It is perhaps ironic that the first KISS-version of one of our commentaries actually comes from an off-site source that has summarized our viewpoint regarding the important distinctions among the terms "addiction," "abuse," and "dependence" perhaps even better for a general audience than our original commentaries. Ms. Jacqueline Marshall recently presented a concise, well-written synopsis that presents our viewpoint on this topic extremely well and in a very readable style. Visit MyAddiction.com to read her excellent commentary. Thank you, Jacqueline, for your excellent presentation!
Our original posts:
Why Distinguishing between Drug Dependence and Drug Addiction is Important
Why Distinguishing between Drug Abuse and Drug Addiction is Important
Distinguishing Drug Abuse from Drug Addiction
We have added several new podcasts this week which are listed below. We're excited about this technology and we're moving ahead, perhaps a little faster than we should according to the experts. Obviously, there is a learning curve and we hope to steadily improve our podcasts with experience. We may even go back and re-record some as we become a bit more 'professional.'
Please note that we will begin posting podcast links at the bottom of the commentaries when available. We are moving from top to bottom posting to avoid our podcast URL being displayed as the beginning of the commentary in summary tables and RSS feeds. Please scroll to the bottom if you're interested in a podcast of a specific commentary. You can also use our ASNet Podcast Directory from our website. Podcasts will be listed there by date and by several other orders of presentation when the page revisions are complete. We are duplicating the listings in different orders to help people find those of interest to our various listeners. The links below are for streaming audio which does not require download of the podcast. We are using another service for streaming podcast at the moment to keep our bandwidth demand manageable on our regular server while we gauge the interest in this channel. You can view and leave feedback as well as 'rate' our podcasts at our Podomatic home page.
ASNet Essential Concepts for Understanding Addiction (length: 1hr2min)
ASNet Why Distinguishing Drug Abuse from Drug Addiction is Important (length: 7min56sec)
ASNet Einstein and the Science of Addiction (length: 7min14sec)
Defining Addiction: What are the necessary attributes? (length: 11min48sec)
ASNet Commentary on New Opioid Prescribing Guidelines (length: 4min51sec)
ASNet Primer on Addiction (length: 15min37sec)
A new commentary is available:
Defining Addiction: What are the necessary attributes? for those who would prefer reading instead of the podcast listed above.
A new ASNet Discussion Forum category has been added to support our Addiction Technology Transfer Initiative. The new forum is provided to discuss specific issues regarding addiction technology transfer, general suggestions, and other feedback; it's intended more to address the approach, style, or other outreach ideas than the actual content of our presentations, but all topics are open. This discussion forum, our Addiction Science Network website, and our new podcast channel are all components of that program. Your comments are always welcomed. We like to know that we are reaching people and how we can improve our independent voice for Addiction Science.
Finally, we are still working on setting up our RSS feeds directly for the podcasts. In the interim, you can subscribe to the RSS feeds for our Announcements to view our list as it become revised periodically.
Obviously we are "back in the saddle again." We don't know how long we'll be on this ride before falling off our horse again, but we're rolling now. Probably by the end of November we will have to turn our attention to completing a book which has been delayed now for far too long.
We have chosen to define “addiction” as a behavioral syndrome where drug use and procurement seem to dominate the individual’s motivation and where the normal constraints on behavior are largely ineffective. There are other important attributes of addiction that are usually included in various definitions of this term. The question of interest is whether other attributes are necessary components of a formal definition or whether they add needlessly to the number of terms used to define what we mean by “addiction.” Succinct definitions not only ‘save words,’ but they keep the focus on the primary variable(s) of interest and help to prevent confusing effects with causes in our definitions. The definition adopted here is less than 25 words, and there are definite advantages to keeping definitions sufficiently short so as to simply memorization and to facilitate accurate conveyance amongst those discussing the same phenomenon. One of the biggest challenges to any discourse, whether it be lay, academic or professional, involves semantics or making sure that all parties are actually discussing the same thing. Succinct, consensually accepted definitions facilitate conversations at all levels.
