Addiction and google affiliate

"Addictive" redirects here. For other uses, see Addictive (disambiguation).
This article is about the concept of addiction. For other uses, see Addiction (disambiguation).
"-holic" and "-holism" redirect here. For the suffixes themselves, see -holic and -holism in Wiktionary. For the unrelated complete word, see Holism.


Bottle of heroin, an addictive drug

An addiction is a persistent behavioral pattern marked by physical and/or psychological dependency that causes significant disruption and negatively impacts the quality of life of an organism. Addictions are frequently linked to substance abuse, particularly psychoactive drugs such as narcotics, stimulants, and sedatives among others. It is common in coloquial English usage to extend the use of the term "addiction" to also encompass apparent compulsive behavior and passionate dedication to activities (such as hobbies) by analogy.


In medicine, an addiction is a chronic neurobiological disorder that has genetic, psychosocial, and environmental dimensions and is characterized by one of the following: the continued use of a substance despite its detrimental effects, impaired control over the use of a drug (compulsive behavior), and preoccupation with a drug's use for non-therapeutic purposes (i.e. craving the drug).[1]

Tolerance to a drug and physical dependence are not defining characteristics of addiction, although they typically accompany addiction to certain drugs. Tolerance is a pharmacologic phenomenon where the dose of a medication needs to be continually increased in order to maintain its desired effects.[2] For instance, individuals with severe chronic pain taking opiate medications (like morphine) will need to continually increase the dose in order to maintain the drug's analgesic (pain-relieving) effects. Physical dependence is also a pharmacologic property and means that if a certain drug is abruptly discontinued, an individual will experience certain characteristic withdrawal signs and symptoms.[2] Many drugs used for therapeutic purposes produce withdrawal symptoms when abruptly stopped, for instance oral steroids, certain antidepressants, benzodiazepines, and opiates.

However, common usage of the term addiction has spread to include psychological dependence.[citation needed] In this context, the term is used in drug addiction and substance abuse problems, but also refers to behaviors that are not generally recognized by the medical community as problems of addiction, such as compulsive overeating.

The term addiction is also sometimes applied to compulsions that are not substance-related, such as problem gambling and computer addiction. In these kinds of common usages, the term addiction is used to describe a recurring compulsion by an individual to engage in some specific activity, despite harmful consequences, as deemed by the user himself to his individual health, mental state, or social life.

Not all doctors agree on the exact nature of addiction or dependency [3] however the biopsychosocial model is generally accepted in scientific fields as the most comprehensive model for addiction. Historically, addiction has been defined with regard solely to psychoactive substances (for example alcohol, tobacco and other drugs) which cross the blood-brain barrier once ingested, temporarily altering the chemical milieu of the brain. However, "studies on phenomenology, family history, and response to treatment suggest that intermittent explosive disorder, kleptomania, problem gambling, pyromania, and trichotillomania may be related to mood disorders, alcohol and psychoactive substance abuse, and anxiety disorders (especially obsessive–compulsive disorder)."[4] However, such disorders are classified by the American Psychological Association as impulse control disorders and therefore not as addictions.

Many people, both psychology professionals and laypersons, now feel that there should be accommodation made to include psychological dependency on such things as gambling, food, sex, pornography, computers, work, exercise, spiritual obsession (as opposed to religious devotion), pain [1], cutting and shopping so these behaviors count as 'addictions' as well and cause guilt, shame, fear, hopelessness, failure, rejection, anxiety, or humiliation symptoms associated with, among other medical conditions, depression and epilepsy.[5][6][7][8] Although, the above mentioned are things or tasks which, when used or performed, do not fit into the traditional view of addiction and may be better defined as an obsessive–compulsive disorder, withdrawal symptoms may occur with abatement of such behaviors. It is said by those who adhere to a traditionalist view that these withdrawal-like symptoms are not strictly reflective of an addiction, but rather of a behavioral disorder. However, understanding of neural science, the brain, the nervous system, human behavior, and affective disorders has revealed "the impact of molecular biology in the mechanisms underlying developmental processes and in the pathogenesis of disease".[9] The use of thyroid hormones as an effective adjunct treatment for affective disorders has been studied over the past three decades and has been confirmed repeatedly.[10] Modern research into addiction is generally focused on Dopaminergic pathways. There is great and sometimes heated debate around the definition of addiction with parties falling into two main camps the Disease model of addiction and the behaviorists, explanations of various models can be found in the article on Drug rehabilitation.
[edit] Signs and symptoms
[edit] Varied forms of addiction

