Addiction

Addiction is a chronic disorder proposed to be precipitated by a combination of genetic, biological/pharmacological and social factors. Addiction is characterized by the repeated use of substances or behaviors despite clear evidence of morbidity secondary to such use.

Decades ago addiction was a pharmacologic term that clearly referred to the use of a tolerance-inducing drug in sufficient quantity as to cause tolerance (the requirement that greater dosages of a given drug be used to produce an identical effect as time passes). With that definition, humans (and indeed all mammals) can become addicted to various drugs quickly. Almost at the same time, a lay definition of addiction developed. This definition referred to individuals who continued to use a given drug despite their own best interest. This latter definition is now thought of as a disease state by the medical community.

Physical dependence, abuse of, and withdrawal from drugs and other miscellaneous substances is outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR). Unfortunately, terminology has become quite complicated in the field. To wit, pharmacologists continue to speak of addiction from a physiologic standpoint (some call this a physical dependence); psychiatrists refer to the disease state as dependence.

The medical community now makes a careful theoretical distinction between physical dependence (characterized by symptoms of withdrawal) and psychological dependence (or simply addiction). Addiction is now narrowly defined as "uncontrolled, compulsive use"; 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 to the definition of some it is not categorized as "addiction". In practice, 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. A patient will exhibit drug-seeking behavior reminiscent of psychological addiction, but they tend to have genuine pain or other symptoms that have been undertreated. Unlike true psychological addiction, these behaviors tend to stop when the pain is adequately treated.

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 agree on what addiction or dependency is, because traditionally, addiction has been defined as being possible only to a psychoactive substance (for example drugs, including alcohol and tobacco), which is ingested, crosses the blood-brain barrier, and alters the natural chemical behavior 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, exercise, cutting, 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 behaviors; 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 behavioral 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 behavioral problem), popular media, and some members of the field, do represent the aforementioned behavioral examples as addictions.

In the contemporary view, the trend is to acknowledge the possibility that the hypothalmus creates peptides in the brain that equal and/or exceed the effect of externally applied chemicals (alcohol, nicotine etc.) when addictive activities take place. For example, when an addicted gambler or shopper is satisfying their craving, chemicals called endorphins are produced and released within the brain, reinforcing the individual's positive associations with their behavior.

Despite the popularity of defining addiction in medical terms, recently many have proposed defining addiction in terms of Economics, such as calculating the elasticity of addictive goods and determining, to what extent, present income and consumption (economics) has on future consumption. ^[1]

Physical dependence on a substance is defined by the appearance of characteristic withdrawal symptoms when the substance is suddenly discontinued. While opioids, benzodiazepines, barbiturates, caffeine, alcohol and nicotine are all well known for their ability to induce physical dependence, other categories of substances share this property and 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 and most often becomes a primary motivator in the continuation of an addiction, the primary attribute of an addictive substance is usually its ability to induce pleasure and its facility in becoming routinely used. An notable exception to this is nicotine. Users report that a cigarette can be pleasurable, but there is a medical consensus that the user is likely fulfilling his/her physical addiction and, therefore, is achieving pleasurable feelings relative to his/her previous state of physical withdrawal. Further, the physical dependency of the nicotine addict on the substance itself becomes an overwhelming factor in the continuation of most users' addictions. Although 35 million smokers make an attempt to quit every year, fewer than 7% achieve even one year of abstinence (from the NIDA research report on nicotine addiction).

Some substances 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, Paxil and Zoloft, 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, the intensity of pleasure or euphoria, and the individual's genetic and psychological susceptibility. Some alcoholics report they exhibited alcoholic tendencies from the moment of first intoxication, while most people can drink socially without ever becoming addicted. Studies have demonstrated that opioid dependent individuals have different responses to even low doses of opioids than the majority of people, although this may be due to a variety of other factors, as opioid use heavily stimulates pleasure-inducing neurotransmitters in the brain. The vast majority of medical professionals and scientists agree that if one uses strong opioids on a regular basis for even just a short period of time, one will most likely become physiologically addicted to the substance. Nonetheless, because of these variations, in addition to the adoption and twin studies that have been well replicated, much of the medical community is satisfied that addiction is in part genetically moderated. That is, one's genetic makeup may regulate how susceptible one is to a substance and how easily one may become psychologically attached to a pleasurable routine.

Eating disorders are complicated pathological mental illnesses and thus are not the same as addictions described in this article. Eating disorders, which some argue are not addictions at all, are driven by a multitude of factors, most of which are highly different than the factors behind addictions described in this article. More information about eating disorders can be found at http://www.edap.org or http://www.something-fishy.org

Psychological addiction is an outmoded concept predating the evidence of the presence of pathology in the brain's reward system, the medial forebrain bundle. The dichotomy between physiologic and psychological addiction stems from the confusion between the development of tolerance and withdrawal, and the disease of addiction. Also some use the term to suggest that addiction utilizing behaviors rather than external substances is somehow less "physical" than the use of drugs and alcohol. In fact, anyone who takes certain substances such as opioids or benzodiazepines will develop tolerance and withdrawal whether they have the disease of addiction or not. On the other hand PET scan evidence shows that gamblers and overeaters share the reward center pathology with those who have addiction and use drugs or alcohol.

depressed go here: [www.moodgym.anu.edu.au]

By far the most common recommendation of therapists when faced with patients who are addicts is to begin attending free twelve-step program recovering meetings -- and this model has now been incorporated by most formal rehabilitation programs which cost money. The original 12 Step Program is Alcoholics Anonymous - which deals with what they call the "powerlessness" to stop drinking alcohol[1]. The 12 Steps have been adopted by other groups including Narcotics Anonymous, Al-Anon, and Nar-Anon for people impacted by having or having had alcoholics or addicts in their life. Although Alcoholics Anonymous and the 12 Steps were initially offered for use by alcoholics, application of the 12 Steps to non-alcoholics is described and specifically invited in the book Alcoholics Anonymous[2], where the steps first appeared. The only requirement for membership of an Alcoholics Anonymous Group "is the desire to stop drinking".

