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.
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 used to describe excessive indulgence in activities such as work, exercise, shopping, sex, the Internet, and gambling.
Causes and symptoms
Some experts describe the range of behaviors designated as addictive in terms of five interrelated concepts: patterns, habits, compulsions, impulse control disorders, and physical addiction. There is ongoing controversy as to whether addictions constitute true physical disease in the same sense that diabetes and hypertension are considered physical diseases. Indeed, the most prevalent model of substance dependence 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.
Other experts disagree with the analogy between substance abuse and physical disease. They believe that addictive behaviors can be better understood as problematic habits or behavior patterns that have been learned in accordance with the principles that guide all learning. To these experts, addictive behaviors are maladaptive habits and behavior patterns that can be "unlearned" and replaced with new, alternative, more healthful behaviors. According to learning theorists, one's past and present experiences, environment, family history, peer group influences, and individual beliefs and expectations, determine who will or will not become addicted to a substance or behavior.
Psychodynamic theorists believe that addicts suffer from an inability to soothe themselves or comfortably manage the emotions of day-to-day life. Feelings such as anxiety, depression, shame, discomfort in social situations, and anger are often believed to be causes of substance abuse. In this sense, many experts believe that addicts self-medicate, that is, use destructive substances to ease their painful emotions.
Disease model adherents believe that the compulsion to use is genetically and physiologically based and that, while the disease can be arrested, the disease is progressive and, if unchecked, fatal. Researchers have found the sons of alcoholics to be twice as prone to alcoholism as other people. Among pairs of identical twins, if one is alcoholic, there is a 60% chance that the other will be also. In spite of an apparent inherited tendency toward alcoholism, the fact that the majority of people with alcoholic parents do not become alcoholics themselves demonstrates the influence of psychosocial factors, including personality factors and a variety of environmental stressors, such as occupational or marital problems.
Both disease model and learning model adherents agree that initial positive consequences of substance abuse or addictive activities are what initially "hook," and then later keep, the addict addicted. Addicts describe feelings of euphoria when using their substance or engaging in their activity of choice. Many experts believe that these substances and activities affect neurotransmitters in the brain. Use causes an increase in endorphin levels, which is believed to be one of the chief causes of the "high" sensation experienced by addicts.
As the addict continues to use, his or her body adjusts to the substance and tolerance develops. Increasing amounts of the substance are needed to produce the same effect. Levels of substances that addicts routinely ingest would be lethal to a non-addict.
Over time, physical symptoms of dependence strengthen. Failure to use leads to withdrawal symptoms, which include flu-like aches and pains, digestive upset, and, in severe cases, seizures, and hallucinatory-like sensations, such as the feeling of bugs crawling on the skin. Damage to various organs of the body, 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.
According to a 1999 national survey, about 14.8 million Americans used an illicit drug at least once in the month prior to the survey, and the chances of receiving a diagnosis of substance abuse or dependence at some point in one's life is 16.7% for people over age 18. The lifetime chances of developing alcohol abuse or dependence is 13.8%; for nonalcohol substances, 6.2%. As of 1995, 6.1% of the population age 12 and older currently used illicit drugs. The most commonly used substances are alcohol and cigarettes, as well as marijuana, hashish, and cocaine. Unfortunately, substance abuse has been on the rise among children and adolescents since 1993.
According to findings of the National Institute of Drug Abuse, overall use of drugs in the United States has decreased by 50% during the past 20 years. However, drug use among adolescents has increased during the past 10 years.
Addiction is more common among men than women, and the use of drugs other than alcohol is skewed even further in that direction. Substance abuse is higher among the unemployed and the less educated. Most current illicit drug users are white. It is estimated that 9.6 million whites (75% of all users), 1.9 million African Americans (15% of users), and 1.0 million Hispanics (8% of users) were using illicit drugs in 1995.
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 0.1%, a person is considered intoxicated. 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.
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 uncomfortable emotions, 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 technques, 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.
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 predominating belief is that recovery is only possible by commitment to complete abstinence from all substance use.
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.
See also Alcohol and related disorders; Amphetamines and related disorders; Anti-anxiety drugs and abuse; Barbiturates; Caffeine-related disorders; Cannabis and related disorders; Denial; Disease concept of chemical dependency; Dual diagnosis; Internet addiction disorder; Nicotine and related disorders; Opioids and related disorders; Relapse and relapse prevention; Sedatives and related disorders; Self-help groups; Substance abuse and related disorders; Support groups; Wernicke-Korsakoff syndrome
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Barbara S. Sternberg, Ph.D.