Know what you’re up against!

When someone asks me what to do about a loved one with addiction issues, I usually ask, “What do you know about addiction?” Understanding addiction is a necessary first step in recovering from the grip of this pernicious disease. This knowledge may also help persons avoid falling into the clutches of addiction themselves.

Interestingly, the APA’s diagnostic “bible,” the DSM-IV TR (as of 2010), does not speak of “addiction” per se, but defines “dependence” as (I’m paraphrasing): continued use despite negative consequences.* Since 2014, the newer DSM-V addresses these issues on a continuum, as a variety of Substance Use Disorders, from mild to severe. Again, the word “addiction” is not used.

Dependence, then, is a physical, medical condition evidenced by the maladaptive behaviors that result from changes in the brain. These changes, which come with substance abuse, affect the more primitive parts of the brain, the parts involved in what is called, “The Reward System.” This connects the primitive survival impulse mechanisms (i.e., instinctive urges to eat, drink, sleep, breathe, fight or flee, and procreate) with the decision-making areas of the brain. The problem is, these substances disrupt the brain’s decision-making areas. Once the connection between the Reward Centers and the substance is made permanent (Dependence), the disease has a permanent influence on those primitive impulses and, consequently, the decision-making.

In other words, at a primitive level, from this point forward, the addict’s brain will be screaming, “We’ve gotta have (booze), or we’re gonna die!” The addict can choose to quit using as easily as you can choose to hold your breath for five minutes; the same part of the brain is involved. (Try it; let me know how that works out!)

It happens in the following progression, from Abstinence to Addiction

Abstinence; Use; Abuse; Tolerance; Dependence; Addiction

The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine recognize the following definitions and recommend their use. (Note: these conditions are listed in the opposite order in which they develop in the normal progression of addictive disease – dj)

I. Addiction

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

II. Physical Dependence

Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

III. Tolerance

Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.

*Criteria for Substance Dependence (From DSM-IV TR) A maladaptive pattern of substance use, 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 amounts 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 manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
(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 necessary 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)

Specify if:

With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present)
Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)

Course specifiers (see text for definitions):

Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment

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