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Understanding Addiction

Posted Aug 27 2009 11:38pm

The notion of addiction is one that includes more than just chemical dependency. Today we are aware that a person can be physically or psychologically addicted to a number of things; drugs, food, sex, and gambling are among the most common. What all addictions have in common is impulsive thrill-seeking. In neurological terms, this involves stimulating the brain's dopaminergic pleasure center. Even highly specific, inherently problematic behaviors, like stealing or setting fires (kleptomania and pyromania, respectively) can be thought of as addictive behavior. But what, exactly, do we mean by "addiction"? Are all addictions the same? What are the defining components of addiction? Are addicts weak and immoral, or are they ill? This article addresses some of these questions and defines what professionals mean when they diagnose abuse and dependency in the context of substance use.

As a lay term, "addiction" can mean any number of things. Clinicians do not use the term officially, and so it has not been operationally defined. Instead, diagnosticians refer to abuse or dependence, the latter including both physical and psychological dependency. Classically these terms have been used to describe substance abuse and chemical dependency, so for illustrative purposes I will use abuse of and dependency upon intoxicants as my example, but keep in mind that the following principles apply equally well to food addiction, or sexual or gambling addictions, et al.

Use…abuse…dependence. Such is the progression, where abuse represents a recurrent pattern of problematic use and marks the beginning of the need for treatment and dependence involves some degree of losing control. Just as not all occasional users become habitual abusers, not all abusers become physically or psychologically dependent. Many factors come into play, including what exactly is being used or abused (some substances have a much higher abuse and dependency potential than others), as well as precisely how it is being abused (smoking cocaine is more addictive than snorting it, for example), how often and for how long. These variables aside, we know that genetics plays a huge role: most people are just inherently--biologically--predisposed to abusing or becoming dependent upon a given substance or they're simply not, such that oftentimes little more than brief exposure is required to set off years and years of severe and debilitating addiction, whereas in other cases a person seems to be more-or-less immune to the perils of dependency, despite frequent and repeated exposure to the drug in question.

Use vs. Abuse. Depending on the substance, use is not necessarily abuse. Many people can use alcohol and not abuse it, and there are millions of people who say the same thing about marijuana, and other recreational drugs. But what if a person drinks too much, experiences a blackout and gets sick? Is that abuse? Or what about heroin? If a person sticks a needle in her arm and injects herself with heroin, is that always abuse, even if she doesn't get sick and never does it again?

This is where clinicians, because they are tasked with identifying those individuals who require treatment from among those who've simply exercised poor judgment, make the distinction that clinical abuse per se involves a recurrent pattern of use despite negative consequences. So, a single episode of problematic use is not, clinically speaking, indicative of an abuse disorder, any more than a single instance of overeating would necessarily indicate an eating disorder. Any one really bad lapse could be a sign of trouble to come, certainly, but alone is not enough to make a diagnosis.

To reiterate: even if use is intemperate or otherwise ill-advised, it does not necessarily meet the diagnostic and statistical criteria (DSM-IV) used by clinicians to indicate clinical abuse. If you gorge on a buffet, and then make yourself sick later, one could certainly argue that it was a bad idea, and that you behaved in an unhealthy manner, but one would not diagnose a clinical abuse disorder based on the one instance alone. All diagnostic abuse criteria (see below) involve recurrent use despite negative consequences.

So what about heroin? Or crack cocaine? There are certain drugs that are considered to be at an extremely high risk of being abused. So high, in fact, that these substances are considered to have no medicinal value whatsoever, despite the fact that they certainly have a pharmacologic effect. They are classified as Schedule I controlled substances and include such things as heroin, cocaine and marijuana (although topical cocaine has some surgical applications and the use of medical marijuana is currently a hotly debated topic). In almost every instance, even one-time recreational use of heroin or crack would be considered abusive by most people, but again, for purposes of diagnosing someone as having a substance abuse disorder, there must be recurrent, continued use that meets the following additional abuse criteria:

Abuse. Abuse is not merely indicated by the fact that bad things arise from using. Abuse is indicated by continued use in the face of those negative outcomes. Many, if not most, people have misused a substance at some point in their lifetime. Overuse of alcohol is extremely common on college campuses. But not every young person who has ever intentionally drank too much alcohol for recreational purposes merits a diagnosis of alcohol abuse, even if that person was very, very sick afterwards and really regretted it. It is only those persons who continue to drink too much, time after time, despite getting sick and despite regretting it every time, that we say have alcohol abuse disorder. I say "have" because, under the medical model, alcohol abuse is a disease. A choice is made, certainly, but any pattern of self-destructive, maladaptive behavior, no matter how indulgent, is properly considered a condition of the brain (this becomes more intuitive in cases that progress to full-blown dependency: see below).

The formal DSM-IV criteria state that abuse involves "continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the substance." This includes the failure to fulfill major role obligations at work, home or school and legal problems. Abuse is also defined as using in physically hazardous situations, such as drinking alcohol while driving or operating heavy machinery--but again, in order to be diagnostic it must be recurrent use in physically hazardous situations: one DWI is bad enough, and it may be a sign of alcohol abuse disorder, but two or more is diagnostic of the disorder of abuse, if not of outright alcohol dependency.

