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Placement of addiction, dependence and withdrawal[edit]

Were should this content generally be placed? Doc James (talk · contribs · email) 08:34, 17 May 2019 (UTC)

1) Section on "side effects"/"adverse effects"[edit]

  • Support Often addiction is listed as a black box warning. It is generally seen as potential a adverse effect. Doc James (talk · contribs · email) 08:34, 17 May 2019 (UTC)
  • support generally agree w/ Doc James...generally seen as potential adverse effect--Ozzie10aaaa (talk) 10:55, 17 May 2019 (UTC)
  • Support From a lay point of view, all three conditions (addiction, dependence and withdrawal) are considered "adverse effects". It seems clear to me that these three topics should be sub-sections of Adverse effects. --RexxS (talk) 11:25, 17 May 2019 (UTC)
  • Oppose Putting addiction, dependence and withdrawal section under adverse effect can be misleading and cause unnecessary panic to parents with child with the indicated syndromes. In general public's impression, adverse effects means "unexpected physiological effects under therapeutic dose". It's the case in Taiwan. --It's gonna be awesome!✎Talk♬ 13:52, 17 May 2019 (UTC)
  • Comment: It's also confusing/controversial even in the academic community as many papers mis-recognize adverse effects of dopaminergic drugs at therapeutic dose as "signs and symptoms of overdose and addition". (See Dopamine_dysregulation_syndrome) --It's gonna be awesome!✎Talk♬ 16:22, 17 May 2019 (UTC)
  • Strong oppose per my comments in discussion. Seppi333 (Insert 2¢) 17:28, 17 May 2019 (UTC)
  • Support. Addiction etc. are certainly adverse effects, even though not every user suffers from these problems. I understand that there is topical sensitivity about this since the opioid addiction crisis has led to opioids being withheld from patients who badly need the pain relief. But addiction is still really not a good thing. Logophile59 (talk) 03:02, 18 May 2019 (UTC)
  • Support dependence formation is unequivocally an adverse effect Cas Liber (talk · contribs) 12:51, 20 May 2019 (UTC)
  • Support per Casliber.--Literaturegeek | T@1k? 18:57, 20 May 2019 (UTC)
  • Support strongly -- There are differences in meaning between "adverse effects" and "side effects", and implied differences of degree between "adverse effects" and "undesirable side effects", not to mention "dangerously adverse effects" or "trivial side effects". There also are such things as "desirable side effects", or if you prefer, "incidental benefits"; for example a drug that is a specific for a painful or upsetting condition might incidentally induce drowsiness and prolonged sleep that promotes recovery or alleviates suffering. And fairly commonly one plays off desirable side effects against adverse effects. All such expressions should be used with precision in our articles; sometimes the difference hardly matters, but WP is an encyclopedia, not a cocktail party, and that justifies effort to express distinctions clearly. Quality matters. JonRichfield (talk) 15:22, 21 May 2019 (UTC)
  • Support This has been Wikipedia's status quo and the usual interpretation of Wikipedia:Manual_of_Style/Medicine-related_articles#Drugs,_treatments,_and_devices. Pharma companies group these things with other side effects on the warning labels. To me this seems like the conventional choice established off-wiki in medical publishing and carried into wiki. I am open to change and I see lots of discourse in this discussion, but I need the case to be made more orderly and briefly. If anyone came up with a few bullet points and a few sentences making a case for change, even in particular circumstances, then I am open to hearing that. I recommend support just because it seems conventional and I have trouble understanding the argument for change because the conversation is long and wanders. Blue Rasberry (talk) 13:26, 31 May 2019 (UTC)

2) Section on "overdose"[edit]

  • Oppose The term overdose is generally used for a significantly larger than usual dose that has the potential to result in serious toxicity not a gradual increase in dose such as results in addiction / dependence. Doc James (talk · contribs · email) 08:34, 17 May 2019 (UTC)
    • MeSH description for a "Drug overdose": "Accidental or deliberate use of a medication or street drug in excess of normal dosage." @Doc James: Your definition seems to be at odds with the conventional medical definition of an overdose. Seppi333 (Insert 2¢) 08:39, 17 May 2019 (UTC)
      • That is oversimplified and not the common usage which more fits with "The inadvertent or deliberate consumption of a dose much larger than that either habitually used by the individual or ordinarily used for treatment of an illness, and likely to result in a serious toxic reaction or death."[1] Doc James (talk · contribs · email) 08:41, 17 May 2019 (UTC)
  • Oppose not all occurrences of addiction, dependence or withdrawal happen as a result of overdose. It seems clear to me that we should not include these as sub-sections of Overdose.
    • I have no idea who I'm responding to given that this is unsigned, but as I described below, addiction almost never occurs when addictive drugs are used at therapeutic doses for any of their indicated uses. Dependence that arises from the use of therapeutic doses is fairly common for drugs that belong to certain drug classes. With that in mind, it is far more common for both disorders to occur from overdose than from therapeutic doses of drugs with addiction and/or dependence liabilities, so that is a rather misinformed justification for opposing this option. Seppi333 (Insert 2¢) 17:28, 17 May 2019 (UTC)
  • Support For instance, methylphenidate addiction and dependence can only happen in overdose scenario rather than an adverse effect under therapeutic dose or under dose titration with supervision. Putting addiction, dependence and withdrawal section under adverse effect can be misleading and cause unnecessary panic to parents with child with the indicated syndromes. Addtionally, a lot of papers investigated doses from 72 mg / day to 130 mg / day to dig out what they called "opitimal doses" and they didn't report addication. Furthermore, I tried to find the cutting dose for addiction and got nothing. It's, therefore, a relatively safer and effective medication compared to other durgs with the abusive potential.--It's gonna be awesome!✎Talk♬ 13:47, 17 May 2019 (UTC)
  • Oppose per above. Undue weight and does not make sense. --Tom (LT) (talk) 06:08, 19 May 2019 (UTC)
  • Oppose per my comments in discussion. Seppi333 (Insert 2¢) 08:09, 20 May 2019 (UTC)
  • Oppose as two different definitions that not necessarily overlap Cas Liber (talk · contribs) 12:58, 20 May 2019 (UTC)
  • Oppose Overdose almost always refers to an acute event involving, typically, very very large quantities of a drug or drugs resulting in serious toxicity. In terms of addiction an overdose is only referred to when a drug abuser takes a dose that causes serious systemic toxicity.--Literaturegeek | T@1k? 19:03, 20 May 2019 (UTC)

3) Place in its own section[edit]

  • Oppose gives undue to weight to the subject in question.Doc James (talk · contribs · email) 08:34, 17 May 2019 (UTC)
  • oppose undue weight is a problem...IMO--Ozzie10aaaa (talk) 11:00, 17 May 2019 (UTC)
  • Comment Of course each of addiction, dependence and withdrawal require their own section if sufficient sources exist discussing them. However, that does not mean that these have to be a level 2 section. It seems to me that a level 3 section under Adverse effects meets the requirement for having their own section(s). --RexxS (talk) 11:25, 17 May 2019 (UTC)
  • Oppose per above. Undue weight. --Tom (LT) (talk) 06:08, 19 May 2019 (UTC)
  • Comment My proposal has gained no traction, so I guess this isn't a viable alternative. Seppi333 (Insert 2¢) 08:09, 20 May 2019 (UTC)
  • Oppose Undue weight Cas Liber (talk · contribs) 13:07, 20 May 2019 (UTC)
  • Weak oppose undue weight generally, although not a big deal that I would lose sleep over.--Literaturegeek | T@1k? 19:05, 20 May 2019 (UTC)

4) Place both "overdose" and "addiction" under "adverse effects"[edit]

