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Definition

Addiction is a dependence on a behavior or sub-stance that a person is powerless to stop. The term has been partially replaced by the word dependence for substance abuse. Addiction has been extended, however, to include mood-altering behaviors or activities. Some researchers speak of two types of addictions: substance addictions (for example, alcoholism, drug abuse, and smoking); and process addictions (for example, gambling, spending, shopping, eating, and sexual activity). There is a growing recognition that many addicts, such as polydrug abusers, are addicted to more than one sub-stance or process.

Description

Addiction is one of the most costly public health problems in the United States. It is a progressive syndrome, which means that it increases in severity over time unless it is treated. Substance abuse is characterized by frequent relapse, or return to the abused substance. Substance abusers often make repeated attempts to quit before they are successful.

In 1995 the economic cost of substance abuse in the United States exceeded $414 billion, with health care costs attributed to substance abuse estimated at more than $114 billion.

By eighth grade, 52% of adolescents have consumed alcohol, 41% have smoked tobacco, and 20% have smoked marijuana. Compared to females, males are almost four times as likely to be heavy drinkers, nearly one and a half more likely to smoke a pack or more of cigarettes daily, and twice as likely to smoke marijuana weekly. However, among adolescents these gender differences are decreasing. Although frequent use of tobacco, cocaine and heavy drinking appears to have remained stable in the 1990s, marijuana use increased.

In 1999, an estimated four million Americans over the age of 12 used prescription pain relievers, sedatives, and stimulants for "nonmedical" reasons during one month.

In the United States, 25% of the population regularly uses tobacco. Tobacco use reportedly kills 2.5 times as many people each year as alcohol and drug abuse combined. According to 1998 data from the World Health Organization, there were 1.1 billion smokers worldwide and 10,000 tobacco-related deaths per day. Furthermore, in the United States, 43% of children aged 2-11 years are exposed to environmental tobacco smoke, which has been implicated in sudden infant death syndrome,low birth weight, asthma, middle ear disease, pneumonia, cough, and upper respiratory infection.

Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating, affect over five million American women and men. Fifteen percent of young women have substantially disordered attitudes toward eating and eating behaviors. More than 1,000 women die each year from anorexia nervosa. A 1997 Harvard study found that an estimated 15.4 million Americans suffered from a gambling addiction. Over half that number (7.9 million) were adolescents.

— Bill Asenjo, MS, CRC

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n.

1. 1. Compulsive physiological and psychological need for a habit-forming substance: a drug used in the treatment of heroin addiction.
   2. An instance of this: a person with multiple chemical addictions.
2. 1. The condition of being habitually or compulsively occupied with or or involved in something.
   2. An instance of this: had an addiction for fast cars.

The consumption of any psychoactive drug, legal or illegal, can be thought of as comprising three stages: use, abuse, and addiction. Initially the user may consume the drug simply to obtain the resulting pleasurable or other beneficial effects. If use of the drug then escalates to the point where it is interfering with the ability of the user to function normally, use may turn into abuse, and if drug consumption increases further the user may become addicted. People can also become addicted to other pleasurable activities, including gambling, computer games, exercise, surfing the Internet, or sex.

The terms ‘abuse’ and ‘addiction’, however, have been defined and re-defined over the years. Addiction used to be a term used to describe only those conditions in which terminating use leads to unpleasant physical signs of withdrawal. These are particularly prominent in regular users of such ‘hard drugs’ as heroin and cocaine, and in alcoholics. The most commonly accepted current modern system of diagnosis is that published by the American Psychiatric Association, in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) , (Washington DC, 1994). This uses the term substance dependence instead of ‘addiction’ and defines it as follows:

DSM-IV Criteria for Substance Dependence (American Psychiatric Association, 1994) A maladaptive pattern of substance abuse, 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 amount 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 defined 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 a persistent desire or unsuccessful efforts to cut down or control substance use.
(5) A great deal of time is spent in activities 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).

This new way of thinking about drug-dependence is significantly different from much of the earlier work in this field. It means that neither physical dependence nor tolerance need necessarily be present to make the diagnosis of ‘substance dependence’. The diagnosis can be made simply on the grounds of psychological dependence. This removes, for example, some of the confusion from previous debates over whether tobacco smoking is ‘addictive’. Even though it does not lead to tolerance or physical dependence, smokers find it very difficult to quit, as do many gamblers, athletes, and surfers of the Internet.

— Leslie L. Iversen

See also alcoholism; drug abuse; nicotine; smoking.

A state of physiological dependence produced by habitually taking drugs such as morphine, heroin or alcohol. The term is also applied to a state of psychological dependence on drugs such as barbiturates. See also exercise addiction.

n

Definition: habit
Antonyms: indifference

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(ədik′shən)
n

The state of being addicted. Although there is no universally accepted definition, addiction is generally considered a condition involving two factors: (1) a compulsive behavior pattern, and (2) an altered physiologic state that requires continued use of the drug to prevent withdrawal symptoms.

Definition

Addiction is a physical or mental dependence on a behavior or substance that a person feels powerless to stop.