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 has roots in genetic predisposition, treatment of dependency is conducted by a wide range of medical and allied professionals, including Addiction Medicine specialists, psychiatrists, and appropriately trained nurses, social workers, and counselors. Early treatment of acute withdrawal often includes medical detoxification, which can include doses of anxiolytics or narcotics to reduce symptoms of withdrawal. An experimental drug, ibogaine, is also proposed to treat withdrawal and craving. Alternatives to medical detoxification include acupuncture detoxification. In chronic opiate addiction, a surrogate drug such as methadone is sometimes offered as a form of opiate replacement therapy. But treatment approaches universal focus on the individual's ultimate choice to pursue an alternate course of action. Anti-anxiety and anti-depressant SSRI drugs such as Lexapro are also often prescribed to help cut cravings, while addicts are often encouraged by therapists to pursue practices like yoga or exercise to decrease reliance on the addictive substance or behavior as the only way to feel good.

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.

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, or the terror of jumping out of an airplane is rewarded with intense pleasure when the parachute opens. 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. Opponent-processes occurring at the sensory level may translate "down-stream" into addictive or habit-forming behavior.
• The disease model of addiction holds that addiction is a disease, coming about as a result of either the impairment of neurochemical or behavioral processes, or of some combination of the two. Within this model, addictive disease is treated by specialists in Addiction Medicine. Within the field of medicine, the American Medical Association, National Association of Social Workers, and American Psychological Association all have policy as to addictive processes representing a disease state. 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. Critics like Stanton Peele describe an absence of medical evidence for an implied physiological process (beyond that of simple mood state changes) that can be equated with the disease of addiction. Organizations such as the American Society of Addiction Medicine believe the research-based evidence for addiction's status as a disease is overwhelming.
• 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 twentieth 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. What also needs to be noted is that when people don't gain a sense of moderation through their development they can be just as likely, if not more, to abuse substances than people born into alcoholic families.^{[citation needed]}
• 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)

The development of addiction is thought to involve a simultaneous process of 1) increased focus on and engagement in a particular behavior and 2) the attenuation or "shutting down" of other behaviors. For example, animals allowed the unlimited ability to self-administer certain 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 is 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 behavior 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.

A specific portion of the limbic circuit known as the mesolimbic dopaminergic system is hypothesized to play an important role in translation of motivation to motor behavior- and reward-related learning in particular. It is typically defined as the ventral tegmental area (VTA), the nucleus accumbens, and the bundle of dopamine-containing fibers that are connecting them. This system is commonly implicated in the seeking out and consumption of rewarding stimuli or events, such as sweet-tasting foods or sexual interaction. However, its importance to addiction research goes beyond its role in "natural" motivation: while the specific site or mechanism of action may differ, all known drugs of abuse have the common effect in that they elevate the level of dopamine in the nucleus accumbens. This may happen directly, such as through blockade of the dopamine re-uptake mechanism (see cocaine). It may also happen indirectly, such as through stimulation of the dopamine-containing neurons of the VTA that synapse onto neurons in the accumbens (see opiates). The euphoric effects of drugs of abuse are thought to be a direct result of the acute increase in accumbal dopamine.

The human body has a natural tendency to maintain homeostasis, and the central nervous system is no exception. Chronic elevation of dopamine will result in a decrease in the number of dopamine receptors available in a process known as downregulation. The decreased number of receptors changes the permeability of the cell membrane located post-synaptically, such that the post-synaptic neuron is less excitable- i.e.: less able to respond to chemical signaling with an electrical impulse, or action potential. It is hypothesized that this dulling of the responsiveness of the brain's reward pathways contributes to the inability to feel pleasure, known as anhedonia, often observed in addicts. The increased requirement for dopamine to maintain the same electrical activity is the basis of both physiological tolerance and withdrawal associated with addiction.

Downregulation can be classically conditioned. If a behavior consistently occurs in the same environment or contingently with a particular cue, the brain will adjust to the presence of the conditioned cues by decreasing the number of available receptors in the absence of the behavior. It is thought that many drug overdoses are not the result of a user taking a higher dose than is typical, but rather that the user is administering the same dose in a new environment.

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)

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 because they prefer a drug induced euphoria to a more popular and socially welcome lifestyle.

In a sense, being 'addicted' to a substance is no different from being 'addicted' to a job that you work everyday.

The word addiction is also sometimes used colloquially to refer to something for which a person has a passion, such as books, chocolate, work, or the web or World of Warcraft.

The word addiction is also sometimes used colloquially to refer to something for which a person has a passion, such as books, chocolate, work, or the web or World of Warcraft as well as the popular webblogging site Myspace.

• National Institute on Drug Abuse
• World Health Organization terminology for substance use and abuse