  • Support as possible option as an overdose is an adverse effect aswell. Doc James (talk · contribs · email) 08:47, 17 May 2019 (UTC)
  • Support From a lay point of view, addiction, dependence, withdrawal and overdose are all possible adverse consequences of a particular drug. It seems clear to me that they should all be level 3 sections under the level 2 Adverse effects. --RexxS (talk) 11:25, 17 May 2019 (UTC)
  • Weak support - This is were I'd expect to find the information as a lay reader. However, the reason it's only a weak support from me is BNF and Drugs.com don't list addiction or dependency in their side effects sections (I wouldn't expect them to list withdrawal or overdose). For example BNF (via MedicinesComplete) has a general "Cautions" section for all opioids, which is separate to - and listed before - the side effects. Little pob (talk) 12:24, 17 May 2019 (UTC)
Strike weak; on the proviso, after taking into consideration Colin's comments below[2], of using an alternative section heading. Something like "Risks", "Guidance and risks", or "Cautions and risks" might work. This would allow the section to cover things like contraindications (e.g. ibuprofen in chicken pox) in addition to the content at the root of the RFC. Little pob (talk) 09:56, 20 May 2019 (UTC)
  • Weak support, a decent option. A new sub-section for overdose/addiction should be created under adverse effect section. --It's gonna be awesome!✎Talk♬ 13:50, 17 May 2019 (UTC)
  • Per Adverse effect,

    In medicine, an adverse effect is an undesired harmful effect resulting from a medication or other intervention such as surgery. An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or procedure, this is called a medical error and not a complication. Adverse effects are sometimes referred to as "iatrogenic" because they are generated by a physician/treatment. Some adverse effects occur only when starting, increasing or discontinuing a treatment.

--It's gonna be awesome!✎Talk♬ 15:08, 17 May 2019 (UTC)

  • Support - this is the least bad of the first 4 options IMO. Seppi333 (Insert 2¢) 00:10, 18 May 2019 (UTC)
  • Weak oppose. To me, an adverse effect is something that occurs when the drug is being used at the approved dose, in the approved way. Negative effects (e.g. overdose) that are the result of mistakes or abuse are different.Logophile59 (talk) 03:08, 18 May 2019 (UTC)
    @Logophile59: adverse effects are almost always negative. It makes sense to discuss adverse effects that occur with normal dose use as well as from an overdose and to do so under the main adverse effect section.--Literaturegeek | T@1k? 19:18, 20 May 2019 (UTC)
    @Literaturegeek: Sorry if I was unclear. Of course, adverse fx are negative by definition. My point was that there is a difference between an adverse effect (an unavoidable consequence of using the drug at the approved dose, often (but not always) an unwanted effect that is a direct result of the drug's mechanism of action) and an overdose (avoidable if the drug is taken correctly). From the scientific point of view the distinction is important, and if anything it's more important (IMO) to distinguish the two for the lay reader. Logophile59 (talk) 01:08, 21 May 2019 (UTC)
  • Support. Overdose and addiction are problems because of the adverse effects of the drug on a person, their body and behaviour, so it make sense to talk about them in this section. Also, the title has a logical name and is likely to be widely understood in English-speaking countries. --Tom (LT) (talk) 06:08, 19 May 2019 (UTC)
  • support per Tom and Doc James--Ozzie10aaaa (talk) 12:38, 19 May 2019 (UTC)
  • Support both can be classed as adverse effects (alternately overdosage (and dosage) could be placed in a pharmacokinetics section I guess) Cas Liber (talk · contribs) 13:08, 20 May 2019 (UTC)
  • Support it is sensible to place this section as a subsection of adverse effects because it is describing adverse effects that occur from the drug in an overdose situation.--Literaturegeek | T@1k? 19:18, 20 May 2019 (UTC)
  • Support as per discussions below Ian Furst (talk) 13:58, 31 May 2019 (UTC)
  • Support (via FRS) - This seems the most-balanced approach. StudiesWorld (talk) 11:04, 10 June 2019 (UTC)

5) Either "Overdose" or "Adverse effects", depending upon the drug as per the original proposal [edit]

