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Addiction is a compulsion to repeat a behaviour regardless of its consequences. A person who is addicted is sometimes called an addict.
There is a lack of consensus as to what may properly be termed 'addiction.' Some within the medical community maintain a rigid definition of addiction and contend that the term is only applicable to a process of escalating drug or alcohol use as a result of repeated exposure. However, addiction is often applied to compulsive behaviours other than drug use, such as overeating or gambling. In all cases, the term addiction describes a chronic pattern of behaviour that continues despite the direct or indirect adverse consequences that result from engaging in the behaviour. It is quite common for an addict to express the desire to stop the behaviour, but find himself or herself unable to cease.
Addiction is often characterized by a craving for more of the drug or behavior, increased physiological tolerance to exposure, and withdrawal symptoms in the absence of the stimulus. Many drugs and behaviours that provide either pleasure or relief from pain pose a risk of addiction or dependency.
Terminology and usage
The medical community now makes a careful theoretical distinction between physical dependence (characterized by symptoms of withdrawal) and psychological addiction (or simply addiction). Addiction is now narrowly defined as "uncontrolled, compulsive use despite harm"; if there is no harm being suffered by, or damage done to, the patient or another party, then clinically it may be considered compulsive, but within this narrow definition it is not categorized as "addiction". In practice, however, the two kinds of addiction are not always easy to distinguish. Addictions often have both physical and psychological components.
There is also a lesser known situation called pseudo-addiction, where a patient will exhibit drug-seeking behaviour reminiscent of psychological addiction; however, in this case, the patients tend to have genuine pain or other symptoms that have been undertreated. Unlike true psychological addiction, however, these behaviours tend to stop as soon as their pain is adequately treated. The term "dry drunk" is sometimes attached to patterns of behavior that persist after an object of dependence and/or misuse has been removed from daily living routines. This type of behaviour is fairly common in early recovery for those recovering from substance misuse.
The obsolete term physical addiction is deprecated, because of its connotations. In modern pain management with opioids, physical dependence is nearly universal but addiction is rare. Some of the highly addictive drugs (hard drugs), such as cocaine, induce relatively little physical dependence.
Not all doctors do agree on what addiction or dependency is*, particularly because, traditionally, addiction has been defined as being possible only to a psychoactive substance (for example alcohol, tobacco, or drugs), which is ingested, crosses the blood-brain barrier, and alters the natural chemical behaviour of the brain temporarily. Many people, both psychology professionals and laypersons, now feel that there should be accommodation made to include psychological dependency on such things as gambling, food, sex, pornography, computers, work, and shopping / spending. However, these are things or tasks which, when used or performed, cannot cross the blood-brain barrier and hence do not fit into the traditional view of addiction. Symptoms mimicking withdrawal may occur with abatement of such behaviours; however, it is said by those who adhere to a traditionalist view that these withdrawal-like symptoms are strictly reflective not of an addiction, but rather of a behavioural disorder. In spite of traditionalist protests and warnings that overextension of definitions may cause the wrong treatment to be used (thus failing the person with the behavioural problem), popular media, and some members of the field, do represent the aforementioned behavioural examples as addictions.
- note: the Diagnostic Statistical Manual (DSM IVR) specifically spells out criteria to define abuse and dependence conditions.
Varied forms of addiction
Physical dependency on a substance is defined by the appearance of characteristic withdrawal symptoms when the drug is suddenly discontinued. While opioids, benzodiazepines, barbiturates, alcohol, and nicotine are all well known for their ability to induce physical dependence, other drugs sharing this property are not considered addictive: cortisone, beta-blockers and most antidepressants are examples. So while physical dependency can be a major factor in the psychology of addiction, the primary attribute of an addictive drug is its ability to induce euphoria while causing harm.