Description

Addiction is one of the most costly public health problems in the United States. It is a progressive syndrome, which means that it increases in severity over time unless it is treated. The term has been partially replaced by the word "dependence" for substance abuse. Addiction has been extended, however, to include mood-altering behaviors or activities. Some researchers speak of two types of addictions: substance addictions (for example, alcoholism, drug abuse, and smoking); and process addictions (for example, gambling, spending, shopping, eating, and sexual activity). There was as of 2004 a growing recognition that many addicts are addicted to more than one substance or process. Substance abuse is characterized by frequent relapse or return to the abused substance. Substance abusers often make repeated attempts to quit before they are successful.

The National Survey on Drug Use and Health (NSDUH) is conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services. Among the findings of the 2003 study are the following:

• In 2003, an estimated 19.5 million Americans, or 8.2 percent of the population aged 12 or older, were current illicit drug users. Current illicit drug use means use of an illicit drug during the month prior to the survey interview. The numbers did not change from 2002.
• The rate of illicit drug use among youths aged 12–17 did not change significantly between 2002 (11.6%) and 2003 (11.2%), and there were no changes for any specific drug. The rate of current marijuana use among youths was 8.2 percent in 2002 and 7.9 percent in 2003. There was a significant decline in lifetime marijuana use among youths, from 20.6 percent in 2002 to 19.6 percent in 2003. There also were decreases in rates of past year use of LSD (1.3 to 0.6%), ecstasy (2.2 to 1.3%), and methamphetamine (0.9 to 0.7%).
• About 10.9 million persons aged 12–20 reported drinking alcohol in the month prior to the survey interview in 2003 (29.0 percent of this age group). Nearly 7.2 million (19.2%) were binge drinkers and 2.3 million (6.1%) were heavy drinkers. The 2003 rates were essentially the same as those from the 2002 survey.
• An estimated 70.8 million Americans reported current (past month) use of a tobacco product in 2003. This is 29.8 percent of the population aged 12 or older, similar to the rate in 2002 (30.4%). Young adults aged 18–25 reported the highest rate of past month cigarette use (40.2%), similar to the rate among young adults in 2002. An estimated 35.7 million Americans aged 12 or older in 2003 were classified as nicotine dependent in the past month because of their cigarette use (15% of the total population), about the same as for 2002.

Demographics

In 2003, the rate of substance dependence or abuse was 8.9 percent for youths aged 12–17 and 21 percent for persons aged 18–25. Among persons with substance dependence or abuse, illicit drugs accounted for 58.1 percent of youths and 37.2 percent of persons aged 18–25. In 2003, males were almost twice as likely to be classified with substance dependence or abuse as females (12.2% versus 6.2%). Among youths aged 12–17, however, the rate of substance dependence or abuse among females (9.1%) was similar to the rate among males (8.7%). The rate of substance dependence or abuse was highest among Native Americans and Alaska Natives (17.2%). The next highest rates were among Native Hawaiians and other Pacific Islanders (12.9%) and persons reporting mixed ethnicity (11.3%). Asian Americans had the lowest rate (6.3%). The rates among Hispanics (9.8%) and whites (9.2%) were higher than the rate among blacks (8.1%).

Rates of drug use showed substantial variation by age. For example, in 2003, some 3.8 percent of youths aged 12 to 13 reported current illicit drug use compared with 10.9 percent of youths aged 14 to 15 and 19.2 percent of youths aged 16 or 17. As in other years, illicit drug use in 2003 tended to increase with age among young persons, peaking among 18 to 20-year-olds (23.3%) and declining steadily after that point with increasing age. The prevalence of current alcohol use among adolescents in 2003 increased with increasing age, from 2.9 percent at age 12 to a peak of about 70 percent for persons 21 to 22 years old. The highest prevalence of both binge and heavy drinking was for young adults aged 18 to 25, with the peak rate of both measures occurring at age 21. The rate of binge drinking was 41.6 percent for young adults aged 18 to 25 and 47.8 percent at age 21. Heavy alcohol use was reported by 15.1 percent of persons aged 18 to 25 and 18.7 percent of persons aged 21. Among youths aged 12 to 17, an estimated 17.7 percent used alcohol in the month prior to the survey interview. Of all youths, 10.6 percent were binge drinkers, and 2.6 percent were heavy drinkers, similar to the 2002 numbers.

Rates of current illicit drug use varied significantly among the major racial-ethnic groups in 2003. The rate of illicit drug use was highest among Native Americans and Alaska Natives (12.1%), persons reporting two or more races (12%), and Native Hawaiians and other Pacific Islanders (11.1%). Rates were 8.7 percent for African Americans, 8.3 percent for Caucasians, and 8 percent for Hispanics. Asian Americans had the lowest rate of current illicit drug use at 3.8 percent. The rates were unchanged from 2002. Native Americans and Alaska Natives were more likely than any other racial-ethnic group to report the use of tobacco products in 2003. Among persons aged 12 or older, 41.8 percent of Native Americans and Alaska Natives reported using at least one tobacco product in the past month. The lowest current tobacco use rate among racial-ethnic groups in 2003 was observed for Asian Americans (13.8%), a decrease from the 2002 rate (18.6%).