  • Support - I find it pretty irritating that the current approach specified in the MOS wasn't even listed as an option considering that it stemmed from a consensus that was established over 4 years ago. The placement of these sections in one section or the other for the past 4+ years has been determined by whether or not the use of a drug in clinical practice at commonly prescribed therapeutic doses results in one of those disorders.
    Except in very rare cases (i.e., psychostimulants for narcolepsy and opiates for end-of-life care), it is extremely unusual for an addictive drug to be commonly prescribed at doses which carry an addiction risk. To be perfectly clear, sustained dosing patterns that do carry the risk of inducing an addiction do not cause an addiction by chance: the development of an addiction when a drug is used at those doses is inevitable and would occur in a significant fraction of patients who are prescribed those doses.
    Dependence, on the other hand, is a much more common occurrence at therapeutic doses for certain drug classes. Consequently, the placement of sections on addiction and dependence under the overdose/adverse effects sections varied by drug article and the two sections weren't necessarily located together under the same level 2 section. Seppi333 (Insert 2¢) 17:28, 17 May 2019 (UTC)
  • Support: Compelling evidence except for Seppi's example of narcolepsy. To my knowledge, the doses of methylphenidate used for treating narcolepsy is more or less comparable with doses used to treat ADHD. --It's gonna be awesome!✎Talk♬ 20:10, 17 May 2019 (UTC)
  • Comment: In DailyMed, overdose, dependence, adverse effects have their own sections in leaflets respectively. Amphetamine, a featured article, has the same arrangement. They are good guidances for us IMO. --It's gonna be awesome!✎Talk♬ 08:14, 19 May 2019 (UTC)
  • Oppose Would love to see a reference for this "it is extremely unusual for an addictive drug to be commonly prescribed at doses which carry an addiction risk". Opioids are prescribed at addictive doses all the time as are benzos. Doc James (talk · contribs · email) 11:17, 19 May 2019 (UTC)
    • @Doc James: Benzodiazepines cause dependence, but not addiction; a number of drugs can cause dependence at therapeutic doses, including both benzos and opioids. I'm not aware of any sources that indicate that the chronic use of opioids at therapeutic doses is associated with the development of an addiction (excluding in the case of end of life care, which I have read about in both medical reviews and textbooks); however, if you can supply one, I will concede my entire argument. In particular, that would imply that the maximum recommended dose of some addictive drugs is not below the threshold for ΔFosB accumulation. Also, the maximum time period over which an addiction could potentially develop, assuming that the dosing pattern of the drug is stable, is equal to the length of time that phosphorylated ΔFosB proteins persist in the brain, which is approximately 2 months.[1][2] Chronic use over longer periods with a stable dosing pattern would not induce an addiction if it hasn't developed by then.
      Also, to further clarify, my argument about the placement of that section under the "Overdose" heading does not apply to addictive drugs that currently have no medical uses, like MDMA, since the concept of an "Overdose" isn't well-defined with respect to a range of therapeutic doses.
      Addendum: I've cited my assertions about benzos and opioids in my response to Cas Liber below. Seppi333 (Insert 2¢) 07:29, 20 May 2019 (UTC); edited 17:56, 20 May 2019 (UTC)
      • FosB does not explain everything about addiction, it is an important part of addiction but you talk about it as being the beginning and end. Plenty of recovering addicts still crave drugs after two months or more clean, when their FosB levels would have normalised. And yes benzodiazepines can be addictive, albeit modestly so, the major issue with benzodiazepines is the risk of physical dependence and serious withdrawal, which is very high. Much of the drug seeking behaviour of benzodiazepines is often about alleviating acute withdrawal effects and is often best treated with reinstating the benzodiazepine followed by gradual titration of dosage over months or longer. Opioids do have a higher risk of addiction and drug seeking to get high than benzodiazepines.--Literaturegeek | T@1k? 19:47, 20 May 2019 (UTC)
        • @Literaturegeek: FosB explains virtually nothing about addiction. DeltaFosB governs its development, not the prognosis. Conditioned memory persists long after DeltaFosB proteins are no longer present in neurons and that is what explains reinstatement. I never once suggested or even wrote anywhere that DeltaFosB governs the presence or absence of an addiction, only its development, because that is what multiple independent sources say. I honestly can't believe that you would offhandedly dismiss the singular importance of that protein in addiction if you've read even one of the review articles about it. Moreover, I've never once stated that it is the only factor involved in the development of an addiction; countless epigenetic proteins (most of which are enzymes) facilitate this process and a unique set of those proteins appear to mediate addictions to specific drugs. Also, your statement about benzos being addictive contradicts the following source as well as the sources it cites in support of its assertions. Seppi333 (Insert 2¢) 20:02, 20 May 2019 (UTC)
        • Plenty of recovering addicts still crave drugs after two months or more clean, when their FosB levels would have normalised. I never even implied that DeltaFosB expression-dependently regulated the intensity of cravings. Even if I did, it would take more than two months for the expression of its downstream targets to subside back to normal levels, so I wouldn't have asserted that to begin with. You are making a lot of erroneous assumptions about what and how I think. Seppi333 (Insert 2¢) 20:12, 20 May 2019 (UTC)
          • Okay, fair enough, but anytime I see you on talk pages talking about addiction, you cite FosB and nothing else to make your points, so it gave me that impression. I have not dismissed the importance of FosB, please reread what I wrote in my prior statement, I clearly said it was an “important part of addiction”.--Literaturegeek | T@1k? 20:33, 20 May 2019 (UTC)
            • You see me talking about it so often simply because its overexpression is what causes addictions. Seppi333 (Insert 2¢) 23:25, 20 May 2019 (UTC)
  • Oppose WTF? we have epidemics of codeine and benzo addiction, stimulants are incredibly tightly regulated in Australia. Many people get addicted to these things in vaguely normal practice Cas Liber (talk · contribs) 13:25, 20 May 2019 (UTC)
    @Casliber: Despite the fact that this area has been a primary focus of my editing for about six years, my statements seem to be summarily disregarded quite often in this RfC.
    From [3]: "Although authors of the guidelines should be commended for not suggesting that addiction is a direct consequence of long-term benzodiazepine use, they do not do enough to clarify the distinction between dependence and addiction in this context. For example, they state that ‘patients should be advised that benzodiazepines may produce both tolerance and dependence, with the risk of withdrawal symptoms’. Several studies (reviewed by Starcevic, 2014) have demonstrated that dose escalation (i.e. tolerance) occurs rarely during a long-term treatment of anxiety disorders with benzodiazepines. In contrast, withdrawal symptoms after an abrupt cessation of long-term benzodiazepine use or precipitous decrease in the dose of benzodiazepines are common, although not inevitable; patients should be rightly cautioned about them, but not intimidated. The important point here is that pharmacological dependence (characterised by tolerance and/or withdrawal symptoms) denotes no more than a normal physiological adaptation to the long-term presence of a substance that affects the central nervous system (O’Brien et al., 2006) and that it is erroneous to consider as addicted all individuals who are dependent on benzodiazepines. Substance addiction is a compulsive drug-seeking behaviour, associated with craving and loss of control, which persists despite multiple adverse consequences (Shaffer, 1999). Addiction-like pattern of benzodiazepine use is rarely seen among patients with anxiety disorders who do not have another substance use disorder (Starcevic, 2014). Therefore, withholding benzodiazepines from such patients on the grounds that they cause addiction and substituting them for medications that may be more harmful represents poor clinical practice." So again, benzos cause dependence, but not addiction. The distinction between those two disorders is very significant. Dependence is relatively transient and generally very unpleasant; addiction is long-term, extremely self-destructive, and generally upends if not ruins a person's life for at least a few years. Seppi333 (Insert 2¢) 14:13, 20 May 2019 (UTC)
    That's a false dichotomy. One sees all grades of dependence/addiction in clinical practice - there is no zone of rarity between dependent and addicted patients. Some people do remain on a long term stable dose of benzos for years but many do escalate (and not just the "nasty addicts"). Cas Liber (talk · contribs) 15:16, 20 May 2019 (UTC)
    Hmm, I'm not sure I entirely understand what you're saying. Are you arguing that a drug necessarily must be able to cause an addiction if it can cause dependence? Also, I would appreciate it if you didn't use the phrase "addict" in a pejorative sense; addiction is a brain disease, not a way of life. Seppi333 (Insert 2¢) 15:21, 20 May 2019 (UTC)
    (edit conflict) Yes. Any dependence-forming drug (in the classical sense - benzos, narcotics, stimulants) can have addicts who resort to great lengths to procure the drugs. Regarding pejorative, do you understand the use of quotation marks? It is the material you are posting that is highlighting the distinction between dependence and addiction, not me Cas Liber (talk · contribs)
    Addiction and dependence have entirely distinct biomolecular mechanisms in the brain, as mentioned in their respective articles, so a number of drugs do in fact cause one but not the other. But, you don't have to take my word for it: "While physical dependence and withdrawal occur with some drugs of abuse (opiates, ethanol), these phenomena are not useful in the diagnosis of an addiction because they do not occur with other drugs of abuse (cocaine, amphetamine) and can occur with many drugs that are not abused (propranolol, clonidine)." (page 367). Seppi333 (Insert 2¢) 15:35, 20 May 2019 (UTC)
    As for opioids: "Research has long demonstrated that patients with no prior history of opioid abuse treated with opioid pain medications over extended periods do not experience euphoria—these patients are therefore unlikely to become addicted [1]. Still, there is a risk that a small percentage (3.27–11.5%) of patients treated with opioids for chronic pain may develop addiction or abuse with negative consequences, complicating the management of chronic pain [9]." To be perfectly clear, this source is saying that the misuse or "abuse" of these drugs as a euphoriant is necessary for the development of an opioid addiction when they're used to treat chronic pain. Moreover, from this review: "The administration of opioids has been used for centuries as a viable option for pain management. When administered at appropriate doses, opioids prove effective not only at eliminating pain but further preventing its recurrence in long-term recovery scenarios. Physicians have complied with the appropriate management of acute and chronic pain; however, this short or long-term opioid exposure provides opportunities for long-term opioid misuse and abuse, leading to addiction of patients who receive an opioid prescription and/or diversion of this pain medication to other people without prescription." This is essentially the same assertion as was made by the preceding review. Seppi333 (Insert 2¢) 14:52, 20 May 2019 (UTC)
    Err, yes, obviously many people can take them safely, but the incidence of dependence and addiction problems is high. In fact the first page you link really goes on about it at great length! Cas Liber (talk · contribs) 15:29, 20 May 2019 (UTC)
    I haven't been arguing that they're not abused. I've been saying that if they're used the way they're supposed to be, the risk of addiction is negligible. These sources corroborate my assertion. Seppi333 (Insert 2¢) 15:40, 20 May 2019 (UTC)
    Well, the argument that patients don’t escalate their benzodiazepines dose is a bit silly as they are not in charge of the dose! The doctor is! The doctor writes the prescription, not the patient! Yes this weak argument is POV pushed that benzos don’t cause tolerance and rarely addiction, originally by researchers tied to the manufacture of Xanax, now repeated by a small number of naive academics. There are lots of flawed research out there. Yes, benzodiazepines have moderate risk of addiction and very high risk of physical dependence and severe withdrawal. The addiction risk is higher with opiates though. As for opiates, sometimes people accidentally discover the euphoriant effects of opiates by taking an extra tablet or two for severe pain relief and this then turns into an addiction coupled often with a physical dependence. Seppi, I have for a while had increasing concerns about your editing, e.g., you have had a very literal interpretation of the word overdose, you have ridiculed my mainstream interpretation of tolerance and dependence and claim you have “corrected me”, you are overly fixated on FosB to the exclusion of other important factors involved in addiction, etc., etc. You appear to latch onto things to the exclusion of other important data and academic viewpoints and then POV push a narrow angle that in my view is out of context. I worry what impact this might have on our articles.--Literaturegeek | T@1k? 19:47, 20 May 2019 (UTC)
    you have ridiculed my mainstream interpretation of tolerance and dependence I'm not sure what you're talking about, as I don't remember doing this; can you clarify?
    you are overly fixated on FosB to the exclusion of other important factors involved in addiction See my reply to your comment above.
    You appear to latch onto things to the exclusion of other important data and academic viewpoints and then POV push a narrow angle that in my view is out of context. That's a bold assertion. You're the one pushing a POV about benzos that contradicts sources. In any event, what viewpoints have I excluded then? I'm sure you can give me at least ONE concrete example of a viewpoint I've omitted. @Literaturegeek: Also, I don't want a hand-waivey bullshit argument; cite a review that covers the viewpoint(s) which you're alleging that I've excluded. Seppi333 (Insert 2¢) 20:18, 20 May 2019 (UTC)
    We discussed tolerance and dependence here: Talk:Lisdexamfetamine#Option_1:_Use_"disputed" and then you appeared to reference this previous discussion on this page: talk:Methylphenidate#Overdose_section where you claim you have previously “corrected me”... The subject of benzodiazepines is controversial with a general consensus that the risk of physical dependence and tolerance is too high to justify long-term use for most patients. Yes some researchers and doctors publish papers challenging the mainstream consensus and you latch on to their arguably weak methodology as if it were the sole and only WP:TRUTH. Addiction risk requires high doses of benzodiazepines to stimulate dopamine release and activate the reward pathway but low dose physical dependence and tolerance is a very well proven risk of benzodiazepines, even a single sleeping tablet per night. My source is the U.K. guidelines in British National Formulary. My other evidence is that the community is roundly rejecting — with a strong consensus — your overly literal interpretation of the term overdose and it’s usage on our articles.--Literaturegeek | T@1k? 20:33, 20 May 2019 (UTC)
    The subject of benzodiazepines is controversial with a general consensus that the risk of physical dependence and tolerance is too high to justify long-term use for most patients. I never asserted anything about this being true or false. The only thing I've stated about benzo dependence is that it occurs at therapeutic doses, so I don't know why you said "Yes some researchers and doctors publish papers challenging the mainstream consensus and you latch on to their arguably weak methodology as if it were the sole and only WP:TRUTH." I don't know how I've "latched on" to an opposing argument about that if I've never even commented on it.
    My source is the U.K. guidelines in British National Formulary. Link the source.
    My other evidence is that the community is roundly rejecting — with a strong consensus — your overly literal interpretation of the term overdose and it’s usage on our articles. Point to me an article in which I've used a "literal interpretation of the term overdose" in the article text. I'd really like to know because I'd like to see how you think I've incorporated that into an article. Seppi333 (Insert 2¢) 20:46, 20 May 2019 (UTC)
    Re your statement in the link you provided about physical dependence: you said "I don’t think so, the fact tolerance and partial tolerance (a need to take increased doses to achieve the same effect) as a result of chronic use of stimulants followed by a withdrawal syndrome occurs is the very definition of physical dependence". Our article on Physical dependence doesn't describe it that way and it never did, even prior to my first edit; it has always qualified the withdrawal syndrome as one involving unpleasant physical/somatic symptoms, not unpleasant physical and psychological symptoms in accordance with your definition. All I said was "It's not the [definition] we use", as in, it's not the definition used in the article. I've added very little text to the article, but if you think what it says is wrong, then cite some sources and fix it. Seppi333 (Insert 2¢) 21:00, 20 May 2019 (UTC)
    @Seppi333: The word physical in physical dependence refers to physiological neuroadaptations in response to the drug which cause a withdrawal syndrome during dose reduction or cessation. It does not mean physical bodily withdrawal symptoms only. This link defines physical dependence better and it includes ‘affective symptoms such as anxiety’ as being part of the withdrawal syndrome consequent of a physical dependence. So anxiety is a psychological symptom that is caused by a physical dependence. Obviously our physical dependence article has been flawed for many years then. Shame on us.--Literaturegeek | T@1k? 21:21, 20 May 2019 (UTC)
    So how do they define psychological dependence in that textbook?
    I’m still waiting for a link to that source you mentioned about benzodiazepines. Seppi333 (Insert 2¢) 01:59, 21 May 2019 (UTC)
    Here is the benzodiazepines BNF link
    Yes, anxiety, craving etc., can also be caused by a psychological drug dependence just like gambling addiction because neuroadaptations as a result of addiction can occur. And sometimes there are psychological reasons for taking the drug to cope which can cause these symptoms as well. But you won’t see sources talk about psychological/psychiatric symptoms of withdrawal such as psychosis, mania, paranoia, hallucinations, delirium etc., being caused by psychological dependence like you will with physical dependence and the resultant physical withdrawal syndrome. So, yes psychological symptoms (including anxiety and depression), often severe, are very much part of the physical withdrawal syndrome (caused by neuroadaptations to counteract the effects of the drug). Obviously the main editors of physical dependence article were confused and have made poor editing choices when building that article. Shame on us.--Literaturegeek | T@1k? 09:05, 21 May 2019 (UTC)

