Addiction

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Addiction

Definition

Most definitions refer to addiction as the compulsive need to use a habit-forming substance, or an irresistible urge to engage in a behavior. Two other important defining features of addiction are tolerance, the increasing need for more of the substance to obtain the same effect, and withdrawal, the unpleasant symptoms that arise when an addict is prevented from using the chosen substance or engaging in the behavior. Relapse and mood modification are also features.

Description

The term addiction has come to refer to a wide and complex range of behaviors. While addiction most commonly refers to compulsive use of substances, including alcohol, prescription and illegal drugs, cigarettes, and food, it is also associated with compulsive behaviors involving activities such as work, exercise, shopping, sex, using the Internet, and gambling.

Causes and symptoms

Causes

The most prevalent model of addiction today is the so-called disease model. This model, first introduced in the late 1940s by E. M. Jellinek, was adopted in 1956 by the American Medical Association. Since that time, the disease model of alcoholism and drug addiction has been well accepted throughout the world. Some experts argue that addiction is better understood as learned behavior and is modifiable through “unlearning” the negative behaviors and then learning new, positive behaviors.

Disease model adherents believe that the compulsion to use is genetically and physiologically based and that, while the disease can be arrested, it is progressive and chronic, and fatal if unchecked. Twin studies have shown that there is a strong heritable component to addiction, although, as with most diseases, environmental factors can also play a role.

Symptoms

The initial positive consequences of substance use or a potentially addictive behavior are what initially “hook” a person, who may then become addicted. People with substance use disorders or behavioral addiction describe feelings of euphoria or release of tension when using the substance or engaging in the activity of choice. Many experts believe that these substances and activities affect neurotransmitters in the brain. The primary pathway involved in the development and persistence of these disorders of addiction is the brain reward pathway, or mesolimbic pathway, which operates via a neurotransmitter called dopamine. The dopamine pathways may interact with other neurotransmitters, including opioid pathways. These neuronal pathways have been identified as underlying both substance use disorders and behavioral addictions.

As a person with an addiction continues to use a substance or engage in a behavior, his or her body adjusts to the substance and tolerance develops. Increasing amounts of the substance are needed to produce the same effect. In some case, levels of substances that a person with a substance use disorder routinely ingests might be lethal to someone who has not built up a tolerance.

Over time, physical symptoms of dependence strengthen. Failure to use a substance or engage in a behavior can lead to withdrawal symptoms, which can vary depending on the substance or behavior involved. For some drugs, these symptoms can include flu-like aches and pains, digestive upset, and, in severe cases, seizures, and hallucinatory sensations, such as the feeling of bugs crawling on the skin. Organ damage, including the brain and liver, can lead to serious and even fatal illness as well as mental symptoms such as dementia. Severe disruption of social and family relationships, and of the ability to maintain a steady job, are also symptoms of the addictive process.

Demographics

According to a 2006 national survey of adolescents, 14.9% of the high-school students surveyed reported having used an illicit drug in the previous month. A 2003 report showed that adolescents and young adults were most likely to have engaged in illicit drug use in the previous month, with the peak occurring 18- to 20-year-old age range; however, drug use among adolescents declined by 17% from 2001 to 2004. In spite of the decline, 19.5 million Americans, about 8.2% of the population, were current users of an illicit drug in 2003. Drugs used included marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically, and the opiates Vicodin and OxyContin have emerged as drugs of concern for their use among high-school students. The most commonly used illicit drug in the United States is marijuana.

Addiction is more common among men than women, and the ratio of men to women using drugs other than alcohol is even higher. Substance abuse is higher among the unemployed and the less educated. Most illicit drug users are white.

Diagnosis

Substance abuse and dependence are among the psychological disorders categorized as major clinical syndromes (known as “Axis 1”) in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Alcohol, classified as a depressant, is the most frequently abused psychoactive substance. Alcohol abuse and dependence affect more than 20 million Americans—about 13% of the adult population. An alcoholic has been defined as a person whose drinking impairs his or her life adjustment, affecting health, personal relationships, and/or work.

When blood alcohol level reaches 0.08%, a person is considered legally intoxicated in most states. Judgment and other rational processes are impaired, as are motor coordination, speech, and vision. Alcohol abuse, according to the DSM-IV-TR, progresses through a series of stages from social drinking to chronic alcoholism. Danger signs that indicate the probable onset of a drinking problem include frequent desire to drink, increasing alcohol consumption, memory lapses (blackouts), and morning drinking. Other symptoms include attempts to hide alcohol from family and colleagues, and attempts to drink in secret. Among the most acute reactions to alcohol are four conditions referred to as alcoholic psychoses: alcohol idiosyncratic intoxication (an acute reaction in persons with an abnormally low tolerance for alcohol); alcohol withdrawal delirium (delirium tremens); hallucinations; and Korsakoff’s psychosis, an irreversible brain disorder involving severe memory loss.

Other substance abuse disorders are diagnosed by looking for patterns of compulsive use, frequency of use, increasing tolerance, and withdrawal symptoms when the substance is unavailable or the individual tries to stop using.

Treatments

Pharmacologic

Addictions are notoriously difficult to treat. Physical addictions alter a person’s brain chemistry in ways that make it difficult to be exposed to the addictive substance again without relapsing. Some medications, such as Antabuse (disulfiram), have shown limited effectiveness in treating alcohol addiction. Substitute medications, such as methadone, a drug that blocks the euphoric effect of opiates, have also shown mixed results. When an addicted individual is using a substance to self-medicate for depression, anxiety, and other psychological symptoms, prescription medications can be an effective treatment.