Young adults aged 18 to 25 had the highest rate of current use of cigarettes (40.2%), similar to the rate in 2002. Past month cigarette use rates among youths in 2002 and 2003 were 13 percent and 12.2 percent, respectively, not a statistically significant change. However, there were significant declines in past year (from 20.3% to 19%) and lifetime (from 33.3% to 31%) cigarette use among youths aged 12 to 17 between 2002 and 2003. Among persons aged 12 or older, a higher proportion of males than females smoked cigarettes in the past month in 2003 (28.1% versus 23%). Among youths aged 12 to 17, however, girls (12.5%) were as likely as boys (11.9%) to smoke in the past month. There was no change in cigarette use among boys aged 12 to 17 between 2002 and 2003. However, among girls, cigarette use decreased from 13.6 percent in 2002 to 12.5 percent in 2003.

Causes and Symptoms

Addiction to substances results from the interaction of several factors.

Drug Chemistry

Some substances are more addictive than others, either because they produce a rapid and intense change in mood or because they produce painful withdrawal symptoms when stopped suddenly.

Genetics

Some people appear to be more vulnerable to addiction because their body chemistry increases their sensitivity to drugs. Some forms of substance abuse and dependence seem to run in families; a correlation that may be the result of a genetic predisposition, environmental influences, or a combination of the two.

Brain Structure and Function

Using drugs repeatedly over time changes brain structure and function in fundamental and long-lasting ways. Addiction comes about through an array of changes in the brain and the strengthening of new memory connections. Evidence suggests that those long-lasting brain changes are responsible for the distortions of cognitive and emotional functioning that characterize addicts, particularly the compulsion to use drugs. Although the causes of addiction remain the subject of ongoing debate and research, many experts as of 2004 considered addiction to be a brain disease, a condition caused by persistent changes in brain structure and function. However, having this brain disease does not absolve the addict of responsibility for his or her behavior, but it does explain why many addicts cannot stop using drugs by sheer force of will alone.

Social Learning

Social learning is considered the most important single factor in causing addiction. It includes patterns of use in the addict's family or subculture, peer pressure, and advertising or media influence.

Availability

Inexpensive or readily available tobacco, alcohol, or drugs produce marked increases in rates of addiction. Increases in state taxes on alcohol and tobacco products have not resulted in decreased use.

Personality

Before the 1980s, the so-called addictive personality was used to explain the development of addiction. The addictive personality was described as escapist, impulsive, dependent, devious, manipulative, and self-centered. Many doctors in the early 2000s believe that these character traits develop in addicts as a result of the addiction, rather than the traits being a cause of the addiction.

When to Call the Doctor

The earlier one seeks help for their teen's behavioral or drug problems, the better. How is a parent to know if their teen is experimenting with or moving more deeply into the drug culture? Above all, a parent must be a careful observer, particularly of the little details that make up a teen's life. Overall signs of dramatic change in appearance, friends, or physical health may signal trouble. If parents believe their child may be drinking or using drugs, they should seek help through a substance abuse recovery program, family physician, or mental health professional.

Diagnosis

In addition to noting a preoccupation with using and acquiring the abused substance, the diagnosis of addiction focuses on five criteria:

• loss of willpower
• harmful consequences
• unmanageable lifestyle
• increased tolerance or escalation of use
• withdrawal symptoms on quitting

Treatment

According to the American Psychiatric Association, there are three goals for the treatment of persons with substance use disorders: (1) the patient abstains from or reduces the use and effects of the substance; (2) the patient reduces the frequency and severity of relapses; and (3) the patient develops the psychological and emotional skills necessary to restore and maintain personal, occupational, and social functioning.

In general, before treatment can begin, many treatment centers require that the patient undergo detoxification. Detoxification is the process of weaning the patient from his or her regular substance use. Detoxification can be accomplished "cold turkey," by complete and immediate cessation of all substance use, or by slowly decreasing (tapering) the dose that a person is taking, to minimize the side effects of withdrawal. Some substances must be tapered because cold-turkey methods of detoxification are potentially life threatening. In some cases, medications may be used to combat the unpleasant and threatening physical and psychological symptoms of withdrawal. For example, methadone is used to help patients adjust to the tapering of heroin use.

The most frequently recommended social form of outpatient treatment is the 12-step program. Such programs are also frequently combined with psychotherapy. According to the American Psychological Association (APA), anyone, regardless of his or her religious beliefs or lack of religious beliefs, can benefit from participation in 12-step programs such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). The number of visits to 12-step self-help groups exceeds the number of visits to all mental health professionals combined. There are 12-step groups for all major substance and process addictions.

Alternative Treatment

Acupuncture and homeopathy have been used to treat withdrawal symptoms. Meditation, yoga, and reiki healing have been recommended for process addictions; however, the success of these programs has not been well documented through controlled studies.