The “Pizza and beer” syllogism is perhaps the most famous example illustrating how a statement that seems logically correct leads to an erroneous conclusion.
- Pizza and beer are better than nothing.
- Nothing is better than going to heaven.
- Therefore, pizza and beer are better than going to heaven!
The syntax is logically correct, but there is a breakdown in semantics involving the meaning of the word “nothing” that invalidates the apparent conclusion. In the first context “nothing” refers to “the absence of anything,” while in the second context it refers to “no-thing.” It is critically important to avoid these types of semantic breakdowns in discussions of addiction, and thus the need for a concise definition that identifies the defining attribute(s) of an addiction while relegating the others characteristics often included to descriptive text.
Addiction is often defined as “a chronically relapsing disorder” or “disease” (whether addiction is indeed a “disorder” or a “disease” is a point of considerable debate in itself; see Drug Addiction as a "Disease"). The phrase "chronically relapsing" certainly describes an important characteristic of an addiction, but is it necessary in a concise definition? The intense motivational strength of an addiction not only predicts the high relapse rates, but it also predicts other attributes of addiction such as motivational toxicity which describes the drug’s impact on normal motivated behaviors such as eating and sexuality. The fact that a single attribute (i.e., motivational strength) can predict from simple logical deduction several other characteristics that are commonly seen in addiction makes this single attribute more valuable as the defining characteristic than is compiling an unnecessarily longer list of characteristics for inclusion in the formal definition of addiction. These other commonly observed features are perhaps best considered simply “characteristics” of an addiction because they can all be derived from the single defining attribute (i.e., high motivation for drug administration). This same logic also applies to adding “motivational toxicity” to formal definitions of addiction. While it may appear to be a defining characteristic, the motivational toxicity inherent in an addiction can also be predicted by simply understanding that addictive drugs produce an intense motivational state and thus even if they lacked their ability to blunt the rewarding impact of natural rewards they would still seemingly overtake the normal motivations in the individual’s life. The same might be said for the second characteristic included in our definition, specifically, that “the normal constraints on behavior are largely ineffective,” but this phrase not only underscores the intense motivation to obtain the addictive drug but also reminds the reader that motivational strength is reflected not only in how hard one will work for the goal object but also by the willingness to overcome aversive conditions which might normally inhibit goal-directed behavior.
Other considerations for inclusion in a comprehensive definition of addiction include the addict’s perceived sense of a “loss of control.” Again, this variable might be deduced simply by considering that the normal choice perceived when several, closely competing goals which vie for the individual’s ‘attention’ and behavior are obviated by a single, overwhelmingly strong motivator—the addictive drug. In other words, the cognitions associated with classic approach-approach and approach-avoidance conflicts might give rise to a sense of ‘choice,’ and these conflicts are less prominent in cases where the motivation to ‘approach’ the goal object (in this case, use the drug) is so strong as to dominate unquestionably the other motivations. In such cases the perception of choice might be absent and the individual may feel that they no longer have control over their own behavior, but rather, that they are being driven by some external force. In a sense they are correct—the stimulus properties of the drug and other cues in conjunction with the (largely unconscious) anticipation of reward engage the individual’s behavior in a manner consistent with the notion of “enslavement” to the external agent (i.e., functionally the drug is serving as the ‘master’ and the addict as the 'slave'). As discussed elsewhere, this apparent “enslavement” is consistent with the etymology of the term “addiction” and adds credence to the use of the term in this fashion as opposed to the popular misconception of “addiction” as physical dependence upon a substance.