Dependence. When a person becomes dependent on a substance (or a behavior, like gambling or binge-eating or engaging in anonymous sex, etc.) the qualifying difference is that now the person has begun to lose control. As with abuse, the addicted person continues to use "despite knowledge of adverse consequences," such as failure to fulfill work role obligations or in physically hazardous situations, etc., but in addition to, say, risking losing one's job with continued use, in dependency other elements are present as well (at least three, according to the DSM-IV): they include giving up or reducing other important social, occupational or recreational activities; devoting an inordinate amount of time obtaining, using or recovering from using; taking larger amounts of a substance and for a longer period of time than intended (or again, gambling and losing more money than originally planned, etc.); a persistent desire or repeated unsuccessful attempts to quit; or, if a person is physically addicted as well, tolerance and/or withdrawal effects. A person may not be consciously aware of it at any given time, but nothing characterizes dependence better than the relative inability to stop.

Tolerance. Tolerance is a marked decrease in effect at a given dose, resulting in a marked increase in the amount of drug taken in order to achieve the same high. The development of rapid tolerance has a special name: tachyphylaxis. For many people, tolerance and/or withdrawal symptoms are the hallmark of "addiction," but the development of some tolerance is a normal finding with many habit-forming medications (such as sleeping pills) that does not, in itself, indicate addiction per se. Furthermore, because not everything is necessarily physically addictive (i.e., allowing for psychological addictions), evidence of tolerance and/or withdrawal is not necessary for a diagnosis of dependency.

Also, consider that people who become dependent upon non-physically-addictive pursuits can also experience this subjective need for "more" to achieve the same thrill, such as when a pathological gambler raises the stakes or when a sex addict takes greater and greater risks in order to reach the same level of prior excitement.

Withdrawal. Withdrawal, on the other hand, is a purely physical consequence. Symptoms are characteristic of the abused substance and range from tremors, sweating, diarrhea, to insomnia, depression, hallucinations--even death. This criterion is met when a person takes the substance to relieve or avoid withdrawal. Some withdrawal can be brief and indeed life-threatening (e.g., alcohol and other sedatives), while other withdrawal syndromes last weeks and only make you wish you were dead (e.g., opiates and related narcotics)! The presence of withdrawal indicates that a significant degree of tolerance has been developed, but the development of physical tolerance does not always result in withdrawal.

Ask yourself. There are various screening tools used by psychologists which consist of self-inventories that patients complete and which are then scored to give an idea as to the likelihood that there is a substance abuse problem. The simplest are the four "CAGE" questions:

  1. Have you tried to (C) cut down?
  2. Do you get (A) annoyed by others' comments about your use?
  3. Do you ever feel (G) guilty about your use?
  4. Do you ever take an (E) eye opener in the morning to get going?

A better survey is the more comprehensive 28-item Drug Abuse Screening Test (DAST) developed in 1982 and based on the Michigan Alcoholism Screening Test (MAST). Questions include: "Are you always able to stop using drugs when you want to?", "Have you ever neglected your family or missed work because of your use of drugs?" and "Have you ever been arrested for driving while under the influence of drugs?" among others.

Remember that these simple, straightforward yes/no questions are designed to assist clinicians in screening for abuse and dependency disorders; unless you are in serious denial, a few moments of quiet introspection will probably tell you most of what you need to know. Given the propensity for denial in most addicts, if you even suspect that you may not be in complete control of your extracurricular activities, that should be a red flag to you. Most people who use drugs "for fun" don't start thinking in terms of addiction until the problems have started piling up, so if you are already wondering about it, chances are you may be on your way to even more serious trouble ahead. Be smart; turn back!

So, to summarize: if you are using a substance (or engaging in some other risky, thrill-seeking behavior) despite the ongoing problems it is causing, you are technically abusing, and if you get so wrapped up in it that you then begin withdrawing from the non-users in your life and begin spending more and more time using or trying to use, or dealing with the fallout of having used, or you spend a lot more time, money and effort than you initially planned on spending (yet again), or you've thought about stopping but somehow haven't been able to… then you have officially become dependent on your new pastime; i.e., you are "addicted."

Why do some people progress from abuse to dependency, and others do not? Most alcoholics will tell you that, looking back, it is obvious to them that their alcohol dependency began with their very first drink, even if their problems didn't start until years or even decades later; most also have strong family histories of alcoholism. Other individuals who used and abused alcohol recreationally for years, say, during college, were able to put it aside after graduation with little or no trouble. It is obvious that for these individuals alcohol dependency was never a real threat. It is not that one group is better or stronger or has more "willpower" than the other: it is simply that one group has the illness and the other group doesn't. Both were exposed to the necessary precipitating factor (alcohol), but only the vulnerable population got sick. This is the medical model of addiction, the same model we apply, for example, to juvenile onset diabetes: genetic vulnerability (biological predisposition) + exposure = illness.

So, what to do if you are affected? Do what I did: get help.

Because it is an illness (no one chooses self-destruction), one thing is certain: you will need help. Not necessarily professional help, but it's always a good start. Doing it alone, on the other hand, is never advisable. Fortunately, you won't have to go it alone, no matter how isolated you may find yourself, because there are millions of people out there suffering the same as you and there are many helping hands. Much more on the topic of addiction, where and how to get help, to come.

Alcoholics Anonymous
Narcotics Anonymous
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