam, and the two of them have never spoken. Meanwhile, the patient’s medicine cabinet holds a combination that any pharmacist would flag — if anyone thought to ask.
Screening and Early Detection
Catching iatrogenic addiction early is possible. The tools exist. They are just underused. Tools such as SOAPP-R and CAGE-AID can support screening, but they measure different kinds of risk and should be used as part of a broader clinical assessment. These tools are brief and practical enough for routine clinical use. Yet both get skipped constantly.
Ongoing monitoring matters just as much. Prescription Drug Monitoring Programs operate in all 50 states now, but a 2023 study out of Minnesota found that four in ten opioid prescribers never checked the PDMP before writing a prescription (Sacarny et al., 2023). Four in ten. That is not an individual failing — it’s a systems problem.
The early warning signs are often subtle. A patient asks for a dose increase ahead of schedule, becomes anxious around refill dates, or shows pushback when tapering is discussed. These shifts deserve attention before anyone meets formal diagnostic criteria. Once someone is doctor-shopping or repeatedly presenting to the ED, the best window for early intervention may already have passed.
Prevention and Ethical Prescribing
The conversation about dependence risk needs to happen before the first pill is dispensed. Not in a consent form buried under six other documents — out loud, in plain language. Most patients do not get this conversation. They should.
When you spread pain management across multiple modalities, no single drug carries the full load. Chronic low back pain might respond better to a low-dose NSAID, physical therapy, and nerve blocks than to oxycodone alone. Same logic for anxiety — an SSRI plus psychotherapy is a different risk equation than a benzodiazepine and a six-week follow-up. None of this is new. It is just underutilized — reimbursement still favors pills over sessions.
Tapering deserves its own mention. Abrupt discontinuation of opioids or benzodiazepines can cause significant withdrawal symptoms, and with benzodiazepines in particular, sudden cessation can trigger seizures. Evidence-based deprescribing guidelines outline gradual dose-reduction strategies that are safer and more practical in clinical care (Pottie et al., 2018). Some of this work also has to happen at the institutional level. Systems that require PDMP review when opioids are prescribed, and that audit whether those checks occur, are more likely to catch high-risk prescribing patterns that individual clinicians may miss.
Implications for Healthcare Education
This is where medicine has genuine catching up to do. A scoping review found very limited coverage of opioid use disorder within the broader literature on substance use disorder education in medical schools. Medical schools have often devoted limited curricular time to addiction education, and that gap shows in clinical practice. Students graduate knowing oxycodone’s pharmacokinetics but not how to recognize when a patient is sliding toward dependence on it.
Continuing education has to pick up the slack. Nurses, counselors, case managers, pharmacists — these professionals encounter iatrogenic addiction regularly, sometimes before the prescribing physician does. Certification bodies need to make addiction-risk literacy a requirement. The LCME still does not mandate specific SUD education hours, so each school decides for itself. A handful — Virginia Commonwealth among them — have embedded addiction rotations into clerkships. Most have not.
I realize “add more training” sounds like a platitude at this point. But the ask here is specific: if you can prescribe a Schedule II controlled substance, you should be able to explain — in clinical terms — how that substance produces dependence. If you can’t, the training failed you somewhere.
Conclusion
First, do no harm. Everyone learns that phrase. Iatrogenic addiction is what it looks like when we fail at it — not because anyone acted with bad intent, but because the screening wasn’t done, the training wasn’t there, or the system made it too easy to keep refilling a prescription nobody was monitoring. The prescriber has to look at their own patterns honestly. The institution has to fund PDMP integration and real addiction coursework, not a single noon lecture during orientation week.
The patients who developed dependence through medical treatment did nothing wrong. They followed instructions. They trusted the system. Earning that trust back means doing the structural work — and then doing the harder thing, which is admitting out loud where we got it wrong.
References
Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain — United States, 2022. MMWR Recommendations and Reports, 71(3), 1–95. https://doi.org/10.15585/mmwr.rr7103a1
Evoy, K. E., Sadrameli, S., Engel, J., Covvey, J. R., Peckham, A. M., & Morrison, M. D. (2021). Abuse and misuse of pregabalin and gabapentin: A systematic review update. Drugs, 81(1), 125–156. https://doi.org/10.1007/s40265-020-01432-7
Mistry, C. J., Bawor, M., Desai, D., Marsh, D. C., & Samaan, Z. (2014). Genetics of opioid dependence: A review of the genetic contribution to opioid dependence. Current Psychiatry Reviews, 10(2), 156–167. https://doi.org/10.2174/1573400510666140320000928
Muzyk, A., Smothers, Z. P. W., Akrobetu, D., Ruiz Veve, J., MacEachern, M., Tetrault, J. M., & Gruppen, L. (2019). Substance use disorder education in medical schools: A scoping review. Academic Medicine, 94(11), 1825–1834. https://doi.org/10.1097/ACM.0000000000002883
Pottie, K., Thompson, W., Davies, S., Grenier, J., Sadowski, C. A., Welch, V., Holbrook, A., Boyd, C., Swenson, R., Ma, A., & Farrell, B. (2018). Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Canadian Family Physician, 64(5), 339–351. https://pmc.ncbi.nlm.nih.gov/articles/PMC5951648/
Sacarny, A., Williamson, I., Merrick, W., Avilova, T., & Jacobson, M. (2023). Prescription drug monitoring program use by opioid prescribers: A cross-sectional study. Health Affairs Scholar, 1(6), qxad067. https://doi.org/10.1093/haschl/qxad067
Vowles, K. E., McEntee, M. L., Julnes, P. S., Frohe, T., Ney, J. P., & van der Goes, D. N. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain, 156(4), 569–576. https://doi.org/10.1097/01.j.pain.0000460357.01998.f1
Author bio: Stephanie Garner, MS, is the Chief Executive Officer of ARVAC Incorporated in Dardanelle, Arkansas, where she has served since 2013. She holds a Master of Science in College Student Personnel from Arkansas Tech University and a Bachelor of Science in Political Science from the University of the Ozarks.