Psychological and psychosocial

It is a commonly held belief by many professionals that people with addictive disorders cannot be treated effectively by conventional outpatient psychotherapy. Substance abusers are often presumed to have severe personality problems and to be very resistant to treatment, to lack the motivation to change, or to be just too much trouble in an outpatient office setting. Unfortunately, these beliefs may create a self-fulfilling prophecy. Many of the negative behaviors and personality problems associated with chronic substance use disappear when use of the substance stops. While some substance abusers do, in fact, have other mental disorders, they represent only a minority of the addicted population.

Most treatment for addictive behaviors is provided not by practicing clinicians (psychiatrists, psychologists, and social workers ), but rather by specialized addiction treatment programs and clinics. These programs rely upon confrontational tactics and re-education as their primary approaches, often employing former or recovering addicts to treat newly admitted addicts.

Some addicts are helped by the combination of individual, group, and family treatment. In family treatment (or family therapy ), “enabling behaviors” can be addressed and changed. Enabling behaviors are the actions of family members who assist the addict in maintaining active addiction, including providing money, food, and shelter. Residential settings may be effective in initially assisting the addicted individual to stay away from the many “cues,” including people, places, and things, that formed the setting for their substance use.

During the past several decades, alternatives to the complete abstinence model (the generally accepted model in the United States) have arisen. Controlled use programs allow addicted individuals to reduce their use without committing to complete abstinence. This alternative is highly controversial. The generally accepted position is that only by complete abstinence can an addicted individual recover. The effectiveness of addiction treatment based on behavioral and other psychotherapeutic methods, however, is well documented. Among these are motivation-enhancing strategies, relapse-prevention strategies using cognitive-behavioral approaches, solution-oriented and other brief therapy techniques, and harm-reduction approaches.

Self-help groups such as Alcoholics Anonymous and Narcotics Anonymous have also developed widespread popularity. The approach of one addict helping another to stay “clean,” without professional intervention, has had tremendous acceptance in the United States and other countries.

Prognosis

Relapse and recidivism are, unfortunately, very common. Interestingly, a classic study shows that people addicted to different substances show very similar patterns of relapse. Whatever the addictive substances, data show that about two-thirds of all relapses occur within the first 90 days following treatment. Many consider recovery to be an ongoing, lifelong process. Because the use of addictive substances alters brain chemistry, cravings can persist for many years. For this reason, the prevailing belief is that recovery is only possible by commitment to complete abstinence from all substance use.

Prevention

Prevention approaches are most effectively targeted at young teenagers between the ages of 11 and 13. It is during these years that most young people are likely to experiment with drugs and alcohol. Hence, reducing experimentation during this critical period holds promise for reducing the number of adults with addictive disease. Effective prevention programs focus on addressing the concerns of young people with regard to the effects of drugs. Training older adolescents to help younger adolescents resist peer pressure has shown considerable effectiveness in preventing experimentation.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington, D.C.: American Psychiatric Association, 2000.

Hurley, Jennifer A., ed. Addiction: Opposing Viewpoints. San Diego, CA: Greenhaven Press, 2000.

Kaplan, Harold I., MD., and Benjamin J. Sadock, MD. Synopsis of Psychiatry:Behavioral Sciences/Clinical Psychiatry. 8th ed. Baltimore, MD: Lippincott Williams and Wilkins, 1998.

Marlatt, G. Alan, and Judith R. Gordon, eds. Relapse Prevention. New York: The Guilford Press, 1985.

Wekesser, Carol, ed. Chemical Dependency: Opposing Viewpoints. San Diego, CA: Greenhaven Press, 1997.

PERIODICALS

Grant, Jon E., JD, MD, MPH, Judson A. Brewer, MD, Ph.D., and Marc N. Potenza, MD, Ph.D. “The Neurobiology of substance and behavioral addictions.” CNS Spectrums 11 (2006): 924–30.

Franken, Ingmar H. A., Jan Booij, and Wim van den Brink. “The role of dopamine in human addiction: From reward to motivated attention.” European Journal of Pharmacology 526 (2005): 199-206.

Kienast, T., and A. Heinz. “Dopamine and the diseased brain.” CNS & Neurological Disorders-Drug Targets 5 (2006): 109–31.

Lobo, Daniela S.S., M.D., Ph.D., and James L. Kennedy, MD, F.R.C.P.C. “The genetics of gambling and behavioral addictions.” CNS Spectrums 11 (2006): 931-9.

Pallanti, Stefano, M.D., Ph.D. “From impulse-control disorders toward behavioral addictions.” CNS Spectrums 11 (2006): 921—2.

Washton, Arnold M. “Why psychologists should know how to treat substance use disorders.” NYS Psychologist January 2002: 9–13.

ORGANIZATIONS

National Institute on Drug Abuse (NIDA). U.S. Department of Health and Human Services, 5600 Fishers Ln., Rockville, MD 20857. <http://www.nida.nih.gov>.

National Library of Medicine. “Drug Abuse.” <http://www.nlm.nih.gov/medlineplus/drugabuse.html>.

Barbara S. Sternberg, Ph.D.

Emily Jane Willingham, Ph.D.

The Gale Encyclopedia of Mental Health