In the United States, physical dependence, abuse of, and withdrawal from drugs and other substances is outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR). It does not use the word 'addiction' at all. It has instead a section about Substance dependence:

"Substance dependence When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. This, along with Substance Abuse are considered Substance Use Disorders..."[11]

Terminology has become quite complicated in the field. Pharmacologists continue to speak of addiction from a physiologic standpoint (some call this a physical dependence); psychiatrists refer to the disease state as psychological dependence; most other physicians refer to the disease as addiction. The field of psychiatry is now considering,[citation needed] as they move from DSM-IV to DSM-V, transitioning from "substance dependence" to "addiction" as terminology for the disease state.

The medical community now makes a careful theoretical distinction between physical dependence (characterized by symptoms of withdrawal) and psychological dependence (or simply addiction). Addiction is now narrowly defined as "uncontrolled, compulsive use"; if there is no harm being suffered by, or damage done to, the patient or another party, then clinically it may be considered compulsive, but to the definition of some it is not categorized as 'addiction'. In practice, the two kinds of addiction are not always easy to distinguish. Addictions often have both physical and psychological components.

There is also a lesser known situation called pseudo-addiction.[12] A patient will exhibit drug-seeking behavior reminiscent of psychological addiction, but they tend to have genuine pain or other symptoms that have been under-treated. Unlike true psychological addiction, these behaviors tend to stop when the pain is adequately treated. The obsolete term physical addiction is deprecated, because of its connotations. In modern pain management with opioids physical dependence is nearly universal. While opiates are essential in the treatment of acute pain, the benefit of this class of medication in chronic pain is not well proven.[citation needed] Clearly, there are those who would not function well without opiate treatment; on the other hand, many states are noting significant increases in non-intentional deaths related to opiate use.[citation needed] High-quality, long-term studies are needed to better delineate the risks and benefits of chronic opiate use.[citation needed]
[edit] Physical dependency

Physical dependence on a substance is defined by the appearance of characteristic withdrawal symptoms when the substance is suddenly discontinued. Opiates, benzodiazepines, barbiturates, alcohol and nicotine induce physical dependence. On the other hand, some categories of substances share this property and are still not considered addictive: cortisone, beta blockers and most antidepressants are examples. So, while physical dependency can be a major factor in the psychology of addiction and most often becomes a primary motivator in the continuation of an addiction, the initial primary attribution of an addictive substance is usually its ability to induce pleasure, although with continued use the goal is not so much to induce pleasure as it is to relieve the anxiety caused by the absence of a given addictive substance, causing it to become used compulsively.

Some substances induce physical dependence or physiological tolerance - but not addiction — for example many laxatives, which are not psychoactive; nasal decongestants, which can cause rebound congestion if used for more than a few days in a row; and some antidepressants, most notably venlafaxine, paroxetine and sertraline, as they have quite short half-lives, so stopping them abruptly causes a more rapid change in the neurotransmitter balance in the brain than many other antidepressants. Many non-addictive prescription drugs should not be suddenly stopped, so a doctor should be consulted before abruptly discontinuing them.