┌─────────────────────────┘ @Literaturegeek: the only thing I see when my browser loads that page is:
“BNF is only available in the UK
The NICE British National Formulary (BNF) sites is only available to users in the UK, Crown Dependencies and British Overseas Territories.“ Seppi333 (Insert 2¢) 00:36, 22 May 2019 (UTC)

  • I haven't been arguing that they're not abused. I've been saying that if they're used the way they're supposed to be, the risk of addiction is negligible. - this is a simplistic and naive attitude. How does any doctor know whether a percentage of his patients unbeknown to him actually get euphoric on codeine/morphine. It is exceptionally common for people to minimise their enjoyment or overuse of things if society frowns on it. Look, I think narcotics and sedatives are highly effective and valuable drugs, but time and time again patients can become dependent or addicted despite their prescribers' best efforts. With vigilance, a decent prescriber can make them safer but nothing is 100% foolproof. The book referred to isn't bad but is simplistic and reductionistic at a psychological level (ummm...gambling addiction anyone?). It is a pity they don't get more input from psychiatrists and psychologists but whatever... Cas Liber (talk · contribs) 20:54, 20 May 2019 (UTC)
    this is a simplistic and naive attitude. Wtf? That's literally what the 2 sources reviews that I quoted say.
    The book referred to isn't bad but is simplistic and reductionistic at a psychological level That textbook didn't mention psychological dependence in the statement I quoted, so I don't know what you're referring to. Seppi333 (Insert 2¢) 21:00, 20 May 2019 (UTC)
    That's the point. It doesn't. And doesn't take on board that if psychological dependence is severe (i.e gambling) then it can be as bad as an addiction (by their definition of addiction). Cas Liber (talk · contribs) 21:10, 20 May 2019 (UTC)
    Psychological dependence typically doesn't last for more than a few weeks. It's unpleasant, but it's nowhere near as severe or protracted as an addiction. Edit: One last point before I need to get off: problem gambling, per our article, entails both an addiction to and dependence upon gambling, not just dependence. Seppi333 (Insert 2¢) 21:13, 20 May 2019 (UTC)
    I am not sure you fully understand physical dependence and psychological dependence as you failed to pick up a flaw in our article, see a wee bit above, my reply to you on this subject.--Literaturegeek | T@1k? 21:25, 20 May 2019 (UTC)
    The article isn’t flawed since “physical dependence” is a term that has 3 different definitions. Do you know what the third is or would you like me to tell you? Seppi333 (Insert 2¢) 01:59, 21 May 2019 (UTC)
    Tell me the third one, it’ll make everyone think you are really clever and you’ll win the ego battle. Replied above a little bit as well.--Literaturegeek | T@1k? 09:05, 21 May 2019 (UTC)