Prognosis

The prognosis for recovery from any addiction depends on the substance or process, the individual's circumstances, and underlying personality structure. People who have multiple substance dependencies have the worst prognosis for recovery. It is not uncommon for someone in a treatment program to have a relapse, but the success rate increases with subsequent treatment programs.

Recovery from substance use is notoriously difficult, even with exceptional treatment resources. Although relapse rates are difficult to accurately obtain, the National Institute on Alcohol Abuse and Alcoholism cites evidence that 90 percent of alcohol dependent users experience at least one relapse within four years after treatment. Relapse rates for heroin and nicotine users are believed to be similar. Certain pharmacological treatments, however, have been shown to reduce relapse rates. Relapses are most likely to occur within the first 12 months of having discontinued substance use. Triggers for relapses can include any number of life stresses (problems in school or on the job, loss of a relationship, death of a loved one, financial stresses), in addition to seemingly mundane exposure to a place or an acquaintance associated with previous substance use.

Prevention

The most effective form of prevention appears to be a stable family that models responsible attitudes toward mood-altering substances and behaviors. Prevention education programs are also widely used to inform young people of the harmfulness of substance abuse.

Parental Concerns

Parents and guardians need to be aware of the power they have to influence the development of their kids throughout the teenage years. Adolescence brings a new and dramatic stage to family life. The changes that are required are not just the teen's to make; parents need to change their relationship with their teenager. It is best if parents are proactive about the challenges of this life stage, particularly those that pertain to the possibility of experimenting with and using alcohol and other drugs. Parents should not be afraid to talk directly to their kids about drug use, even if they have had problems with drugs or alcohol themselves. Parents should give clear, no-use messages about smoking, drugs, and alcohol. It is important for kids and teens to understand that the rules and expectations set by parents are based on parental love and concern for their well being. Parents should also be actively involved and demonstrate interest in their teen's friends and social activities. Spending quality time with teens and setting good examples are essential. Even if problems such as substance abuse already exist in the teen's life, parents and families can still have a positive influence on their teen's behavior.

Resources

Books

Haugen, Hayley Mitchell. Teen Smoking. Minneapolis, MN: Sagebrush Bound, 2004.

Raczek, Linda Theresa. Teen Addiction. San Diego, CA: Lucent Books, 2003.

Stevens, Sally J., and Andrew R. Morral. Adolescent Substance Abuse Treatment in the United States: Exemplary Modelsfrom a National Evaluation Study. Binghamton, NY: Haworth Press, 2002.

Townsend, John. Drugs—Teen Issues. Chicago, IL: Raintree, 2004.

Periodicals

Johnson, Kate. "Tobacco Dependence: Even Minimal Exposure Can Cause Rapid Onset; Daily Smoking Not Necessary." Family Practice News (June 15, 2004): 66.

Kaminer, Yifah, and Chris Napolitano. "Dial for Therapy: Aftercare for Adolescent Substance Use Disorders." Journal of the American Academy of Child and Adolescent Psychiatry (September 2004): 1171.

"SAMHSA Reveals State Estimates of Substance Use for the First Time: Washington, D.C. Ranks Highest in Illegal Drug Use." Alcoholism & Drug Abuse Weekly (August 16, 2004): 31.

"Sexually Active Friends Can Signal Increase in Teen's Substance Abuse Risk." Obesity, Fitness & Wellness Week (September 18, 2004): 410.

Sherman, Carl. "Early Disorders Often Precede Substance Abuse." Clinical Psychiatry News (June 2004): 34.

Organizations

Alateen. 1600 Corporate Landing Parkway, Virginia Beach, VA 23454. Web site: www.al-anon.alateen.org.

National Academy of Child & Adolescent Psychiatry. 3615 Wisconsin Ave. NW, Washington, DC 20016. Web site: www.aacap.org.

Web Sites

"Fact Sheet: Addiction (Substance Dependence)." New York Presbyterian Hospital. Available online at www.noahhealth.org/english/illness/mentalhealth/cornell/conditions/substdep.html (accessed November 8, 2004).

"National Youth Anti-Drug Media Campaign." Parents: The Anti-Drug. Available online at www.theantidrug.com (accessed November 8, 2004).

[Article by: Bill Asanjo, MS, CRC Ken R. Wells]

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Although there is no definition of "addiction" that is universally accepted, in general, addiction refers to a physiological and psychological dependency on a drug. While some drugs of abuse induce physiological addiction, others do not. Alternatively, some drugs that are physiologically addictive generally are not abused (e.g., caffeine). Tolerance to drug effects, and withdrawal symptoms upon abrupt cessation of use, which develop over time, are characteristic features of physiological addiction. "Habituation" is the term used to refer to psychological dependence on a drug. Some drugs of abuse are highly rewarding because of their influence on reinforcing neurobiological processes, but they do not necessarily result in "tissue" related withdrawal symptoms. Cessation of such drugs may lead primarily to subjective craving due to previous drug conditioning (perhaps true of some marijuana users) and craving may be more readily evoked or deeply conditioned among some persons than others ("addictive personalities"). Primary methods of assessment of addiction and habituation are completed through clinical interviews or self-report surveys (e.g., American Psychiatric Association DSM-IV, World Health Organization ICD-10). Treatment paradigms for the cessation of addiction begin with initial detoxification or withdrawal, followed by inpatient or outpatient program participation (e.g., 12-step programs, milieu, cognitive-behavioral, or behavioral). Pharmacological efforts (e.g., methadone maintenance) may be used as harm-reduction strategies among those who seem unable to quit drug use.