The last consideration that might be addressed by our definition of addiction is whether we consider it a disease or a disorder. The definition used here avoids this debate by simply defining “addiction” as a “behavioral syndrome.” Whether it is truly best considered a disease or a disorder is moot for our definition which emphasizes the behavior of the individual as being the primary descriptive variable and hence is consistent with the term’s etymology of "addiction" as "enslavement." As discussed elsewhere, the disease-disorder debate resolves down to one largely of who ‘owns’ the territory—the medical establishment or psychologists, counselors, and social workers (see Drug Addiction as a "Disease"). There are of course other important considerations for whether a pathology is considered a disease or disorder, such as locus of control—biological or more “psychological”—along with the ensuing implications of how to best approach treatment and the degree of individual responsibility for their own ‘problem’ (e.g., the use of the term “disease” implies that the individual has relatively little control over the course of the pathology and that some external treatment is necessary to remediate the problem). There would appear to be no advantages to including the term “disorder” in a formal definition of addiction, but additional characteristics conveyed by the use of the term “disease” merit further consideration for future revisions to our ‘working’ definition. On the other hand, the use of the term disorder would imply that addiction is not a disease, while the description as “a behavioral syndrome” avoids pronouncement on this hotly debated topic.
It is always tempting when formulating definitions to be all encompassing or at least to describe enough of the phenomenon under discussion to vividly illustrate its many facets. Indeed, the more one knows the more eagerly one tries to share their knowledge with anyone and everyone who will listen. Understanding the many aspects of addiction, something shared by more than a few researchers and clinicians, seemingly implores one to offer mini-lectures or tutorials at every opportunity. And when it comes to formal definitions, the desire to share all often gets the best of even academic scholars who should understand well the need for concise definitions devoid of superfluous adjectives. Nonetheless, multifaceted phenomena like addiction are often described from the perspective of individual disciplines studying only one or a few of its many features without trying to identify a common underlying variable responsible for the various attributes.
In this way most definitions focus too much on the vicissitudes of addiction which distract from the core phenomenon responsible for these other, secondary characteristics. Indeed, this often overshadows the primary characteristic of an addiction. In other words, the motivational characteristic of an addiction (which is used here as the basis for its definition) produces the other features such as “chronically relapsing disorder,” the addict’s “perceived loss of control,” and even the “motivational toxicity” inherent in an addiction. Inclusion of these other, secondary characteristics tends to obscure the primary characteristic of the addiction and in some respects seemingly confuses its effects with its cause (i.e., the intense motivational strength can be viewed as the cause and these other features as effects of the addiction!) This is an example of why good science strives to simplify things, to render them in their simplest, not most complex, terms; good definitions like good theories retain a vision of “the forest for the trees,” hence not letting the details obscure the bigger picture. In case anyone is still wondering whether a useful definition of addiction can be resolved down to just 25 words or less the answer is yes, indeed it can, and we are better off ‘keeping it simple stupid’ to ensure the semantic integrity of our discussion of this seemingly complex, multifaceted phenomenon.
So what do we have nearly 1400 words later when we’ve finished with this relatively brief examination of the terms frequently used to define addiction? We’re right back where we started: “addiction” can be defined as a behavioral syndrome where drug use and procurement seem to dominate the individual’s behavior and where the normal constraints on behavior are largely ineffective. The difference between the closing and beginning positions of this discourse lies in the certainly with which we succinctly define addiction—acknowledging the phenomenology of these other important attributes, but rendering their incorporation into a formal definition of addiction (albeit a ‘working’ one) unnecessary.
The podcast of this presentation can be downloaded from our ASNet Podcast Directory.
Click here to listen to the podcast without downloading (length: 11min48sec). Click on the ASNet podcast logo (Anpu) to pause the imbedded player.
The terms drug dependence and drug addiction are often used interchangeably, but this practice leads to confusion among professionals regarding the diagnostic implications of these terms and also contributes to misunderstanding the underlying causes of substance use. As described earlier, drug addiction refers to a behavioral syndrome where the procurement and use of a drug seem to dominate the individual's motivation and where the normal constraints on the individual's behavior seem largely ineffective. Inherent in this definition is the overwhelmingly powerful motivation to obtain and self-administer the drug. And as noted earlier, drug abuse simply means that the substance is used in a manner that does not conform to social norms; the motivation to use the substance may or may not be particularly strong compared with other motivators. The causes of drug abuse and drug addiction can be the same, but they are very often much different. Specifically, drug addiction involves the biological action of a drug on brain reward and motivation systems, while drug abuse often involves other psychosocial factors with only modest direct effects on brain reward systems.