┌──────────────────────────────┘ My bad about the pissing contest. I was rather irritated yesterday. In any event, if you look at older sources (like >3 decades ago) on pubmed, you will find that the terms “addiction” and “physical dependence” are fully conflated and used as synonyms in countless articles. Also, you might be interested in reading PMID 26740398 since it elucidates the distinction between physical dependence and psychological dependence on the basis of pathophysiology (NB: this paper uses the phrase “reward tolerance and dependence” in lieu of “psychological dependence”; since that entails a motivational and/or hedonic deficit, it’s consistent with how the author defines psychological dependence in his neuropharmacology textbook). Seppi333 (Insert 2¢) 14:34, 21 May 2019 (UTC)

Discussion[edit]

These listed under both "side effects" and "overdose". They do not make sense under overdose as addiction and dependence are gradual processes well the subsequent withdrawal does not occur as a result of overdose.

This ref defines overdose "The inadvertent or deliberate consumption of a dose much larger than that either habitually used by the individual or ordinarily used for treatment of an illness, and likely to result in a serious toxic reaction or death."[4] Doc James (talk · contribs · email) 06:58, 17 May 2019 (UTC)

See the proposal below. Seppi333 (Insert 2¢) 08:26, 17 May 2019 (UTC)
Re above - MeSH description for a "Drug overdose": "Accidental or deliberate use of a medication or street drug in excess of normal dosage." Seppi333 (Insert 2¢) 08:39, 17 May 2019 (UTC)
Am just thinking that much drugs, such as clonidine, many antidepressants, requires a tapering off after the ceasation is decided. Not sure if these drugs also warrant the potential of dependence. It seems to me that a lot of drugs give rise to withdrawl symptoms but not all of these drugs are attributed to "having potential of dependence or addition". --It's gonna be awesome!✎Talk♬ 14:13, 17 May 2019 (UTC)

Proposal: restructuring the layout of drug articles for drugs with an addiction liability[edit]

ΔFosB accumulation from excessive drug use
ΔFosB accumulation graph
Top: this depicts the initial effects of high dose exposure to an addictive drug on gene expression in the nucleus accumbens for various Fos family proteins (i.e., c-Fos, FosB, ΔFosB, Fra1, and Fra2).
Bottom: this illustrates the progressive increase in ΔFosB expression in the nucleus accumbens following repeated twice daily drug binges, where these phosphorylated (35–37 kilodalton) ΔFosB isoforms persist in the D1-type medium spiny neurons of the nucleus accumbens for up to 2 months.[1][2]

The original proposal for placing sections on "Addiction", "Dependence", and/or "Withdrawal" in articles on drugs implicated in substance use disorders is located at Wikipedia_talk:Manual_of_Style/Medicine-related_articles/Archive_8#Section_ordering_for_addictive_drugs. There was unanimous consensus for the current approach at the time the proposal was archived.

Doc James seems to have a problem with it now despite agreeing with it back then; he wishes to move all of these sections to the "Adverse effects" section of drug articles even for drugs that lack the capacity to induce an addiction at low doses (NB: the reason as to why dosage of an addictive drug matters is that all addictive drugs have a threshold dose beyond which stable and long-lasting [i.e., phosphorylated] DeltaFosB isoforms start to accumulate, and without the accumulation of those isoforms, DeltaFosB overexpression is literally impossible; the overexpression of that transcription factor in the nucleus accumbens is the biomolecular trigger for the development of an addiction, hence, no DeltaFosB overexpression → no addiction). I won't accept this approach due to how grossly misleading the implication is; if there were consensus for it, I would actively oppose its implementation even knowing that I'd probably get banned for doing that.

So, in order to avoid implicitly suggesting that all addictive drugs with a clinical use carry the risk of inducing an addiction even at low/therapeutic doses in our articles, I am now proposing that these sections be placed in their own level 2 section instead of a level 3 subsection under either "Overdose" or "Adverse effects" (see MOS:MED#Drugs, treatments, and devices for how the layout of these articles is currently specified). Unless someone has another idea, this seems like the only feasible solution that addresses both of our concerns. Seppi333 (Insert 2¢) 08:23, 17 May 2019 (UTC)

No it should not be in its own section. It fits best under "adverse effects" or "side effects" which is were it should go. Doc James (talk · contribs · email) 08:30, 17 May 2019 (UTC)
We could also simple put "overdose" under the side effect heading. Doc James (talk · contribs · email) 08:40, 17 May 2019 (UTC)
@Doc James: While I'm not particularly keen on doing that, juxtaposing those two sections under Adverse effects seems markedly less misleading than throwing the addiction section under that heading by itself; it would no longer carry a clear implication of "this is a possible drug effect at normal doses", but it would carry an ambiguous implication of "this is a possible drug effect at either normal or high doses". Perhaps there's another alternative that we can both agree on. Anyway, I need to go to sleep. Seppi333 (Insert 2¢) 08:53, 17 May 2019 (UTC)

This RfC is malformed given that up until today, these sections weren't "generally placed" in either "Adverse effects" or "Overdose". Their placement depended entirely upon the prevailing opinion in medical literature about the potential for individual addictive drugs to induce an addiction when used at commonly prescribed doses. In other words, the placement has been on a case-by-case basis. Consequently, I can't support or oppose either of the first two options despite having a clear opinion about them. The wording of the RfC does not take my position into account. Seppi333 (Insert 2¢) 08:43, 17 May 2019 (UTC)