It is estimated that approximately 15 percent of the world's adults have serious substance abuse problems (not including nicotine addiction), and that this percentage has remained fairly constant over the past twenty-five years. Of these substance abusers, about two-thirds abuse alcohol and one-third abuse other substances, mainly marijuana, amphetamines, cocaine, and heroin. Approximately2.5 percent of the population abuse marijuana, 0.5 percent abuse stimulants, 0.3 percent abuse cocaine or opioids (such as heroin), and up to 0.8 percent abuse other substances (e.g., inhalants, depressants, hallucinogens). Sites of drug production and manufacturing, and distribution routes, tend to identify regions at high risk for abuse.

Drug abuse causes significant health-related consequences and financial losses to legitimate economies. The financial cost to society is estimated to be approximately $600 billion per year worldwide. This does not include the cost of nicotine abuse, which, through its influence on heart disease, lung cancer, chronic obstructive lung disease, and numerous other consequences, is the number one behavioral killer of people worldwide. Drugs of abuse are also associated with the production of psychotic symptoms (e.g., paranoid ideation) and with injuries due to accidents and violence. Approximately 50 percent of automobile fatalities involve alcohol-impaired drivers, and many auto crashes also involve chronic marijuana or amphetamine users.

In addition, each drug class is associated with a unique set of potential consequences. Some drugs of abuse are likely to have lethal consequences (e.g., opiates and depressants), and some have a high potential for addiction. Health consequences can also vary by drug. For example, depressants, PCP, stimulants, steroids, and cannabis are associated with cardiovascular diseases. Stimulant use is linked to seizure, digestion problems, and lung problems. Documented consequences of marijuana use include lung damage and short-term memory problems. Dementia, seizure, memory impairment, central and peripheral nervous systems impairment, gastrointestinal diseases, and cancers of the gastrointestinal tract are all consequences of alcohol consumption. Steroid use is associated with high blood pressure, potential heart attacks, liver tumors, transient infertility, and tendon degeneration. Inhalants are well-known causes of kidney, brain, and liver damage.

The development and maintenance of the addictive process involves multiple pathways and levels of influence within biological, psychological, and sociological domains. Influences exogenous to the individual include environmental, cultural, and social factors. Cultural and social norms, variations in drug use practices, and the values and behaviors of parents, siblings, friends, and role models can all affect an individual's drug experiences. Processes contributing to individual differences in substance use include physiological susceptibility, as measured in genetics studies; affective states; personality; and cognition—including expectancies and memory processes. Substance abuse versus substance use is more strongly related to intra-personal processes (e.g., self-medication for emotional distress) than social processes, although both are influential in the addictive process.

Substance Abuse and Dependence

Substance use pertains simply to the use of a drug. Substance misuse means using a drug for a purpose or in a manner in which it was not intended or prescribed. Substance abuse is marked by an accumulation of negative consequences resulting from drug use. Substance use that leads to a decreased level of performance in major life roles, or to dangerous actions, legal problems, or social problems, indicates abuse. Substance dependence is a more severe form of drug abuse that also includes tolerance (the need for markedly increased amounts of the substance to achieve the desired drug effect), withdrawal symptoms when stopping substance use, unpredictability of substance use, and an inability to control the use of a substance to the point that it consumes one's daily life.

Withdrawal symptoms vary from drug to drug. For example, withdrawal from alcohol, sedatives, or anxiolytic agents may involve autonomic reactivity, hand tremor, insomnia, nausea or vomiting, transient illusions or hallucinations, psycho-motor agitation, anxiety, and grand mal seizures. Amphetamine or cocaine withdrawal can include fatigue, unpleasant and vivid dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation. For substance abusers, withdrawal is often a difficult process with numerous symptoms, while abstaining from drug use can lead to recovery from physical and psychological problems and an improvement in overall health.

The Drug Abuse Continuum

Conceptually, substance abuse can be seen as a continuum, with individuals at one end being relatively "disease-free" but engaging in maladaptive behaviors over which they have some control. These individuals may repetitively use drugs, and over time they may abuse drugs. They choose to live a certain lifestyle in which their maladaptive behavior may or may not result in other disease states associated with use (e.g., cirrhosis of the liver). If these individuals stop this negative cycle they can, perhaps on their own, learn alternative coping mechanisms and self-efficacy. Individuals at the other end of the continuum, however, seemingly have no control over their use. Some individuals appear to lose control the first time they use drugs. For these individuals drug use is like a toggle switch that is either on or off. For them, total abstention is the only alternative because they have no control processes once the switch is turned on. They may use until they die unless someone else can turn their switch off and keep it off. There is no logic to this behavior, and no choice. Users of this type will often ruin their own lives and the lives of those around them in their drive to use their drugs of choice. It seems that as one moves toward a more "at-risk" end of the continuum there is less and less control over substance use.

