Addiction

Physical dependency

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

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.

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, amphetamine derivatives, cannabinoids, cocaine, barbiturates, hallucinogens (tryptamines, LSD, phenylethylamines) and a variety of more modern synthetic drugs, and unlicensed production, supply or possession is a criminal offense.

Usually, however, drug classification 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. Typically nicotine (in the form of tobacco) is regulated extremely loosely, if at all, although it is well-known as one of the most addictive substances ever discovered, while substances known to have no addictive qualities at all (such as LSD and psilocybin) are strictly regulated.

Also, although the legislation may be justifiable on moral grounds to some, it can make addiction or dependency a much more serious issue for the individual. Reliable supplies of a drug become difficult to secure as illegally produced substances may have contaminants. The withdrawal from the substances or the contaminants can cause additional health issues and the individual becomes vulnerable to both criminal abuse and legal punishment. Criminal elements that can be involved in the profitable trade of such substances can also cause physical harm to users in some cases.

Methods of care

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. 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, 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:

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.

Alternative solutions for treating disorders and/or addictions are also available. One such viable alternative option is Yoga. It is not suggesting that all cases are the same, nor believed that Yoga alone can work for everyone; however, there is substantial evidence that coincides with the success rates increasing when Yoga was added as part of the recovery plan. The mind / body connection that Yoga creates a bridge for helps the individual when assessing their addiction and the control it has over them. Addictions are not always chemical in nature. Some are addicted to sex, being needed/wanted/loved/attenetion. Even self abuse can be an addiction of sorts. Whether the addiction is chemical or psychological Yoga can assist the individual who wants to make positive changes in his or her life. Additionally, it gives the inner strength to follow through on the necessary changes.

Diverse explanations

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

Neurobiological basis

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)

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."

Rat Park was a study into drug addiction conducted in the 1970s by American psychologist Bruce K. Alexander at Simon Fraser University in British Columbia, Canada.

Alexander's hypothesis was that drug addiction is a myth, and that the apparent addiction to morphine commonly observed in laboratory rats exposed to it is attributable to their living conditions, and not to any addictive property of the drug itself. He told the Canadian Senate in 2001 that experiments in which laboratory rats are kept isolated in cramped metal cages, tethered to self-injection apparatus, show only that "severely distressed animals, like severely distressed people, will relieve their distress pharmacologically if they can."

To test his hypothesis, Alexander built Rat Park, a 200-square-foot (18.6 m²) housing colony, 200 times the square footage of a standard laboratory cage. There were 16–20 rats of both sexes in residence, an abundance of food, balls and wheels for play, and private places for mating and giving birth. The results of the experiment appeared to support his hypothesis. Rats who had been forced to consume morphine hydrochloride for 57 consecutive days were brought to Rat Park and given a choice between plain tap water and water laced with morphine. For the most part, they chose the plain water. "Nothing that we tried," Alexander wrote, "... produced anything that looked like addiction in rats that were housed in a reasonably normal environment."

A stronger form of 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 Spain, philosopher, lawyer and sociologist Antonio Escohotado coined the term pharmacological dissidence to better describe so-called drug addiction as a sociological and recurrent form of political persecution, where mass hysteria and commercial interests working together promote, with non-democratic tactics, the consumption of certain drugs (the legal ones: alcohol, tobacco, etc) among general population, by designing its exposure to drug war propaganda.

Notes

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.