That may be how you have been doing it. You could add that as an option. But it is one I disagree with. Doc James (talk · contribs · email) 08:46, 17 May 2019 (UTC)
  •  Comment: MEDMOS does not dictate the order or presence of sections, and never has done. I know this, because I wrote those parts of MEDMOS. While developing the guideline, I analysed the current medical FAs and GAs and found absolutely no pattern. The guidance is MEDMOS has always been "suggested sections" for new articles or where there is a substantial rewrite. In my experience, it is only ever harmful for editors to require a certain article structure "compliant with MEDMOS". Far better to argue for article structure because it benefits the flow of ideas presented in the article to the reader, or wrt prominence in the subject. For what it is worth, I can't understand the demand that "Addiction and dependence" be placed under "Overdose". I can't see the discussion that User:Seppi333 refers to. The current wording added by Seppi333, that suggests the same subheadings of "Overdose" as well as "Adverse effects" is symptomatic of both editors not "getting it" about this being "suggested" and not "the law". A topic ban on rearringing articles "compliant with MEDMOS" is long overdue. Given that both Seppi333 and Doc James are currently edit warring here and at Methylphenidate suggests that both editors should be blocked for warring. -- Colin°Talk 09:25, 17 May 2019 (UTC)
    • @Colin: Wikipedia_talk:Manual_of_Style/Medicine-related_articles/Archive_8#Section_ordering_for_addictive_drugs (also linked at the top of this subsection) Seppi333 (Insert 2¢) 17:28, 17 May 2019 (UTC)
      • User:Seppi333 I see a very confused proposal containing "either .. or.. " but not explicitly saying you intend "both" in the guideline. Your claim for 100% unanimous support is really ridiculous. I see there is an agenda at play here, with claims that certain drugs are not addictive at "therapeutic" dose, only at "overdose". For that reason, I strongly oppose including addiction under "overdose" rather than the NPOV of "adverse effects" or its own section if prominence in literature. Really it would be better if you and James stopped using MEDMOS to force your POV or to restrict editorial choices per article. These are matters to be argued per article based on how the best quality literature approaches the topic, and in as neutral a way as we can. -- Colin°Talk 17:45, 17 May 2019 (UTC)
        • @Colin: Uncontested support from 2 out of 2 people would correctly be described as "unanimous". I left that section open for 6 months before implementing it; at the very least, I can't force more people to provide their feedback.
          I see there is an agenda at play here, with claims that certain drugs are not addictive at "therapeutic" dose, only at "overdose". I'm sorry, what? I'm assuming you didn't read my explanation as to the mechanisms of how it arises at the top of this section (in small font). Developing an addiction is entirely determinsitic and is fully dependent upon an individual's genetic loading and the sustained dosing pattern of an addictive drug. If the dosage is increased above the threshold dose at which stable DeltaFosB isoforms readily accumulate within neurons, then an addiction is bound to occur in a significant fraction of people who are prescribed those doses, specifically, in people with higher genetic loadings for addiction. If the dose prescribed is below the threshold dose, those isoforms do not accumulate. If, after reading this and my explanation about mechanisms above, you still think I have an agenda, then it's clear you think I'm talking out of my ass when I explain how addiction develops, in which case, there's literally no point in continuing this conversation any further.
          FWIW, given that an addiction is a lifelong disorder with extreme personal and excessive societal consequences, the notion that a typical doctor would knowingly prescribe an addictive drug at a dose that would induce an addiction with sustained use is just fucking stupid. IMO it's blatant malpractice for a doctor to prescribe an addictive drug at doses which carry that risk (NB: the overprescription of opioids is a fairly common malpractice case). The extremely limited exceptions (re: psychostimulants for narcolepsy and opiates for end of life care) for when this is a common practice are very unique cases with mitigating circumstances for prescribing them in that manner. Seppi333 (Insert 2¢) 18:18, 17 May 2019 (UTC)
        • Addendum re the "confused proposal": I used the language "substance dependence and/or addiction" in the original proposal because for any given drug, the former, the latter, or both may result from its use. I was not waffling over what to specify in the header since those are entirely distinct disorders that may occur together or alone. If a drug can cause dependence but not addiction, it should not have a section on addiction and vice versa; if it can cause both, it should have sections on both.
          My use of the DSM-IV's conflated diagnostic label ("substance dependence") in the second paragraph to refer to them does seem like a cause for confusion though. Nowadays, I generally avoid using diagnostic labels to refer to those disorders unless I'm discussing their diagnosis. Seppi333 (Insert 2¢) 00:04, 18 May 2019 (UTC)
          • I read the responses from two people and no they did not give you "uncontested support". WAID's comment was quite negative, rightly questioning the confusion of addiction and dependence, which you are again confusing in your proposal. James's comment was also that addiction in opiates occurs at therapeutic doses. But even if those two responses were positive, you cannot claim they represent consensus. I suspect your proposal was so confused that most people went "meh" and waited to see what change you might actually make. Now we see the change and see your agenda.
The definition of "overdose" is a dose "much higher" than normal e.g. "An excessive and dangerous dose of a drug", "A quantity of a drug well in excess of the recommended dose". You appear to have a binary definition of "therapeutic dose" that is always safe, non-addictive, always helpful, and anything above that is "overdose". I see you arguing above with Doc James about this. I'm afraid you are simply wrong. Once again I see you take language and apply your own interpretation of it, unshakable despite other editors disagreeing. You are also only considering the use of drugs for medical therapeutic purposes. What you write about DeltaFosB is all very well in lab rats and the latest theory, but a bit of humility about our understanding of the human brain is necessary. Your language about "entirely deterministic and is fully dependent" is just so wrong headed and I suspect driving your agenda.
Addiction, just like having permanent toxic effects on an organ, is dose-related and duration-related but there is no precise formula for working out therapeutic dose, and nobody except Seppi333 considers "overdose" to be any dose above that level. Working out the dose to use is based on many factors, including the patient's response (genes in future), duration of therapy, how ill the patient is, what other drugs they are on, etc, etc. Let's leave the question of what is therapeutic and what is overdose separate from the toxic, addictive, dependency and other ill effects of a drug. By putting "addiction" inside "overdose" one is claiming that therapeutic doses are not addictive and that the drug is only addictive in doses well in excess of normal doses. I don't think that is a common enough and proven enough scenario to warrant MOS change. Also I don't think Seppi has made the case for dependency and withdrawal to be sub-sections of overdose. But I repeat again, I wish you guys would stop using MEDMOS as the hammer to force rigid structure to medical articles. MEDMOS does not have the power to settle arguments at article level over where to put this section inside that section. It can only make a suggestion for the generally most likely useful case.
Lastly I would like to plead with James to stop making RFCs with numerous options and immediate voting. That is always disruptive. Please read the many wiki guidelines against voting: it should only be done after there appears to have developed a community consensus, and that prior to voting, your intention should be to encourage the community towards finding a consensus. By laying out 5 different possible options, you confine the discussion to your own imagination of possible options, you make it very time-consuming for anyone to argue "none of the above, this instead...." and you force the discussion along railway tracks. Instead you should open the discussion with a neutral explanation of the conflict and ask people to make a comment and suggest solutions. How anyone is supposed to make sense of the random arrays of support votes and comments here, I do not know. -- Colin°Talk 10:13, 18 May 2019 (UTC)
No one disagreed with me in that proposal; hence it was uncontested. Doc James agreed with me. Hence, that's uncontested support from 2/2 people. I don't see why that's so hard for you to follow. I don't see anything confusing about it. Your definition of overdose is completely different from the MeSH definition; so if anything, it's you misusing language, not me. That said, unlike you, I realize words have multiple definitions, and the MeSH descriptor happens to be the conventional medical definition.
DeltaFosB overexpression has been confirmed in human addicts postmortem; you should probably reserve your opinions for topics you actually understand anyway, since you clearly do not understand what an addiction is, how it develops, or what it entails.
Your language about "entirely deterministic and is fully dependent" is just so wrong headed and I suspect driving your agenda. This would be you talking out of your ass. Try to read some research before you open your mouth and talk. You could have alternatively read the addiction article since it corroborates this statement with a citation to the statement: "exposure to sufficiently high doses of a drug for long periods of time can transform someone who has relatively lower genetic loading into an addict." To explain that for you in plain English since I know you're struggling with this stuff: that means anyone can become an addict if the dose is high enough.
I don't think Seppi has made the case for dependency and withdrawal to be sub-sections of overdose. That's because I'm not making the case that they go in the overdose section? Do you even understand what I'm advocating or are you just trying to argue with both Doc James and I for no apparent reason? Facepalm Facepalm Seppi333 (Insert 2¢) 12:59, 18 May 2019 (UTC)
Addiction, just like having permanent toxic effects on an organ That is an entirely incorrect interpretation of an addiction; addiction may be lifelong due to learning, but its neuroplasticity is fully reversible; differences in brain structure and function from healthy adults are eventually undetectable with abstinence.
but there is no precise formula for working out therapeutic dose, and nobody except Seppi333 considers "overdose" to be any dose above that level. Lol? Really? Give me an example of an addictive controlled substance that does not have a maximum recommended dosage then. Also, it should be therapeutic doses, as I'm talking about a dose range, not a single arbitrary dose, when I say "a therapeutic dose" in generality. As all controlled substances have maximum recommened doses, that's the upper bound for that range. It's not an upper bound for what a doctor can prescribe, but it's the amount that the vast majority of prescriptions are less than or equal to in the US. In any event, the underlined part is you talking out of your ass again because you didn't know what I've stated here despite ranting about the absence of dosing limits like this. Seppi333 (Insert 2¢) 13:25, 18 May 2019 (UTC)
Working out the dose to use is based on many factors, including the patient's response (genes in future), duration of therapy, how ill the patient is, what other drugs they are on, etc, etc. Let's leave the question of what is therapeutic and what is overdose separate from the toxic, addictive, dependency and other ill effects of a drug. True for some drugs; not true at all for controlled substances. I'd concede my point if there were uncontrolled addictive drugs, but none exist.
By putting "addiction" inside "overdose" one is claiming that therapeutic doses are not addictive and that the drug is only addictive in doses well in excess of normal doses. I don't think that is a common enough and proven enough scenario to warrant MOS change. Your notion that modern medicine is trying to turn patients into addicts deserves an extra Facepalm Facepalm. Seppi333 (Insert 2¢) 13:25, 18 May 2019 (UTC)
  • Strongly agree we write as far as what the science says. No exception. No original research. --It's gonna be awesome!✎Talk♬ 14:55, 17 May 2019 (UTC)
Alternate proposal[edit]