It is unclear what causes the difference in loss of control among those at different points of the continuum. Researchers do not understand the process very well. They do know that other factors may exacerbate the process, including biologically based differences in metabolic processes, different levels of susceptibility to the reinforcing effects of drugs, personality disorders or depression, and an inability to tolerate frustration or emotional discomfort. Some processes are under individual control, but many are not, and it does appear that the less control the individual has over these types of processes, the more likely he or she is to fall into substance abuse.

Stages of Alcoholism and Drug Abuse

During the early stages of substance abuse, the alcoholic or drug abuser experiences increasing tolerance and use. Substance use at this stage is generally for purposes of self-medication. In the later stages of abuse, life becomes centered around obtaining, using, and recovering from drug use. Loss of control, ethical deterioration, and noticeable withdrawal symptoms ensue. It is unclear, however, whether such a progression is inevitable.

In a 1991 empirical review of the study of progression in alcoholism, Jill Littrell found that approximately 60 percent of adolescent problem drinkers remit to nonproblematic levels of drinking when they reach their 20s, and that 25 percent of young adults remit to nonproblematic levels of drinking before they reach age 35. Studies examining data on adult alcoholics who have undergone a variety of treatments as inpatients and outpatients during follow-up periods of up to fifteen years provide a general profile of outcomes. Between 25 and 35 percent remain abstinent, whether or not they continue treatment. An additional 15 to 25 percent will be abstinent most of the time, with some lapse periods. Approximately 6 to 9 percent will become nonproblematic or controlled drinkers (particularly those who were lighter drinkers and suffered fewer negative consequences while drinking). Another 20 to 33 percent become stable problematic drinkers, while 15 to 25 percent will die from alcohol-related causes.

It is uncertain whether drug abusers follow a progression similar to that of alcoholics. There probably is some validity to a notion of progression for drug use in general, but more longitudinal studies are needed in this area. It is possible that such a progression might simply express the accumulation of consequences one endures each time one takes a chance by drinking or using drugs. As opposed to the stages outlined above, a substance abuser may simply incur more problems over time, along with an increased tolerance for alcohol or other drugs of abuse.

(SEE ALSO: Abstinence; Alcohol Use and Abuse; Behavior, Health-Related; Cocaine and Crack Cocaine; Drug Abuse Resistance Education [DARE]; Marijuana; Medications Abuse, Elderly; National Institute on Drug Abuse; Smoking Behavior; Smoking Cessation; Substance Abuse, Definition of)

Bibliography

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington, DC: Author.

Littrell, J. (1991). Understanding and Treating Alcoholism: An Empirically Based Clinician's Handbook for the Treatment of Alcoholism. Norwood, NJ: Lawrence Erlbaum Associates.

Newcomb, M., and Earlywine, M. (1996). "Intrapersonal Contributors to Drug Use: The Willing Host." American Behavioral Scientist 39:823–837.

Sussman, S., and Ames, S. L. (2001). The Social Psychology of Drug Use and Abuse. Buckingham: Open University Press.

U.S. Department of Health and Human Services (1998). International Epidemiology Work Group on Drug Abuse 1997 Proceedings. Rockville, MD: NIH Publications No. 98–4208B.

White, T. (1999). UN Office for Drug Control and Crime Prevention, Global Illicit Drug Trends. New York: United Nations Publication, No. E.99.XI.16, ISBN 92–1-148122–8.

— STEVEN SUSSMAN; SUSAN AMES

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Addiction in its broadest sense can be defined as the habituation to a practice considered harmful. A more narrow definition of the term refers to chronic use of a chemical substance in spite of severe psychosocial consequences. Terms such as "workaholic," "sex addict," and "computer junkie" arose to describe behaviors that have features in common with alcoholism and other substance addictions. The most convincing data supporting a role of genetics in addiction has been collected for alcoholism, although genetics most likely has a role in other forms of addiction.

Definitions

In order to assess alcoholism, or any form of addiction, a clear definition of the condition is necessary. The American Psychiatric Association and the World Health Organization have developed clinical criteria (DSM-IV and ICD10, respectively) that are widely used for the diagnosis of substance-use related disorders. DSM-IV criteria recognizes ten classes of substances (alcohol, amphetamines, cannabis, hallucinogens, inhalants, nicotine, opioids, phencyclidine, and sedatives) that lead to substance dependence, another term for addiction.

