Gerald Hurowitz, M.D.·Published 27 September 2008·10 min read
Key points
Identifying the exact point at which the use of a substance constitutes an addiction ought to be easy, but it is not.
The symptoms have never met the criteria for substance dependence for this class of substance.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Confu- sion arises because we are limited to observing and describing behaviors, when what we are really trying to define involves a change in the way the brain functions as a result of exposure to an addicting substance.
Identifying the exact point at which the use of a substance constitutes an addiction ought to be easy, but it is not.
Confu- sion arises because we are limited to observing and describing behaviors, when what we are really trying to define involves a change in the way the brain functions as a result of exposure to an addicting substance. It's the same problem that appears in the story of the three blind men and the elephant.
One man feels the elephant's ears and concludes that the creature is broad, thin, and waving like a leaf in the wind. Another feels the elephant's trunk and believes that he is touching something long and sinuous, like a snake.
The third feels the elephant's leg, and notes that it is chunky and sturdy, resembling the trunk of a tree. All three are correct, but none has discovered the true nature of the elephant. Addiction is a complicated condition, with biological, physiological, psychological, behavioral, and spiritual aspects. For this reason it is best to think of alcoholism and drug addiction as multifaceted disorders, only one of which is the compulsive use of the addicting substance.
In 1972 the National Council on Alcoholism and Drug Dependence convened a group of researchers and clinicians to propose a broad working definition of alcoholism. They came up with the following: "Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.
The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic" (Journal of the American Medical Association 268, no. 8 [1972]: 1012–13).
This statement encompasses several aspects of the disorder of alcoholism, and applies also to drug addiction. The two key elements that will constitute our working definition of addiction are (1) loss of control over the use of the substance, and (2) continued use despite negative consequences.
Defining addiction in the abstract is hard enough. Diagnosing addiction can be even more difficult. In extreme cases the diagnosis of addiction is obvious - the street addict who commits crimes in order to support the addiction, or the skidrow alcoholic. But what about the business executive who has two or three drinks - never more - every evening on the train home from work, but has withdrawal symptoms after elective surgery when his routine is disrupted? Or the church deacon who mostly shuns alcohol but several times a year goes on out-of-town benders for a week or so? Or the person who has one arrest for driving under the influence (DUI) and is sent by the court for alcohol and drug assessment? {pagebreak}
The mere use of substances - even to excess - is not enough to diagnose addiction, so we look for behavioral clues. The Diagnostic and Statistical Manual, 4th edition (DSM-IV) is the current standard for diagnosis that is used by most mental health professionals, and it contains a working definition of addiction (fig.1.1). Interestingly, the manual does not use the term "addiction"; instead, the terms "abuse" and "dependence" are defined.
Written and revised by
Gerald Hurowitz, M.D.
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Either abuse or dependence is present when the use of the substance continues despite negative consequences, interferes with important obligations, and causes noticeable distress or significant impairment in functioning.
- Fig. 1.1. Diagnostic and Statistical Manual, 4th edition
Criteria for Substance Abuse
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
B. The symptoms have never met the criteria for substance dependence for this class of substance.
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Criteria for Substance Dependence
A maladaptive pattern of substance use, 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 amounts 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 manifested 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 persistent desire or unsuccessful efforts to cut down or control substance use
5) a great deal of time is spent in activities necessary 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)
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association, Washington, D.C. {pagebreak} -
The criteria for dependence also include those that indicate physiological dependence (tolerance and withdrawal), as well as a loss of control as evidenced by repeated unsuccessful attempts to quit or cut down.
The term "addiction" closely resembles the definition of "dependence" as found in the DSM-IV. This is because the definition of dependence implies that there has been some change in the way the brain is functioning, as evidenced by the development of tolerance and withdrawal symptoms and by loss of control, which indicates the development of cravings.
But in an individual case, the distinction between abuse and dependence is not always clear, because behavioral or descriptive criteria are imprecise. For practical purposes, we can say that people who meet the criteria for the abuse of a substance are at high risk for developing addiction or for already having the brain dysfunction that constitutes dependence or addiction.
For the clinician, distinguishing abuse from dependence is difficult but has important implications for predicting the course and prognosis of an individual's case.
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Dependence implies that biologically based addiction has occurred with the associated changes in brain functioning. If it were possible to measure this brain dysfunction with a scan or a test, the determination would be easy. But we can't do that, so we infer the diagnosis from behavior and history.