Some drugs induce physical dependence or physiological tolerance but not addiction. Examples are: many laxatives, which are not psychoactive; nasal decongestants, which can cause rebound congestion if used for more than a few days in a row; and some antidepressants, most notably Effexor and Paxil, as they have quite short half-lives, so stopping them abruptly causes a more rapid change in the neurotransmitter balance in the brain than many other antidepressants. Many non-addictive prescription drugs should not be suddenly stopped, so a doctor should be consulted before abruptly discontinuing them.
The speed with which a given individual becomes addicted to various substances varies with the substance, the frequency of use, the means of ingestion, and the individual. Some alcoholics report they exhibited alcoholic tendencies from the moment of first intoxication, while most people can drink socially without ever becoming addicted. Because of this variation, some people hypothesise that physical dependency and addiction are in large part genetically moderated. Nicotine is one of the most addictive psychoactive substances: although 35 million smokers make an attempt to quit every year, fewer than 7% achieve even one year of abstinence.*
While eating disorders, like other behavioral addictions, are usually considered primarily psychological disorders, they are sometimes treated as addictions, especially if they include elements of addictive behaviour. Sufferers may experience withdrawal or withdrawal-like symptoms if they alter their diet suddenly. This suggests that some common food substances, especially chocolate, sugar, salt, and white flour may have the potential for addiction. In addition, frequent overeating can also be considered an addiction.
- From the NIDA research report on nicotine addiction.
Psychological addictions are a dependency of the mind, and lead to psychological withdrawal symptoms. Addictions can theoretically form for any rewarding behavior, or as a habitual means to avoid undesired activity, but typically they only do so to a clinical level in individuals who have emotional, social, or psychological dysfunctions, taking the place of normal positive stimuli not otherwise attained (see Rat Park).
Addiction assessment measures have been developed to facilitate addiction assessment. They include:
- Alcohol use measures
- Drug addiction measures
- Gambling assessment measures
- Substance abuse assessment measures
Methods of care
Early editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) described addiction as a physical dependency to a substance that resulted in withdrawal symptoms in its absence. Recent editions, including DSM-IV, have moved toward a diagnostic instrument that classifies such conditions as dependency, rather than addiction. The American Society of Addiction Medicine recommends treatment for people with chemical dependency based on patient placement criteria (currently listed in PPC-2), which attempt to match levels of care according to clinical assessments in six areas, including:
- Acute intoxication and/or withdrawal potential
- Biomedical conditions or complications
- Emotional/behavioral conditions or complications
- Treatment acceptance/resistance
- Relapse potential
- Recovery environment
Some medical systems, including those of at least 15 states of the United States, refer to an Addiction Severity Index to assess the severity of problems related to substance use. The index assesses problems in six areas: medical, employment/support, alcohol and other drug use, legal, family/social, and psychiatric.
While addiction or dependency is related to seemingly uncontrollable urges, and may have roots in genetic predisposition, treatment of dependency is always classified as behavioral medicine. Early treatment of acute withdrawal often includes medical detoxification, which can include doses of anxiolytics to reduce symptoms of withdrawal. In chronic opiate addiction, a surrogate drug such as methadone is sometimes offered as a form of opiate replacement therapy. But treatment approaches universally focus on the individual's ultimate choice to pursue an alternate course of action.
Therapists often classify patients with chemical dependencies as either interested or not interested in changing. Treatments usually involve planning for specific ways to avoid the addictive stimulus, and therapeutic interventions intended to help a client learn healthier ways to find satisfaction. Clinical leaders in recent years have attempted to tailor intervention approaches to specific influences that effect addictive behavior, using therapeutic interviews in an effort to discover factors that led a person to embrace unhealthy, addictive sources of pleasure or relief from pain.