An alternate proposal is to group together all possible adverse consequences under a level 2 Adverse effects section. Where the sections Addiction, Dependence, Withdrawal, and Overdose have sufficient sources to discuss separately, they should be level 3 sub-sections of Adverse effects. If any of these are routinely linked together closely according to the sources, then they may be combined, such as in Addiction and withdrawal, or in Overdose and addiction. Any well-documented relationships between these factors will naturally be discussed in the appropriate section – for example, where addiction only occurs under circumstances of chronic overdosing. For what it's worth, my lay understanding of overdose (confirmed by reading through numerous results of a Google search) is that it is principally concerned with situations where too much of a drug is consumed. Whether that is 'too much' for safety or 'too much' to avoid issues of addiction is probably no more than semantics, and is the likely root of the disagreement between Seppi and James. --RexxS (talk) 11:44, 17 May 2019 (UTC)

  • Support. Seems perfectly reasonable.--Iztwoz (talk) 11:53, 18 May 2019 (UTC)
  • I don't think it makes sense to put an Overdose heading under Adverse effects since "taking an overdose" is not an adverse effect. Of course, the adverse effects (and much more) are likely to appear in an overdose scenario. So, if overdosing on a given medicine is rare and seldom discussed per WP:WEIGHT then it likely does not require a section at all, and could me noted (if necessary) inside the Adverse effects section. -- Colin°Talk 17:23, 18 May 2019 (UTC)
  • Support but, taking Colin's comments into consideration, with an alternative section heading. Something like "Risks", "Guidance and risks", or "Cautions and risks" might work. Little pob (talk) 09:18, 20 May 2019 (UTC) Strike duplicate !vote. Little pob (talk) 09:57, 20 May 2019 (UTC)
  • Comment: This proposal is more-or-less identical to option #4 above; !votes should really go there. Seppi333 (Insert 2¢) 09:22, 20 May 2019 (UTC)
Idiosyncratic language and agenda pushing[edit]

It is clear that two editors here have their own idiosyncratic interpretations of language and are here to push an agenda. It is also clear that this MOS is being altered because of a dispute at Methylphenidate and wrong-headed use of MOS in which to settle disputes. Above Seppi33 is now resorting to throwing insults, and I have no wish to argue with such editors. What matters, with language, is how people generally use the terms and what our readers expect to find in sections and sub-sections. Misusing language because (a) you have misunderstood what a dictionary says and does not say about usage or (b) to push an agenda, is harmful to our readers. It is also important to remember that drugs are not always used in a therapeutic setting. This may include illegal usage of drugs but also legal usage such as smoking, vaping and alcohol.

  • Overdose Most people regard this as describing a single event where someone has greatly exceeded the normal dose and as a result need urgent medical attention. The most common consequence of overdose is elevation of the adverse effects and consequences of toxicity, which may be permanent or fatal. In that regard, they would not expect to find addiction or dependence under that heading. Acute overdose is often a result of addiction and tolerance, not a cause of it. Even in the disputed Methylphenidate the section on overdose only describes "acute overdose" and makes no mention of, for example, someone regularly taking a dose above normal prescribed levels.
  • Adverse effects This includes all ill effects from taking the drug. One user with an agenda is arguing that addiction, dependence and withdrawal should not be listed as adverse effects if they are generally not seen at therapeutic levels: "Putting addiction, dependence and withdrawal section under adverse effect can be misleading and cause unnecessary panic to parents with child with the indicated syndromes."

So we have two editors with their reasons to choose idiosyncratic definitions of overdose and adverse effects in order to emphasise that methylphenidate is not addictive or causes dependence at therapeutic doses. And they want MOS to agree with this agenda so they can force it on one article. I strongly oppose this and agree with Doc James recent edit to the page to keep Addiction, Dependence, Withdrawal as Adverse effects and not under Overdose. -- Colin°Talk 17:23, 18 May 2019 (UTC)

I never once insulted you; I stated that you didn't understand the topic about which you were talking, that you were talking out of your ass (which means the exact same thing), and that you said something worthy of a facepalm. Face-smile.svg You've been pushing your own agenda by taking a clear position on this and attempting to convince others of your viewpoint, so welcome to the club? Also, your definition of overdose is the conventional one only in the context of toxicity. The NLM definition is by far the more widely used. Seppi333 (Insert 2¢) 17:40, 18 May 2019 (UTC)
Also re - your block comment in the edit summary, I'd support a block of your account. :) I don't know why you make pointlessly inflammatory remarks like that. Seppi333 (Insert 2¢) 17:46, 18 May 2019 (UTC)
Would it be too unacceptable to use a simpler section heading Unwanted effects this could also encompass allergic reactions, and effects of alcohol with drugs? --Iztwoz (talk) 20:29, 18 May 2019 (UTC)
Iztwoz, "unwanted" would simply be a non-standard way of saying "adverse effects". This discussion is the first time I have ever encountered anyone claiming that "adverse effects" should not discuss effects at therapeutic doses, lest we scare parents who might otherwise give their children stimulant drugs. Let us not bend language into unnatural ways simply to appease those who are here to push an agenda, or have invented idiosyncratic meanings. It is most disappointing that the above abuse by Seppi333 doesn't invoke an immediate block. -- Colin°Talk 19:56, 19 May 2019 (UTC)
simply to appease those who are here to push an agenda Such as yourself. Face-smile.svg Seppi333 (Insert 2¢) 21:45, 19 May 2019 (UTC)

Expert consultation[edit]

I have a colleague, who is one of Canada's leading experts on toxicology, dependence, and addiction. Here is his CV page for reference. I explained the debate we are having, and asked for both his input and open source references. Here is his response.

