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).
Dr. Phil and other tele-psychologists promote fundamental misunderstandings about addiction. Playing out in a type of public psychodrama, the inflicted guest is usually told how the problem is easily solved “if you only . . .” as the ‘all-knowing sage’ offers insight (and often resolution) within a single 60-minute episode. This kind of 'pop psychology' is replete with misinformation about addiction—what it is, its nature, and its treatment. Increased sensitivity to the problem of addiction notwithstanding, the misinformation promoted on such popular television programs as Dr. Phil and Oprah does a considerable disservice to addiction science as well as to the addicts themselves. Much of the misinformation may be promoted out of ignorance but some is motivated by commercial interests. The sad fact is that the pain and misery of addiction ‘sells’ and the turmoil of those affected both directly and indirectly is commonly exploited by the popular media: rating points go up as the tissues come out.
Addiction technology transfer attempts to narrow the gap between what is known from the science of addiction and what is commonly practiced in the clinic, promoted on talks shows, and believed by laymen in general. A primary mission of the ASNet is to help narrow this gap through its addiction technology transfer initiative. Indeed, this ‘thread’ is part of that effort. Other efforts include the Addiction Science Network website, university courses, and public lectures. And although this work may seem to have a small impact against the rising tide of tele-psychologists exploiting addiction for rating points, “it’s better to light a single candle than to curse the darkness.” So here’s a flicker of a flame which hopefully contributes to the work of others slowly narrowing the gap between knowledge and ignorance.
Some of the common fallacies promoted by 'talk show' psychologists and other popular media include the following.
Addiction describes any obsession with something that is stronger than the desire most people experience. This type of fixation can occur to almost anything because it is an attribute of the individual and not related to the actual object being desired.
This is one of the most fundamental misunderstandings about addiction and the proper use of this term. There is a wide range of motivational levels individual people express for normal rewards. Being on the upper tail of a normal distribution remains part of that NORMAL distribution. For example, a particularly strong desire to improve ones life by attending college despite personal hardships may be atypical but it is not pathological!Addiction describes a behavioral syndrome where the use of a substance seems to dominate the individual’s motivation and where the normal constraints on the individual’s behavior seem largely ineffective. This is caused by disturbances in normal brain chemistry that can be produced by the use of certain types of drugs (i.e., addictive drugs) and may also occur with the use of some other substances and even with non-chemical rewards in some people predisposed to developing an addiction. It does not involve any kind of psychological fixation caused by arrested psychosexual development in the Freudian sense nor does it involve the same process as that found with obsessive-compulsive disorders. Addiction is distinctively different from normal motivation and from other mental illnesses and therefore merits its own unique classification as a behavioral disorder. The single most prominent feature of addiction is the intense motivation to take the drug, motivation that exceeds the motivational level seen for most natural rewards. Consequential to this is a disruption of the individual’s normal motivational priorities (i.e., motivational toxicity) which is subjectively experienced typically as a sense of “loss of control” over ones own behavior.
Common gateway drugs propel the individual to seeking stronger and stronger psychoactive substances to escape reality or to self-medicate some underlying psychological disorder. Use of marijuana or even tobacco products is a necessary step in developing an addiction and suppressing the use of these substances would prevent most cases of addiction.
A corollary of this premise is that the distinction between hard and soft drugs becomes blurred because soft drugs are actually just one step below the use of hard drugs in the genesis of an addiction. And it also follows that the medicinal use of marijuana is unacceptable (despite its demonstrated effectiveness in certain disorders) because it will lead not only to marijuana addiction but addiction to hard drugs such as cocaine and heroin as well. Of course most people who experiment with hard drugs have first experimented with soft drugs, but this is no reason to assume that soft-drug use was a necessary first step or that it somehow goaded the individual into using hard drugs. (For another example of falsely attributing cause-and-effect from similar data, see The Power of the Blog: We did It—Medical Marijuana is Almost Here!) People who experiment with drugs tend to ‘experiment with drugs!' This leads to an increased likelihood of trying a highly addictive drug and developing an addiction. However, people can easily side-step experimentation with soft drugs and begin experimentation with heroin or cocaine if those are the only drugs available. The use of soft drugs such as marijuana in no way ‘propels’ most individuals into hard drug use. It’s even possible many that people who experiment with soft drugs somehow satisfy some adolescent need to try drugs as an expression of independence and social defiance, and if only hard drugs were available the incidence of drug addiction would be even higher.
This and the following false premise are related to the "denial of brain disorder" problem addressed by ASNet's addiction treatment-facility rating project. Part of the problem may be one of semantics and failing to distinguish drug abuse from drug addiction. But this distinction is often deliberately blurred to incorporate the severe emotional and behavioral turmoil of addiction with simple cases of drug abuse which are more easily remediated.
The notion of the curative power of 'insight' is used to justify the seemingly endless 'psycho-rumination' which discusses over-and-over the addiction in telling emotional terms until the 'flash of light' illuminates the true source of the problem and the desire for drug use stops. There are cases where this type of 'psychotherapy' may be useful, but it has little impact on true drug addiction which has a biological basis.