The philosophy of successful addiction treatment is based on the idea of complete abstinence from all mood-altering chemicals. This approach is the result of years of experience on the part of clinicians and of those with long-term recovery in programs such as Alcoholics Anonymous.
But now and then a study is done revealing that a number of people who have gone through treatment for "alcoholism" have returned, apparently successfully, to social drinking. It may be that what was felt to be alcoholism was actually alcohol abuse and was not yet associated with the brain changes that occur in alcohol dependence. Until the distinction between alcohol abuse and dependence can be made with certainty, it would seem prudent to recommend total abstinence.
The criteria for diagnosing abuse or dependence are based on a look at the consequences that have occurred. But since the nature and degree of the consequences caused by the use of the substance depend to a large extent on what individuals are doing while intoxicated, it is also important to consider the entire context of their lives. For example, it can be difficult to identify any negative consequences of drinking (such as DUI arrests or loss of jobs) in a housewife who does all of her drinking at home alone. This is one of the reasons why alcoholism in women has been underrecognized. But a close look at the quality of such a person's relationships and achievements in the context of her social setting can often clarify the picture.
The stage of life someone is in is also important to consider. {pagebreak}
Regarding alcohol, for instance, it is not uncommon for young people who drink socially to go through a brief period of time when alcohol is abused for its intoxicating qualities. Sooner or later, however, some type of negative consequence will occur. It might be a bad hangover or an episode of embarrassing behavior. At that point most people will correctly identify the drinking as having caused the negative consequence and will modify their behavior. Some, however, continue to drink despite increasingly negative consequences - and this is addiction.
The prevailing culture is another factor. In a culture where daily social drinking is acceptable, the fact that someone is drinking regularly is less important. On the other hand, in cultures where drinking is highly frowned upon, even occasional alcohol use might be a concern.
Smoking is another example. It has been said that as the prohibitions against smoking have increased, the characteristics of smokers have changed. Those who continue to smoke have a stronger addiction to nicotine, and are less able to use the methods for quitting that have worked for others. So a smoker in the late 1990s in the United States might be much more likely to have severe addiction than a smoker in the early 1950s.
Let's look at how use of a substance gradually progresses from social use to abuse to dependence (addiction).
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Some people never use an addictive substance. Others, who suffer minor consequences such as a hangover or an upset stomach, limit and control use of the substance. "Social drinkers" or "casual users" use the substance periodically, and some will continue to do so indefinitely if it does not cause much in the way of uncomfortable consequences. They are able to maintain control.
But some people, in continuing to use a substance, will escalate the amount and start to experience more negative consequences. Often this is the point at which the substance begins to be used more for its pharmacological effects - as a sedative or tranquilizer, for example. This "hazardous use" might lead to substantial consequences, and in some cases the person will recognize the problem and begin to abstain from the substance, therefore regaining control. Sometimes people go through a period of abusing substances during stressful periods in their lives. They might experience some fairly severe consequences, such as alcohol-related motor vehicle accidents, other legal charges, or behavioral problems related to intoxication. Some of these people will be able to recognize that using the substance is causing more trouble than it's worth. Control will be regained, and they will begin to abstain.
But some will continue using regularly despite repeated and increasingly severe consequences, exercising no control over the use of the substance. At this point in the continuum, dependence, not just abuse, is present. This is addiction.
The continued use of the substance becomes the focal point of life. And when that change occurs, even when it is very subtle, all other aspects of life - relationships, jobs, responsibilities, goals - become less important than the addiction.
It is not uncommon for an addict to lose everything before entering treatment. Incarceration or even death may occur before the addict has the chance to enter treatment.
When we think about the continuum from experimentation and casual use on to abuse and dependence, it is important to recognize that some people are probably genetically predisposed to developing dependence and also that the "addictiveness" of a substance will affect the rate at which loss of control and subsequent abuse and dependence occur.
These factors - genetic traits and the addictiveness of the substance - interact with each other in the development of addiction in an individual. People who come from families where there is a great deal of alcoholism and addiction may progress more quickly to dependence and addiction, even with substances that are less highly addictive for others.
For those people, even social drinking may be hazardous.
With highly addictive substances such as heroin and crack cocaine, genetics may be less important, and users may have little opportunity to experience negative consequences and to retreat from casual use before addiction occurs. So, with these substances, even experimentation can be dangerous.
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