Drug dependence, in contrast to the two terms described above, refers to a state where the individual is dependent upon the drug for normal physiological functioning. Abstinence from the drug produces withdrawal reactions which constitute the only evidence for dependence. Drug dependence can involve disturbances in general bodily (i.e., somatic) function such as vomiting, diarrhea, sweating, and the resulting symptoms indicate a physical dependence syndrome which is usually specific for a given class of drug. Drug dependence can also involve disturbances in psychological functioning, such as inability to concentrate, anxiety, depression, and the resulting symptoms indicate a psychological dependence syndrome which often shares common features with other abused drugs. It is important to note that psychological dependence has a physiological basis and thus it is preferable to use the term physical dependence to refer to disturbances in somatic function to avoid confusion.
A number of substances produce psychological and/or physical dependence without producing an addiction. The therapeutic uses of certain steroids, antidepressant medication of the SSRI class, and even some antihistamines all produce characteristic withdrawal syndromes when their use is abruptly discontinued. However, there is no strong motivation to continue the use of these substances for most patients; some patients even refuse to resume treatment with such drugs because of their adverse experience during unsupervised withdrawal.
Other substances can produce a notable psychological dependence without producing an exceptionally strong motivation to avoid abstinence. Caffeine has desirable stimulating effects that involve general arousal accompanied by a mild mood elevation for many daily coffee drinkers. And while the avid coffee drinker usually chooses not to miss their morning or afternoon ‘brew,’ many voluntarily abstain when the cost is too high ($8 for a cup of coffee in NYC?) or access is difficult. The ensuing abstinence syndrome has both psychological (e.g., lethargy) and physical (e.g., mild headache) withdrawal signs, but the motivation to abate this condition is far below the level produced by highly addictive drugs such as cocaine and heroin.
Physical dependence often occurs without addiction (e.g., therapeutic use of steroids, SSRIs), and addiction can occur without appreciable physical dependence (e.g., cocaine). Similarly, psychological dependence can occur without addiction (e.g., morning coffee for millions of regular users), but it’s not clear whether addiction ever occurs without psychological dependence. And of course drug abuse may or may not be accompanied by drug dependence and addiction.
The fact that notable signs of physical dependence occur with some of the more addictive drugs (e.g., heroin, barbiturates, alcohol) has lead many to mistakenly attribute the motivation for substance use to the avoidance of withdrawal discomfort. Other drugs, such as the psychomotor stimulants, do not produce these characteristic withdrawal reactions and have helped to debunk this common misconception. Of course there are other compelling lines of evidence that physical dependence is not the primary cause of drug addiction (see Bozarth, 1989, 1990, 2009; Bozarth & Wise, 1984; Wise & Bozarth, 1987) although it can contribute to the overall motivation for continued drug use (see Bozarth, 1994).
In summary, drug addiction describes the motivational strength of substance use; drug abuse describes the misuse of a substance without explicit reference to motivational strength; and drug dependence describes the necessity of using a substance to maintain normal psychological and/or somatic functioning without reference to the motivational strength of the substance use or to whether the substance use violates cultural norms. These three terms have distinctively different meanings although there are obvious and numerous cases where all three apply to the same drug-use situation (i.e., the individual may be dependent upon a drug which they abuse because they are addicted).
