Addiction

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Addiction is a compulsion to repeat a behavior regardless of its consequences. A person who is addicted is sometimes called an addict.

Many drugs (sometimes called hard drugs) or behaviors are seen to precipitate an addiction, or a chronic pattern of behaviour, which includes a craving for more of the drug, or of the initial behavior, increased physiological tolerance to exposure, and withdrawal symptoms in the absence of the stimulus. Most drugs and behaviors that directly provide either pleasure or relief from pain pose a risk of dependency. Addictions can also be formed due to opponent process reactions. For example the terror of jumping out of an airplane is rewarded with intense pleasure when the parachute opens. Because of this opponent process, criminal behavior, running, stealing, violence, acting, and test taking can become habit forming.

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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 obsolete term physical addiction is deprecated because of its pejorative connotations, especially in modern pain management with opioids where physical dependence is nearly universal but addiction is rare.

Also, it should be noted that some highly addictive drugs (so-called hard drugs), such as cocaine, induce relatively little physical dependence, whilst other drugs (so-called soft drugs) such as magic mushrooms and peyote are not normally considered to give rise to any significant degree of addiction or 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 not strictly reflective 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.

Varied forms of addiction

Physical dependency

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 share this property that 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 - for example 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 considered by many to be the most addictive substance in the world, although there has been no way found to determine this. Caffeine, ingested by more than 80% of human adults, is the most popular psychoactive substance in the world.

Psychological 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).

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 behavior. Sufferers may experience withdrawal or withdrawal-like symptoms if they alter their diet suddenly. This suggests that some common food substances, especially chocolate, sugar and salt, may have the potential for addiction. In addition, frequent overeating can also be considered an addiction.

Addiction and drug control legislation

Most countries have legislation which brings various drugs and drug-like substances under the control of licensing systems. Typically this legislation covers any or all of the opiates, cannabinoids, cocaine, barbiturates, hallucinogens and a variety of more modern synthetic drugs, and unlicensed production, supply or possession is a criminal offence.

Usually, however, drug clasification under such legislation is not related simply to addictiveness. The substances covered often have very different addictive properties. Some are highly prone to cause physical dependency, whilst others rarely cause any form of compulsive need whatsoever.

Also, although the legislation may be justifiable on moral or public health grounds, it can make addiction or dependency a much more serious issue for the individual: reliable supplies of a drug become difficult to secure, and the individual becomes vunerable to both criminal abuse and legal punishment.

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
Behavioral Pattern Intervention Goals
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

Diverse explanations

Several explanations (or "models") have been presented to explain addiction:

  • The moral model states that addictions are the result of human weakness, and are defects of character. Those who advance this model do not accept that there is any biological basis for addiction. They often have scant sympathy for people with serious addictions, believing either that a person with greater moral strength could have the force of will to break an addiction, or that the addict demonstrated a great moral failure in the first place by starting the addiction. The moral model is widely applied to dependency on illegal substances, perhaps purely for social or political reasons, but is no longer widely considered to have any therapeutic value. Elements of the moral model, especially a focus on individual choices, have found enduring roles in other approaches to the treatment of dependencies.
  • The opponent-process model generated by Richard Soloman states that for every psychological event A will be followed by its opposite psychological event B. For example the pleasure one experiences from heroin is followed by an opponent process of withdrawal. This model is related to the opponent process color theory. If you look at the color red then quickly look at a gray area you will see green. There are many examples of opponent processes in the nervous system including taste, motor movement, touch, vision, and hearing.
  • The disease model holds that addiction is an illness, and comes about as a result of the impairment of healthy neurochemical or behavioral processes. While there is some dispute among clinicians as to the reliability of this model, it is widely employed in therapeutic settings. Most treatment approaches involve recognition that dependencies are behavioral dysfunctions, and thus involve some element of physical or mental disease.
  • The genetic model posits a genetic predisposition to certain behaviors. It is frequently noted that certain addictions "run in the family," and while researchers continue to explore the extent of genetic influence, there is strong evidence that genetic predisposition is often a factor in dependency. Researchers have had difficulty assessing differences, however, between social causes of dependency learned in family settings and genetic factors related to heredity.
  • The cultural model recognizes that the influence of culture is a strong determinant of whether or not individuals fall prey to certain addictions. For example, alcoholism is rare among Saudi Arabians, where obtaining alcohol is difficult and using alcohol is prohibited. In North America, on the other hand, the incidence of gambling addictions soared in the last two decades of the 20th century, mirroring the growth of the gaming industry. Half of all patients diagnosed as alcoholic are born into families where alcohol is used heavily, suggesting that familiar influence, genetic factors, or more likely both, play a role in the development of addiction.
  • The blended model attempts to consider elements of all other models in developing a therapeutic approach to dependency. It holds that the mechanism of dependency is different for different individuals, and that each case must be considered on its own merits.
  • The habit model proposed by Thomas Szasz questions the very concept of "addiction." He argues that addiction is a metaphor, and that the only reason to make the distinction between habit and addiction "is to persecute somebody." (Szasz, 1973)