The precise diagnostic criteria for dependence vary among substances. DSM-IV defines dependence as manifesting, within a twelve-month period, at least three of the following criteria:

• Tolerance (increased dose needed to achieve the same affect, or reduced response to the same dose)
• Withdrawal symptoms
• Progressive increase in dose or time used
• Persistent desire for, or failure to reduce substance use
• Increasing efforts made to obtain substance
• Social, occupational, or recreational activity is replaced by activity associated with substance use
• Continued substance use despite recognized physical and psychological consequences

Heritability in Humans

Most family, twin, and adoption studies have shown that addiction to alcohol has significant heritability. For example, there is an increased risk for alcoholism in the relatives of alcoholics. Depending on the study, the risk of alcoholism in siblings of alcoholics is between 1.5 and 4 times the risk for the general population. The identical twins of alcoholics (who share 100 percent of their genes) are more likely to be alcoholics than the fraternal twins of alcoholics (who share only about 50 percent). Adoption study data suggest that the risk for developing alcoholism for adopted children is influenced more by whether their biological parents were alcoholics than whether their adopted parents are alcoholics, suggesting that genes contribute to alcoholism more than environment. Similar but less extensive data has been collected for nicotine addiction. Very little genetic epidemiological data has been collected for illegal drugs.

The only genes that have been conclusively shown to affect susceptibility to addiction in humans are genes that encode proteins responsible for the metabolism of alcohol. In the body, ethanol ("drinking" alchohol) is oxidized by enzymes to acetaldehyde and then to acetate. Certain alleles of aldehyde dehydrogenase genes that are common in some populations, such as Asians, lead to increased levels of acetaldehyde when alcohol is consumed. Acetaldehyde causes an unpleasant flushing reaction that leads to a voluntary reduction of alcohol consumption. The systematic search for other genes that affect susceptibility to alcohol and nicotine addiction in humans has lead to the identification of chromosome loci that may contain genes that affect susceptibility to addiction, but has not lead to the identification of any specific genes.

Models of Addiction

Progress in genetic analysis of addiction in animal models has been more successful. The pharmacologic effects of abused substances can readily be demonstrated in many model systems, from worms to rodents. Rodents can be trained to voluntarily consume alcohol and other abused substances. Once trained, these rodents will expend energy to continue to receive drugs and will display withdrawal symptoms when denied drugs. Chromosomal regions with naturally occurring variants that affect voluntary consumption, intoxication, and withdrawal have been mapped in mice. The specific genes responsible for these effects have not yet been identified.

Cell biology and neurochemistry studies in humans and model systems have identified many molecules that have altered abundance and distribution, enzymes with altered activity, and genes with altered expression resulting from substance abuse. In particular, the dopamine and serotonin neurotransmitter systems have been the focus of intense studies. These are brain systems directly involved in many basic responses, including pleasure and reward systems.

To directly test the role of specific genes and pathways, mice have been engineered to delete or over-express genes. Mice lacking any of these genes (called PKC_ε, DRD2, and DBH) are more sensitive to the effects of alcohol and consume less alcohol. In contrast, mice lacking any one of four other genes (PKA regulatory II_β, NPY, or 5-HT_1b) are less sensitive to the effects of alcohol and consume more alcohol. Mice cannot be trained to self-administer alcohol if they lack the Mu opioid receptor, which is involved in transmitting signals to the body's own internal opiate system.

Mutant fruit flies with altered responses to alcohol intoxication have also been created. Two mutants, called "cheapdate" and "amnesiac," arise from different mutations in the same gene. These mutations affect the cellular level of the signal transduction molecule cyclic-AMP. As the names imply, flies with cheapdate mutations are very sensitive to the affects of alcohol, and flies with amnesiac mutations are unable to learn.

The major conclusion from work in model systems is that the pathways and systems involved in addiction are central to normal behaviors with instinctive reward processes, such as feeding and procreation. Addiction is a process that involves learning and the subversion of these basic reward pathways.

Bibliography

American Psychiatric Association Task Force on DSM-IV. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.

Begleiter, Henri, and Benjamin Kissan, eds. The Genetics of Alcoholism. New York: Oxford University Press, 1995.

Tamara J. Phillips, et al. "Alcohol Preference and Sensitivity Are Markedly Reduced in Mice Lacking Dopamine D2 Receptors." Nature Neuroscience 1 (1998): 610-615.

Theile, Todd, et al. "Ethanol Consumption and Resistance Are Inversely Related to Neuropeptide Y Levels." Nature 396 (1998): 366-369.

—Kirk C. Wilhelmsen

A state of physiological dependence produced by habitually taking drugs such as morphine, heroin, or alcohol. The term is also applied to a state of psychological dependence produced by drugs such as barbiturates.

The Latin addictus refers to a person who is bound and dependent as a result of unpaid debts. Metaphorically, this term came to be used for any behavior that results from a heavy dependence on something, such as a drug. A number of common substances or those that can be freely purchased can be used as drugs or become addictive substances: medication, alcoholic beverages, glue, and so on. Psychoanalytically, the power of a particular addiction depends both on the unconscious fantasies that underlie the subject's ingestion, and the substance's actual chemical effect.