Most addicts relapse to using drugs. If this were the sole criterion for treatment effectiveness, drug addiction treatment would be deemed ineffective. But effective treatment does increase the time before relapse, and drug addicts often re-enter treatment making progress each time towards eventually remaining drug abstinent for a sufficiently long period to consider the treatment overall effective if not 'perfect.' So treatment does work even though addicts typically relapse, but there's no 28- or 90-day program that magically saves the addict from their addiction. Too many treatment facilities promise unrealistic results and focus on treatment approaches that are known to be ineffective while enhancing the psychodrama aspects of addiction.
On the positive side, the portrayal by tele-psychologists often promotes:
So the question open for comment is:
Do tele-psychologists like Dr. Phil do more harm than good for understanding and treating drug addiction?
And subtopics include specific examples where the popular portrayals of addiction help and hinder a better understanding of this disorder. Of course general comments on "Dr. Phil's [portrayal of] Addiction" are also welcomed.
Wow, just a few days after we clarified our position supporting the medicinal use of marijuana, President Obama has ordered a shift in the Federal marijuana policy consistent with recognizing medical marijuana. The power of the blog is indeed amazing. Who would have thought ASNet would wield such power? Had we any notion that we could provoke such a radical shift in policy, we would have moved our medical marijuana advocacy out of the back pages and into the forefront much sooner. Or did we really have the implied impact?
For those who just can’t dump epidemiological research as a means of inferring causation, take a lesson here. The correlation with our policy announcement is high; others have been publically promoting the medicinal use of marijuana for years without much apparent impact on the Federal government. Within a week and a half of our announcement through the ASNet Discussion Forum, BINGO, marijuana is one giant step closer to being recognized as a legitimate medical treatment at the Federal level—wow! Of course we have advocated that the laws be ‘relaxed’ to recognize medical marijuana use since 2004, but we didn’t promote this position until recently and shortly thereafter the major shift in Federal policy occurred. We must have caused it, right? Well, maybe not. Think about this example the next time you try to infer causation from an epidemiological study. And learn from it.
Lead story: “Attorney general signals shift in marijuana policy” from Associated Press.
After only 5 postings (and two of them hardly count because they are administrative announcements), we have our first ‘oops.’ The “Position Statement on Medical Marijuana” was posted as if it were a significant change in policy when in fact it actually wasn’t anything new. Yes, it should have been obvious to many that the ASNet tacitly supported the medicinal use of marijuana from the mere absence of any mention on the ASNet website of the alleged high addiction liability of marijuana. And yes, those privy to an advanced copy of “Fundamentals of Drug Addiction” are abundantly aware that marijuana is not considered a prototypic addictive drug and in fact not even discussed until over half way through the book. But surely the public announcement endorsing the medicinal use of marijuana was new, wasn’t it? Well, not exactly.
Hidden among the pages of the ASNet website is a page describing the advocacy of rational drug-regulation policy as being an objective of the ASNet. Surprise, surprise—prominently displayed on the corresponding page is a recommendation to “Relax the current Federal laws regarding medicinal marijuana, permitting its use for a limited number of conditions where its psychoactive as well as its clinical effects are beneficial. Follow the progressive lead of several states (e.g., California) and Canada where medicinal marijuana is currently permitted.” The copyright date on that page is 2004.
And now you have the secret as to why the Google AdSense material appears on so many of the ASNet web pages. Google provides real-time counts of visitors to the pages where these advertisements appear. Relax, no tracking information is collected (we wouldn’t know what to do with it if we had it); only the number of page visits to each corresponding page is updated in near real-time and logged for later reference. This helps direct the work on this website to the pages where the most interest is being shown as evidenced by the number of page visits. And of course, we make a few cents when you click on the links provided by the Google Ads (at least I think we do; I’m not really sure because the ‘cash register’ isn’t ringing much). But most importantly, we get feedback and encouragement to resume work on this website which is all the ‘pay’ really needed and perhaps more than sometimes deserved. The previous policy statement was re-discovered when exploring the pages that needed to be ported from the old Addiction Research Unit website hosted by the University at Buffalo. That website has been defunct for some time; it was developed to support the neuroscience research facility which was closed shortly after the start of the “New Millennium.” A number of Addiction Research Unit web pages remain in limbo or as URL markers directing viewers to the phoenix version found on the ASNet.
The nice thing about being a scientist is that one can acknowledge and correct their ‘mistakes.’ Science is said to be ‘self correcting’ in the sense that new evidence or even re-interpretation of existing data often prompts a revision in theory, policy, or simply the assertions promoted by the scientific entity be it an organization or an individual. The ASNet will undoubted have to correct or even recant some statements found on these pages from time-to-time. Hopefully, it won’t happen often, but if the worst ‘oops’ is in the past we certainly would be very, very lucky.
