Addiction

An agreed upon definition of addiction does not exist among medical and psychological theorists and researchers. The term addiction has taken on new meanings as knowledge about the misuse of alcohol and other drugs has progressed and as cultural conceptions of excessive or inappropriate drug usage and behavior have evolved. The concept—not necessarily the term—was first invoked in the description of alcohol problems but has since been applied to other classes of drugs, such as opioids and stimulants, as well as to potentially problematic and “addictive” behaviors that do not involve ingestion of psychoactive substances (e.g., gambling, eating, sex).

In Colonial times, the excessive use of alcohol was viewed as a choice made for pleasure, and repetitive drunkenness earned one the label of drunkard. Heavy drinking was very common, and in fact per capita alcohol consumption in the United States reached its highest levels to date in the mid-1800s. As the Temperance Movement of the 19th century developed[Page 25] into an abstinence movement that eventually spawned the Prohibition Era (1920–1933), the idea that alcohol use can become compulsive and beyond one's control firmly took root. This emphasis on loss of control and the progression of drinking behavior to harmful levels are essential tenets of the disease model of alcoholism and, by extension, of other addictions as well. The disease model of addiction promotes education about drugs and the addictive process and total abstinence as the treatment goal, and has been the prevailing view embodied by most alcohol and drug rehabilitation agencies for several decades. In addition, Alcoholics Anonymous and the American Medical Association endorse this concept and have been instrumental in developing and promoting this view, although not without challenges from those who think of problematic alcohol and drug use and their treatment as more behavioral and psychological, rather than biological and medical, in nature.

Specific definitions of addiction vary in length, specificity, and emphasis. For example, the term has been defined generally as an overwhelming preoccupation with obtaining and using one or more drugs and a tendency to resume use after stopping. Other components of the many definitions available include the notion that usage is clearly nonrecreational and may occur at inappropriate times (e.g., morning drinking) and places (e.g., at work), and that its negative consequences are severe in several domains of functioning and may be felt almost immediately (e.g., hangover) or long term (e.g., liver disease). Traditionally, addiction has meant the most severe form of drug abuse that includes an intense desire or craving (a biopsychological phenomenon) for the drug, physiological tolerance resulting in a need to take more of the drug to achieve the desired effect, and physiological withdrawal symptoms that occur when use of particular drugs is stopped or decreased.

Current conceptions of addiction and problem drug use give more prominence to psychosocial variables and consequences. For example, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) describes criteria for substance use disorders, the most serious of which is labeled substance dependence. Criteria for a diagnosis of substance dependence (e.g., alcohol dependence, cocaine dependence, opioid dependence) are met if a person experiences clinically significant impairment or distress, and at least three of the following are present within the same 12 months: (1) tolerance; (2) withdrawal syndrome for a particular substance; (3) substance often taken in larger amounts or over a longer period than intended; (4) persistent desire or unsuccessful efforts to cut down or control substance use; (5) great deal of time spent in activities necessary to obtain, use, or recover from the substance's effects; (6) important social, occupational, or recreational activities are given up or reduced because of the substance; (7) and the substance use is continued despite knowledge of having a recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. These criteria apply to both licit and illicit substances. Additionally, the diagnosis may be specified further by indicating whether the substance disorder is accompanied by physiologic dependence (evidence of tolerance or withdrawal) or does not include symptoms of physiologic dependence (no evidence of tolerance and withdrawal). Note that the word “addiction” does not appear in these criteria or in any portion of the DSM-IV because of the ambiguity and disagreement that the term invokes from researchers, clinicians, and theorists in the field. Some also point out that to describe someone as addicted, or to label them as an “addict,” may lead to stigmatization and dehumanization, or refusal on the part of the person to acknowledge the problem and seek help for it. Another area of current controversy involves the question of whether the addiction term and concept should extend to potentially addictive behaviors that do not involve drug ingestion. Does “addiction” to the internet, shopping, gambling, sex, work, exercise, or eating exist? Clearly, negative consequences and personal distress may be associated with these often compulsive behaviors, yet should the cultural popularity and ubiquity of the term compromise behavioral science standards and nomenclature?

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