Sigmund Freud refers to addiction in an early paper on "Hypnosis" (1891d, p. 106), and in a letter to Wilhelm Fliess of December 22, 1897, he refers to masturbation as the "primary addiction" (1950a, p. 272; 1985c, p. 287). Karl Abraham (1908/1927) studied alcohol addiction. Sándor Radó (1933) associated addiction with a regression to childhood. Otto Fenichel (1945) developed the concept of addiction as a regression to infantile stages, and his descriptions of alcohol as a means of diluting the superego are especially interesting. Herbert Rosenfeld (1965) referred to the manic-depressive signs that underlie addiction, and connected addiction to pathological narcissism of the Self. Donald Winnicott (1951/1953) associated addiction with a pathology of the transitional. Winnicott's transitional object, a creation/discovery of the subject, opens up an intermediary zone of experience, which then expands into play and cultural life, while the transitional object is disinvested and loses its meaning. In addiction, this process of opening up and development is held back, and the transitional object continues to carry out its original function (counter-acting depressive anxiety), in the form of a continuing disavowal. The transitional object is concretized, is "fetishized," and becomes susceptible to replacement by a drug as an object that can be manipulated by the omnipotent subject, enabling him to deny the separation and the resulting depression.

A number of authors who have studied compulsive behavior have included a dependence on alcohol or another substance into their inquiry. Dostoyevsky, in The Brothers Karamazov, provides a clear description of the motivations that underlie addictive behavior, such as sexual dependency and pathological games.

Addiction to a substance is sometimes replaced with another form of dependence, for example, addictions to food, to sex with prostitutes, to gambling, to spree-buying, to physical exercise, to web surfing, or to playing video games (whereby the internal world is projected onto the characters who fight, kill, love, or hate on screen). There is also the addiction to pseudo-religious cults, which serves as a substitute for a dependence on and subjugation to drugs. It is important to note that the other can also become an addictive object (McDougall, 1982), serving as a drug might, to fill holes in the subject's identity.

Bibliography

Abraham, Karl. (1927). The psychological relations between sexuality and alcoholism. In Selected papers on psychoanalysis, London: Hogarth Press. (Original work published 1908)

Freud, Sigmund. (1891d). Hypnosis. SE, 1: 103-114.

——. (1897a). Infantile cerebral paralysis. (Lester A. Russin, Trans.). Coral Gables, FL: University of Miami Press, 1968.

——. (1950a [1887-1902]). Extracts from the Fliess papers. SE, 1: 173-280.

——. (1985c [1887-1904]). The complete letters of Sigmund Freud to Wilhelm Fliess, 1887-1904 (Jeffrey M. Masson Ed. and Trans.). Cambridge, MA, London: Belknap/Harvard University Press.

Fenichel, Otto. (1945). The psychoanalytic theory of neurosis. New York: W.W. Norton.

McDougall, Joyce. (1982). The narcissistic economy and its relation to primitive sexuality. Contemporary Psychoanalysis, 18, 373-396.

Radó, Sándor. (1933). The psychoanalysis of pharmacothymia. Psychoanalytic Quarterly. 2, 1-23.

Rosenfeld, Herbert. (1965). Psychotic states: A psychoanalytic approach. London: Hogarth Press.

Winnicott, Donald W. (1953). Transitional objects and transitional phenomena, a study of the first not-me possession. Collected papers, through paediatrics to psycho-analysis (pp. 229-242). (Reprinted from International Journal of Psycho-Analysis, 34 (1951), 89-97.)

—DAVID ROSENFELD

Physiological dependence on some agent, usually a plant, with a tendency to increase its use. Whether true addiction ever occurs in animals is doubtful. Field evidence does point to preferential grazing of some known toxic plants, e.g. Astragalus, Swainsona spp.

• drug a. — abuse of narcotic drugs is a hazard of veterinary practice because of the availability of addictive agents to registered veterinarians. The same laws apply to members of the veterinary profession as to the medical profession and are designed to protect them against becoming dependent upon any drug. Deregistration and a consequent isolation from the prohibited substances is the usual penalty.

IN BRIEF: The state of being obsessed with something, as with drugs.

Charlie was addicted to his morning cup of coffee.

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Quotes:

"I feel that any form of so called psychotherapy is strongly contraindicated for addicts. The question Why did you start using narcotics in the first place? should never be asked. It is quite as irrelevant to treatment as it would be to ask a malarial patient why he went to a malarial area." - William S. Burroughs

"It is not heroin or cocaine that makes one an addict, it is the need to escape from a harsh reality. There are more television addicts, more baseball and football addicts, more movie addicts, and certainly more alcohol addicts in this country than there are narcotics addicts." - Shirley Anita Chisholm

"It is not I who become addicted, it is my body." - Jean Cocteau

"If an addict who has been completely cured starts smoking again he no longer experiences the discomfort of his first addiction. There exists, therefore, outside alkaloids and habit, a sense for opium, an intangible habit which lives on, despite the recasting of the organism. The dead drug leaves a ghost behind. At certain hours it haunts the house." - Jean Cocteau

"My case is a species of madness, only that it is a derangement of the Volition, and not of the intellectual faculties." - Samuel Taylor Coleridge

"In this country, don't forget, a habit is no damn private hell. There's no solitary confinement outside of jail. A habit is hell for those you love. And in this country it's the worst kind of hell for those who love you." - Billie Holiday

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