Physiological basis

Although the term addiction is sometimes often used loosely rather than as a medical classification, there are some physiological conditions related to everyday behaviors that are also related to the more commonly recognized mechanisms associated with addiction. Pleasurable activities cause the release of endorphins, and this endorphin-rush can conceivably become 'addictive'. Evolutionary biologists have suggested this process of attentuating pleasure pathways is part of the brain's natural system for ensuring that humans develop abiding interests. Since human societies depend on enduring attachments, many theorists suggest such addictions are not necessarily a problem. Other views, such as the those summarized in Buddhist concept of tanha, suggest trivial attachments are at the root of much human suffering.

The pathways oriented to endorphins, sometimes called pleasure centers originated in small organisms such as insects, which rely on the neurological system to help them find familiar sources of food.

Endorphins stimulate activity of the neurotransmitter dopamine after initially activating opioid receptors earlier in the nervous circuit. Increased dopamine activity is often met by a decrease in the number of receptors sensitive to dopamine. This process is called downregulation. The decreased number of receptors tends to result in reduced electrical activity along post-synaptic nerve pathways, unless some behavior or substance causes a continued high level of dopaminergic stimulation. The absence of a pleasurable sensation in conditions that were formally sufficient can cause a mild feeling of let-down after receptors have been downregulated. The increased requirement for dopamine to maintain the same electrical activity is the basis of both physiological tolerance and withdrawal associated with addiction.

The middle striatal reward pathway has been most strongly linked with addictive and reward behavior. This pathway utilizes dopamine as a neurotransmitter and receives presynaptic input (from earlier in the circuit--it gets signals from these earlier in the circuit cells) from cells that respond to cannabinoids, nicotine (receptor subtype is nicotinic), and from cells that respond to endogenous opioid substances such as endorphins or enkephalins. Cells that are said to respond to a particular neurotransmitter (or agonists) contain, at the postsynaptic end (receiving area of the cell) receptors for that neurotransmitter. Many believe that there are more neurotransmitters involved with addiction than just dopamine including serotonin, norepinephrine, and the endocannabinoid anandamide.

In cases of physical dependency on depressants of the central nervous system such as opioids, barbiturates, or alcohol, the absence of the substance can lead to symptoms of severe physical discomfort. Withdrawal from alcohol or sedatives such as barbiturates or benzodiazepines (valium-family) can result in seizures and even death. By contrast, withdrawal from opioids, which can be extremely uncomfortable, is rarely if ever life-threatening. In cases of dependence and withdrawal, the body has become so dependent on high concentrations of the particular chemical that it has stopped producing its own natural versions (endogenous ligands) and instead produces opposing chemicals. When the addictive substance is withdrawn, the effects of the opposing chemicals can become overwhelming. For example, chronic use of sedatives (alcohol, barbiturates, or benzodiazepines) results in higher chronic levels of stimulating neurotransmitters such as glutamate. Very high levels of glutamate kill nerve cells (called excitatory neurotoxicity).

Opioids present extreme risks of dependency because they are chemically similar to endorphins, causing an upregulation of dopaminergic receptors without stimulation of the endorphin systems. Cocaine and amphetamines also pose risks associated with physical attenuation, in both cases because they cause increases in the levels of the neurotransmitters dopamine and norepinephrine which acts indirectly to stimulate dopaminergic pathways in the brain.

Criticism

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."

Casual addiction

The word addiction is also sometimes used colloquially to refer to something a person has a passion for. Such "addicts" include:

See also

External links

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