|Treatment Modality Matrix|
|Low self esteem, anxiety, verbal hostility||Relationship therapy, client centered approach||Increase self esteem, reduce hostility and anxiety|
|Defective personal constructs, ignorance of interpersonal means||Cognitive restructuring including directive and group therapies||Insight|
|Focal anxiety such as fear of crowds||Desensitization||Change response to same cue|
|Undesirable behaviors, lacking appropriate behaviors||Aversive conditioning, operant conditioning, counter conditioning||Eliminate or replace behavior|
|Lack of information||Provide information||Have client act on information|
|Difficult social circumstances||Organizational intervention, environmental manipulation, family counseling||Remove cause of social difficulty|
|Poor social performance, rigid interpersonal behavior||Sensitivity training, communication training, group therapy||Increase interpersonal repertoire, desensitization to group functioning|
|Grossly bizarre behavior||Medical referral||Protect from society, prepare for further treatment|
|Adapted from: Essentials of Clinical Dependency Counseling, Aspen Publishers|
- Main article: Models of addiction
The development of addiction is thought to involve a simultaneous process of 1) increased focus on and engagement in a particular behaviour and 2) the attenuation or "shutting down" of other behaviours. For example, animals allowed the unlimited ability to self-administer psychoactive drugs will show such a strong preference that they will forgo food, sleep, and sex for continued access. The neuro-anatomical correlate of this that the brain regions involved in driving goal-directed behavior grow increasingly selective for particular motivating stimuli and rewards, to the point that the brain regions involved in the inhibition of behaviour can no longer effectively send "stop" signals. A good analogy is to imagine flooring the gas pedal in a car with very bad brakes. In this case, the limbic system is thought to be the major "driving force" and the orbitofrontal cortex is the substrate of the top-down inhibition.
- Main article: Neurobiology of addiction
Levi Bryant has criticized the term and concept of addiction as counterproductive in psychotherapy as it defines a patient's identity and makes it harder to become a non-addict. "The signifier 'addict' doesn't simply describe what I am, but initiates a way of relating to myself that informs how I relate to others."
A stronger form or criticism comes from Thomas Szasz, who denies that addiction is a psychiatric problem. In many of his works, he argues that addiction is a choice, and that a drug addict is one who simply prefers a socially taboo substance rather than, say, a low risk lifestyle. In Our Right to Drugs, Szasz cites the biography of Malcolm X to corroborate his economic views towards addiction: Malcolm claimed that quitting cigarettes was harder than shaking his heroin addiction. Szasz postulates that humans always have a choice, and it is foolish to call someone an 'addict' just becuase they prefer a drug-induced euphoria to a more popular and socially welcome lifestyle.
A similar conclusion to that of Thomas Szasz may also be reached through very different reasoning. This is the somewhat extreme, yet tenable, view that humans do not have free will. From this perspective, being 'addicted' to a substance is no different than being 'addicted' to a job that you work at every day. Without the assumption of free will, every human action is the result of the naturally occuring reactions of particle matter in the physical brain, and so there is no longer room for the concept of 'addiction', since, in this view, choice is an illusion of the human experience.
The word addiction is also sometimes used colloquially to refer to something a person has a passion for. Such "addicts" include:
- Nesse, R.M. (2002). Evolution and Addiction. Addiction, 97, 4, 470-1. Full text
- information on treatment
- The New Science of Addiction: Genetics and the Brain
- Hypoism Hypothesis
- nature neurosience - Focus on Neurobiology of addiction (freely available online through January 2006)
- National Institute on Drug Abuse
- Definitions Related to the Use of Opioids for the Treatment of Pain (2001) - a joint statement by the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine
- World Health Organization terminology for substance use and dependence
- Cocaine User Helping Hand
- Narcotics Anonymous Help for Addicts by addicts
- Alcoholics Anonymous
- Four Stages of Breaking an Addiction
- Marijuana Anonymous
- Methadone Anonymous World Services, Inc.
- Methadone & Methadone Anonymous Support
- National Institute on Chemical Dependency
- Harrowing Heroin by Geoff Morton
- AddictionInfo contemporary addiction information
- NIDA research report on Nicotine Addiction
- Gatehouse Academy - Gatehouse Academy offers the opportunity for young adults age 17-25 to learn life skills, continue formalized education, enhance physical well-being, and recover from the detrimental effects of chemical dependency.