One last note in case you look for this post in the somewhat distant future (tomorrow?). The nice thing about being the blog ‘owner’ is that one gets to rewrite history, to correct the glaring mistakes, to fix to awful omissions and the embarrassing blunders as well, of course, to correct ones position when found to be incorrect. A few snips with the text editor and the reference to “coming out of the closet” (it was a very bad pun anyway ) will be lost forever, and the ASNet will proudly display its position endorsing the use of medicinal marijuana while subtlety mentioning that this position has been publically advocated since 2004.
“The (sometimes absent-minded) Professor”
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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.
The scientific evidence overwhelmingly favors the medical use of marijuana. After ‘sitting on the fence’ for over a decade (i.e., since the beginning of the ASNet), it’s past time to ‘come out of the closet’ (there’s a pun in there somewhere ) and endorse the medical use of marijuana. The evidence has been compelling for a long time; in fact, several Presidential Committees spanning several decades have uniformly concluded that there is substantial evidence for medicinal effects from marijuana, and heightened interest in the past decade has prompted considerable study both empirical and theoretical. The overwhelming conclusion remains the same as purported over three decades ago with added emphasis on decriminalizing small quantities of marijuana for personal use.
Click here to listen to a podcast discussing why it's unlikely that medical marijuana will ever be approved in the United States. (length: 24 minutes)
ASNet drug-regulation policy recommendations and interpretations of extant scientific evidence are generally concordant with the major themes adopted by the National Institute on Drug Abuse (NIDA) and by the mainstream medical community except for two prominent issues: the “nicotine addiction” hypothesis” and “medical marijuana.” ASNet strongly disagrees with the assertion that nicotine is a highly addictive substance comparable to cocaine and heroin and that marijuana is similarly addictive. It further advocates the use of marijuana medicinally for appropriate cases and objects to the continued stigmatization and repressive regulation of tobacco products for use by adults. These two discordant positions are not intended to undermine the staunch support ASNet expresses for most NIDA research and policy recommendations: ASNet remains concordant with NIDA on most other issues and continues to respect the many friends and colleagues working for NIDA’s intramural program and those supported by NIDA’s extramural grant program.
The primary reason for remaining silent on these two issues of discordance with the prevailing government opinion is that both positions seem to discredit each other. That is, the pejorative assertions that “not surprisingly ASNet advocates marijuana use because they encourage tobacco smoking too” or “naturally ASNet disagrees with the idea of nicotine addiction because they also recommend marijuana use.” Of course, both statements are false distortions of our actual position. ASNet simply disagrees with the opinion that nicotine is highly addictive like cocaine and heroin and further disagrees with the opinion that marijuana is similarly highly addictive while advocating medicinal use of marijuana. Nonetheless, adopting both of these positions seems mutually discrediting; therefore ASNet has retained a low profile on the “nicotine addiction” issue and has not previously advocated the use of medical marijuana. With this current policy statement, ASNet now ‘steps forward’ and explicitly supports the medical use of marijuana.
We respect the decision displayed by many of our fellow scientists either working for various government agencies or supported by government grants who find it politically inconvenient to similarly ‘come out of the closet.’ Yes, there are many scientists who concur with the ASNet on both of these topics but fear repercussions should they express their opinions publically. And while we refuse to redefine “integrity” to meet the currently popular usage of this term, we do respect their decision to protect and further their careers. (“Integrity” is traditionally defined as “firm adherence to a code of especially moral or artistic values, incorruptibility [Merriam-Webster’s Online Dictionary].”) After all, it’s only tantamount to the Nazi book burning and not really persecuting any specific group of people; or is it?
The ASNet specifically:
(1.) endorses the medicinal use of marijuana for compassionate use including non-terminal but chronic illnesses such as multiple sclerosis, fibromyalgia, and other conditions involving neuropathic pain unresponsiveness to conventional medications,
(2.) firmly disagrees with the National Institute on Drug Abuse (NIDA), the Food and Drug Administration (FDA), the Drug Enforcement Administration (DEA), and other government agencies that purport marijuana to be a highly addictive substance similar to cocaine and heroin (in fact, we consider this assertion to be particularly irresponsible and call upon these government agencies to soften their rhetoric regarding marijuana and to recognize its actual status as a ‘soft drug’),
(3.) supports the decriminalization of marijuana and applauds progressive state legislative bodies such as that seen in our home state of New York who have already de facto decriminalized marijuana, and
(4.) while not advocating the recreational use of marijuana presently withholds opinion on this popular activity.
However, ASNet does not endorse the legalization of marijuana for the reasons outlined in Bozarth (2009).
For more information, check our webpage on medical marijuana.
[Note: The comments regarding the “nicotine addiction” hypothesis were included in the current policy statement only because this view is a matter of public record (e.g., 1994 FDA testimony transcribed in the Federal Record) that could be used to undermine the current advocacy of medical marijuana through ad hominid attack (e.g., “of course they don’t think marijuana is addictive, they don’t think nicotine is addictive either”). That’s right! But ASNet is not currently prepared to debate this second topic further than the public comments already posted on the subject. We feel that opening one ‘can of worms’ at a time is sufficient controversy and distraction from our overall mission. ]
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