The terms "drug abuse" and "drug addiction" are often used interchangeably, but in fact, they denote very different conditions. The term "drug abuse" refers to the use of a substance in a manner that deviates from the culturally acceptable norms, while the term "drug addiction" describes a disorder where the drug appears to be the dominant influence on the individual's behavior. More specially, drug addiction is behavioral syndrome where the individual’s motivation is dominated by the procurement and use of a drug and where the normal constraints on the individual’s behavior are largely ineffective (Bozarth, 2009; see also Bozarth, 1990). This condition may or may not be accompanied by physical dependence, but it does seem to be invariably accompanied by psychological dependence. Psychological dependence, however, is NOT equivalent to addiction. Psychological dependence, like its physical dependence counterpart, simply means that the individual requires the substance for normal psychological functioning. That is, abstinence from the substance produces withdrawal reactions that disrupt normal psychological (or in the case of physical dependence, physiological) function. Of course psychological dependence has an underlying neurophysiological basis; therefore the syndrome describing disturbances in normal physiological function other than psychological aspects (such as disturbances in autonomic nervous system producing nausea, chills, tremors, etc.) are better denoted as physical dependence and withdrawal. There are undoubtedly cases of psychological dependence without addiction to the substance—the substance is necessary for ‘normal’ psychological functioning, but the motivation to obtain the substance is insufficiently strong to constitute an addiction to that substance (e.g., daily caffeine use for many people).
There are many cases where the use of a substance constitutes drug abuse but not addiction. For example, any use of an illicit substance is considered drug abuse even if the substance is used only rarely and the individual retains control of their substance use. There are even numerous cases where the individual seems to loose control of their substance use, but it still doesn’t constitute true addiction to that substance (see below). Drug abuse is defined by the society in which it exists; what is considered drug abuse in one culture may be perfectly acceptable in another. Drug abuse does not necessarily imply that the motivation to continue use of the substance is strong.
The causes of drug addiction and of drug abuse are often quite different. Drug addiction, although the more intense motivational condition, is actually less complex than is drug abuse. Drug addiction involves the drug’s action on brain reward and motivation systems whereby it produces neurochemical disturbances that result in the drug becoming the dominant motivational factor for the individual. This involves an “incentive contrast” where there is a dramatic increase in the incentive value or attraction to the drug reward and a marked decrease in the incentive value or interest in other, normal rewards (Bozarth, 2009). The ensuing motivational toxicity is a characteristic of addiction that requires no pre-existing conditions or special personality types—simply the neurochemical action of certain (i.e., addictive) drugs on brain reward systems.
Drug abuse, on the other hand, involves the ‘misuse’ of a substance (according to social norms) that may or may not be accompanied by a strong motivation to continue the use of the substance. In cases where drug abuse appears to be strongly motivated, the motivation actually depends on characteristics of the individual or of the social setting to produce these strong motivational effects. That is, apparent “addictiveness” in cases of strongly motivated drug abuse without addiction does not actually involve an attribute of the drug per se. Rather, some set of psychosocial factors account for the strong motivation to engage in substance abuse. In many cases of pathological drug abuse where the motivation to continue the substance use seems strongly motivated, other psychiatric disturbances are present. These comorbid disorders are much different than actual addiction to the substance and need to be carefully distinguished from true drug addiction when considering the appropriate treatment approach.
There are obviously many cases of drug abuse that do not constitute drug addiction. In contrast, most cases of drug addiction involve drug abuse; however, there are even a few cases where drug addiction does not constitute drug abuse such as prescribed high-dose opiate medication for chronic pain.
Determining whether the use of an illicit substance constitutes simply drug abuse or true drug addiction can seem daunting, but it’s actually quite simple. If the substance use is intensely motivated as is inherent in the definition of addiction AND if the motivation for the substance use arises from its action directly on brain reward systems, it constitutes drug addiction. If special, pre-existing psychosocial factors are necessary for the substance use to develop (regardless of how strongly that behavior seems to be), then it constitutes drug abuse which involves more than just the substance’s action on brain reward systems and therefore is not truly an addiction to that substance. In cases of compulsive drug abuse comorbid disorders are very likely to be present.
Does considering drug addiction as a "disease" help or hinder a better understanding about the nature, cause, and treatment of this 'disorder?'
Please see the Comments from "The Professor" for the ASNet perspective on considering "Addiction" as a disease.
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