Frequently Asked Questions (FAQs) - and Answers

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Responses to Frequently Asked Questions (FAQs) were developed by the editorial staff of Addiction Treatment Forum and made possible by an educational grant from Mallinckrodt Inc., a manufacturer of methadone and naltrexone.

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Understanding Drug Addiction

How is drug addiction defined?

After repeated use of certain medications, illicit drugs, and/or alcohol, brain function can become altered and the person transformed by the chronic, progressive, relapsing disease of “drug addiction.” Addiction is a “choice” only in that the person makes an initial, voluntary decision to either avoid or use addictive substances or alcohol.

Substances of abuse essentially hijack reward circuits in the brain and acquire overpowering survival value for the individual. This explains, at least in a general sense, why addicted persons will forsake all other life activities and obligations and even their own health in pursuit of more drugs (or alcohol).

A very commonly used reference text from the American Psychiatric Association – the Diagnostic and Statistical Manual of Mental Disorders – does not use the term addiction at all; rather, it uses “substance dependence.” And, to be more precise, the particular drug involved is specified: e.g., heroin dependence, alcohol dependence, etc. However, in general use by the public, the term “addiction” is synonymous with “substance dependence.”

Substance Dependence (Addiction) is considered in the Diagnostic and Statistical Manual as a maladaptive pattern of substance use leading to significant impairment or distress in three (3) or more of the following 7 areas during a 12-month period:

Tolerance – defined by either: a) a need for increased amounts of substance to achieve intoxication or desired effects, b) diminished effect with continued use of the same amount of substance.
Withdrawal – evident by either: a) characteristic, uncomfortable abstinence signs/symptoms for the particular substance, b) the same (or closely related) substance is taken to relieve or avoid the withdrawal syndrome.
The substance is used in greater quantities or for longer periods than intended.
There is a persistent desire or unsuccessful efforts to cut down or control substance use.
Considerable time and effort are spent in obtaining or using the substance or in recovering from its effects.
Important social, employment, and recreational activities are given up or reduced because of an intense preoccupation with substance use.
Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or worsened by the substance. For example, depression caused by cocaine, or an ulcer made worse by alcohol.

Substance dependence (addiction) may occur with or without the first 2 criteria on the list – called physiological dependence (tolerance and/or withdrawal). A key issue in evaluating substance dependence is the patient’s complete failure or inability to abstain from using the substance. Thus, loss of control is a most critical factor.

Overall, then, the definitions of addiction is based on the self-reported behaviors and/or thought processes of the addicted patient. In some cases, behaviors – excessive (compulsive) use, loss of control, neglect of activities/obligations – may be confirmed by others close to the patient. Physical or physiologic dependence – tolerance and withdrawal – is not necessary for a diagnosis of addiction; however, it usually is present to some extent if a patient’s history is fully explored.

Furthermore, no single event or criteria is diagnostic of an addictive disorder; rather, addiction becomes evident via a pattern of behavior that takes place over time. In that regard, drug addiction is not solely associated with drug-induced euphoria (feelings of well-being), craving, or physical withdrawal (hyperexcitability, tremors, seizures, etc.). Nor are persons who merely use drugs too often and/or in high quantities necessarily addicted, at least not according to commonly used definitions.

In many ways, current definitions incorporate only the most superficial levels of our understandings of addiction. More objective, underlying neurobiological dysfunctions – such as, disrupted chemical balance in the brain – are not taken into account, largely because they cannot easily be clinically assessed.

Sources:

APA (American Psychiatric Association). Diagnostic and Statistical Manual of Mental Disorders. 4 th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000.Erickson CK, Wilcox RE. Neurobiological causes of addiction. In: Straussner SLA. Neurobiology of Addictions: Implications for Clinical Practice. J Soc Work Prac Addictions. 2001;1(3):7-22.

Gardner EJ. The neurobiology and genetics of addiction: implications of the ‘reward deficiency syndrome’ for therapeutic strategies in chemical dependency. Chap 3. In: Elster J, ed. Addiction: Entries and Exits. New York: Russell Sage Foundation; 1999:57-119.

Jaffe JH. Current concepts on addiction. Addictive States. In: O’Brien CP, Jaffe JH. Addictive States. New York: Raven Press;1992:1-21.

Leshner AI. Understanding drug addiction: Insights from the research. In: Graham AW, et al. (eds). Principles of Addiction Medicine. 3 rd ed. Chevy Chase, MD: American Society of Addiction Medicine; 2003: 47-56.

Nestler EJ, Malenka RC. The addicted brain. Scientific American. 2004 (March edition). Also published online at: http://www.sciam.com (February 9, 2004).

SAMHSA (Substance Abuse and Mental Health Services Administration). 2002 National Survey on Drug Use and Health (NSDUH). Washington, DC: Substance Abuse and Mental Health Services Administration; 2003.

Added November 2004

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Is addiction truly a brain disease?

addiction brain disease Many published “authorities,” as well as some workers within the addiction treatment field, assert that addiction is not a disease. Rather, they say, it relates more to poor choices people make based on a distorted value system. This is an old and outdated argument that views persons who develop addictions as being weak-willed, morally corrupt, and irresponsible individuals. Such perspectives ignore the evidence-based findings of modern neuroscience.

Using advanced techniques, research scientists have been able to conclusively demonstrate that there are chemical, anatomical, and functional changes in the brains of substance-addicted persons. For example, the pictures below depict SPECT images (from Amen 2001) demonstrating that addictions, as well as mental disorders, affect brain structure (and consequent functioning) just as much as a physical impairment such as stroke. Single-photon emission computed tomography (SPECT) uses small doses of radioisotope tracers to study regional cerebral blood flow and thus, indirectly, brain function during health and disease states.

The images graphically show the cerebral regions of different patients. As can be seen, compared with a normal subject, there are severe and multiple disruptions in the brains of these patients. The Swiss cheese appearance indicates defects in blood circulation and, hence, abnormal cerebral activity. Portions of the cerebral cortex are responsible for executive functions of cognition, judgement, and impulse control – which become critically dysfunctional in mental and addictive disorders. Also, deeper areas of the brain are adversely affected (though not depicted in the scans here).

Thus, substance addiction may best be understood as a neurological disease process. With effective medical and psychological treatment, patients benefit from at least partial “normalization” of brain activity in the affected regions.

Sources:

Amen DG. Why don’t psychiatrists look at the brain? The case for greater use of SPECT imaging in neuropsychiatry. Neuropsychiatry Rev. 2001;2(1).

Andreasen NC. Linking mind and brain in the study of mental illnesses: a project for scientific psychopathology. Science. 1997;275:1586-1593.

Dolan RJ. Emotion, cognition, and behavior. Science. 2002;298:1191-1194.

Added November 2004

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