I coauthored a paper a few years ago on addiction and dependence. It's open source. [3] The use of opioids for chronic noncancer pain has increased dramatically over the past 25 years in North America and has been accompanied by a major increase in opioid addiction and overdose deaths. The increase in opioid prescribing is multifactorial ... Dependence is absolutely a side effect. I discuss it here (although it likely won't meet your criteria for citation).[4] Withdrawal is a side effect too, in that it DEFINES dependence in its pharmacologic sense. It's a weird side effect of course, in that one wouldn't experience it if they kept taking the drug. But because dependence is a drug-related harm, and because it's defined by withdrawal upon cessation, you're on safe ground calling it a harm I think. I think most people recognize addiction as a potential harm of opioids, even though we don't know the true incidence. Tolerance - this is also a side effect, in that it (that is, a rightward shift in the dose-response curve) only arises because of exposure to the drug. I'm sorry I don't have a lot of other open-source reviews. If I find one I will send it along. Hope this is of some use. dave.

In current literature, there is a debate about the definition of dependence and addictions. If we reach consensus on the topic, I can pull textbook references. However, I agree that dependence, addiction, and withdrawal should be under adverse effects (which, to me, is synonymous with harmful effects). All are clinically undesirable effects we balance against positive effects like pain-relief. Ian Furst (talk) 10:56, 21 May 2019 (UTC)

Since Doc James and I, as well as most of the !votes, support option 4, placing overdose, addiction, and dependence under adverse effects seems like the it’ll be the outcome of this RfC. Seppi333 (Insert 2¢) 14:50, 21 May 2019 (UTC)
Maybe standardized 3 level-3 sections, with drugs that have the risk profile, all under Adverse effects. Dependence and withdrawal, Addiction, Overdose. Ian Furst (talk) 17:03, 21 May 2019 (UTC)
Amendment to the last note; I was over at methamphetamine, and the side effects title works well. There are lots of effects that are neither therapeutic, nor harmful (erection, in response to sildenfil for pulmonary hypertension comes to mind). Aside from the Dependance, withdrawal, addiction, and overdose discussion , it raises the question of harmful vs routine or trivial side effects. Ian Furst (talk) 11:59, 22 May 2019 (UTC)

I really like "harmful effects" User:Ian Furst. Might be better than side effects or adverse effects. Harmful effects and clear and concise. Doc James (talk · contribs · email) 11:17, 22 May 2019 (UTC)

I can agree to that. Side effects, while accurate, is non-intuitive for a casual reader and too broad imo. Ian Furst (talk) 11:46, 22 May 2019 (UTC)
Amendment to the last note; I was over at methamphetamine, and the side effects title works well. There are lots of effects that are neither therapeutic, nor harmful (erection, in response to sildenfil for pulmonary hypertension comes to mind). Aside from the Dependence, withdrawal, addiction, and overdose discussion , it raises the question of harmful vs routine (or trivial) side effects. Ian Furst (talk) 11:59, 22 May 2019 (UTC)

References

  1. ^ a b Nestler EJ, Barrot M, Self DW (September 2001). "DeltaFosB: a sustained molecular switch for addiction". Proc. Natl. Acad. Sci. U.S.A. 98 (20): 11042–11046. doi:10.1073/pnas.191352698. PMC 58680. PMID 11572966. Although the ΔFosB signal is relatively long-lived, it is not permanent. ΔFosB degrades gradually and can no longer be detected in brain after 1–2 months of drug withdrawal ... Indeed, ΔFosB is the longest-lived adaptation known to occur in adult brain, not only in response to drugs of abuse, but to any other perturbation (that doesn't involve lesions) as well.
  2. ^ a b Nestler EJ (December 2012). "Transcriptional mechanisms of drug addiction". Clin. Psychopharmacol. Neurosci. 10 (3): 136–143. doi:10.9758/cpn.2012.10.3.136. PMC 3569166. PMID 23430970. The 35–37 kD ΔFosB isoforms accumulate with chronic drug exposure due to their extraordinarily long half-lives. ... As a result of its stability, the ΔFosB protein persists in neurons for at least several weeks after cessation of drug exposure. ... ΔFosB overexpression in nucleus accumbens induces NFκB
  3. ^ Juurlink, David N.; Dhalla, Irfan A. (2012-12). "Dependence and Addiction During Chronic Opioid Therapy". Journal of Medical Toxicology. 8 (4): 393–399. doi:10.1007/s13181-012-0269-4. ISSN 1556-9039. PMC 3550262. PMID 23073725. Check date values in: |date= (help)
  4. ^ Juurlink, David (August 8, 2018). "Tox and Hound – Dependence Isn't Addiction, But It's Still A Problem". emcrit.org. Retrieved 2019-05-21.

About face[edit]

@Doc James: See my edit summary for explanation. I prefer option 1>5>4>2 in that order now since option 1 is more parsimonious than 5 and doesn’t necessesitate changing a lot of articles like 4. My reasoning about 2 was explained in detail somewhere in the massive blob of text that this RfC has become. The unexpectedly large number of erroneous preconceived notions and various misinterpretations in this RfC made me change my mind vis a vis my nihilistic edit summary. (struck since my meaning wasn’t clear; I was referring to most of the responses I quoted in green) If you want to close it, go ahead. Seppi333 (Insert 2¢) 00:25, 22 May 2019 (UTC)

This is a tangential issue, but are the terms "adverse effects" and "side effects" completely synonymous with exception for the fact that a side effect includes non-harmful drug effects? These sources didn't help - [5][6][7] - other than to equate "adverse reactions/events" with "side effects". Seppi333 (Insert 2¢) 01:08, 22 May 2019 (UTC)
[8] makes a distinction between "adverse drug effect" and "side effect" based upon dosage, but also asserts "side effect" is an imprecise term. Seppi333 (Insert 2¢) 01:25, 22 May 2019 (UTC)
The WHO provides the same definition [9][10] for side effects. Seppi333 (Insert 2¢) 01:32, 22 May 2019 (UTC)
One is simple the more technical term for the other. I am happy with either.
Looks like there is consensus to have addiction and dependence under side effects / adverse effects generally.
Also looks like "overdose" could either go under side effects / adverse effect or be on its own below that section. Doc James (talk · contribs · email) 11:10, 22 May 2019 (UTC)
If "side effects" is used in the article, a level 2 "Long-term adverse effects" section is the approach I'm going to take. I strongly disagree about putting overdose under a side effects heading; if the WHO defines it as an effect of a normal dose, then there are likely many individuals who interpret that term to be defined that way. The Merck ref indicates that it's often used in that manner. Seppi333 (Insert 2¢) 19:44, 22 May 2019 (UTC)
I'd prefer overdose not in a side effects section either. It'd be better in a dosage or pharmacokinetics section. Cas Liber (talk · contribs) 20:28, 22 May 2019 (UTC)

Example: eyes needed[edit]

Right folks, can folks take a look at Amphetamine (Talk:Amphetamine#Addiction_under_Overdose_vs_side_effects) as this falls under the category of what we've been discussing above? Cas Liber (talk · contribs) 04:03, 22 May 2019 (UTC)

Refs 8, 9, and 10 above. Seppi333 (Insert 2¢) 05:04, 22 May 2019 (UTC)
Which means what. You are the only person on this page who wants to put addiction into overdose and you are reverting to keep it that way. Cas Liber (talk · contribs) 07:20, 22 May 2019 (UTC)
I explained the problems with your edit on the article talk page, but if that’s what you want to believe, feel free to continue making stupid assumptions about my motivations. Seppi333 (Insert 2¢) 07:55, 22 May 2019 (UTC)
I'm not making any assumptions, just trying to align articles and prevent material being misrepresented Cas Liber (talk · contribs) 20:26, 22 May 2019 (UTC)
Right, so you go into an article you've never edited before which just happens to be my topmost edited article and start completely fucking it up. How would you like it if I did the same to you? Seppi333 (Insert 2¢) 02:57, 23 May 2019 (UTC)
source: https://web.archive.org/web/20200105113633/https://en.wikipedia.org/wiki/Wikipedia_talk:Manual_of_Style/Medicine-related_articles

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