addiction

addiction The consumption of any psychoactive drug, legal or illegal, can be thought of as comprising three stages: use, abuse, and addiction. Initially the user may consume the drug simply to obtain the resulting pleasurable or other beneficial effects. If use of the drug then escalates to the point where it is interfering with the ability of the user to function normally, use may turn into abuse, and if drug consumption increases further the user may become addicted. People can also become addicted to other pleasurable activities, including gambling, computer games, exercise, surfing the Internet, or sex.

The terms ‘abuse’ and ‘addiction’, however, have been defined and re-defined over the years. Addiction used to be a term used to describe only those conditions in which terminating use leads to unpleasant physical signs of withdrawal. These are particularly prominent in regular users of such ‘hard drugs’ as heroin and cocaine, and in alcoholics. The most commonly accepted current modern system of diagnosis is that published by the American Psychiatric Association, in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), (Washington DC, 1994). This uses the term substance dependence instead of ‘addiction’ and defines it as follows:
DSM-IV Criteria for Substance Dependence (American Psychiatric Association, 1994) A maladaptive pattern of substance abuse, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:(1) Tolerance, as defined by either of the following:(a) A need for markedly increased amount of the substance to achieve intoxication or desired effect.(b) Markedly diminished effect with continued use of the same amount of the substance.(2) Withdrawal, as defined by either of the following:(a) The characteristic withdrawal syndrome for the substance.(b) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.(3) The substance is often taken in larger amounts or over a longer period than was intended.(4) There is a persistent desire or unsuccessful efforts to cut down or control substance use.(5) A great deal of time is spent in activities to obtain the substance (e.g. visiting multiple doctors or driving long distances), use the substance (e.g. chain-smoking), or recover from its effects.(6) Important social, occupational, or recreational activities are given up or reduced because of substance use.(7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g. current cocaine use despite recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

This new way of thinking about drug-dependence is significantly different from much of the earlier work in this field. It means that neither physical dependence nor tolerance need necessarily be present to make the diagnosis of ‘substance dependence’. The diagnosis can be made simply on the grounds of psychological dependence. This removes, for example, some of the confusion from previous debates over whether tobacco smoking is ‘addictive’. Even though it does not lead to tolerance or physical dependence, smokers find it very difficult to quit, as do many gamblers, athletes, and surfers of the Internet.

Leslie L. Iversen

See also alcoholism; drug abuse; nicotine; smoking.