The speed with which a given individual becomes addicted to various substances varies with the substance, the frequency of use, the means of ingestion, the intensity of pleasure or euphoria, and the individual's genetic and psychological susceptibility. Some people may exhibit alcoholic tendencies from the moment of first intoxication, while most people can drink socially without ever becoming addicted. Opioid dependent individuals have different responses to even low doses of opioids than the majority of people, although this may be due to a variety of other factors, as opioid use heavily stimulates pleasure-inducing neurotransmitters in the brain. Nonetheless, because of these variations, in addition to the adoption and twin studies that have been well replicated, much of the medical community is satisfied that addiction is in part genetically moderated. That is, one's genetic makeup may regulate how susceptible one is to a substance and how easily one may become psychologically attached to a pleasurable routine.

Eating disorders are complicated pathological mental illnesses and thus are not the same as addictions described in this article. Eating disorders, which some argue are not addictions at all, are driven by a multitude of factors, most of which are highly different than the factors behind addictions described in this article. It has been reported, however, that patients with eating disorders can successfully be treated with the same non-pharmacological protocols used in patients with chemical addiction disorders.[13] Gambling is another potentially addictive behavior with some biological overlap. Conversely gambling urges have emerged with the administration of Mirapex (pramipexole), a dopamine agonist.[14]

The DSM definition of addiction can be boiled down to compulsive use of a substance (or engagement in an activity) despite ongoing negative consequences—this is also a summary of what used to be called "psychological dependency." Physical dependence, on the other hand, is simply needing a substance to function. Humans are all physically dependent on oxygen, food and water. A drug can cause physical dependence and not addiction (for example, some blood pressure medications, which can produce fatal withdrawal symptoms if not tapered) and can cause addiction without physical dependence (the withdrawal symptoms associated with cocaine are all psychological, there is no associated vomiting or diarrhea as there is with opioid withdrawal).

In the now outdated conceptualization of the problem, psychological dependency leads to psychological withdrawal symptoms (such as cravings, irritability, insomnia, depression, anorexia, etc). Addiction can in theory be derived from any rewarding behaviour, and is believed to be strongly associated with the dopaminergic system of the brain's reward system (as in the case of cocaine and amphetamines). Some claim that it is a habitual means to avoid undesired activity, but typically it is only so to a clinical level in individuals who have emotional, social, or psychological dysfunctions (psychological addiction is defined as such), replacing normal positive stimuli not otherwise attained.

A person who is physically dependent, but not psychologically dependent can have their dose slowly dropped until they are no longer physically dependent. However, if that person is psychologically dependent, they are still at serious risk for relapse into abuse and subsequent physical dependence.

Psychological dependence does not have to be limited only to substances; even activities and behavioural patterns can be considered addictions, if they become uncontrollable, e.g. problem gambling, Internet addiction, computer addiction, sexual addiction / pornography addiction, overeating, self-injury, compulsive buying, or work addiction.
[edit] Management

Early editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) described addiction as a physical dependency to a substance that resulted in withdrawal symptoms in its absence. Recent editions, including DSM-IV, have moved toward a diagnostic instrument that classifies such conditions as dependency, rather than addiction. The American Society of Addiction Medicine recommends treatment for people with chemical dependency based on patient placement criteria (currently listed in PPC-2), which attempt to match levels of care according to clinical assessments in six areas, including:

* Acute intoxication and/or withdrawal potential
* Biomedical conditions or complications
* Emotional/behavioral conditions or complications
* Treatment acceptance/resistance
* Relapse potential
* Recovery environment

Some medical systems, including those of at least 15 states of the United States, refer to an Addiction Severity Index[15] to assess the severity of problems related to substance use. The index assesses problems in six areas: medical, employment/support, alcohol and other drug use, legal, family/social, and psychiatric.

While addiction or dependency is related to seemingly uncontrollable urges, and arguably could have roots in genetic predispositions, treatment of dependency is conducted by a wide range of medical and allied professionals, including Addiction Medicine specialists, psychiatrists, psychologists, and appropriately trained nurses, social workers, and counselors. Early treatment of acute withdrawal often includes medical detoxification, which can include doses of anxiolytics or narcotics to reduce symptoms of withdrawal. An experimental drug, ibogaine,[16] is also proposed to treat withdrawal and craving. Alternatives to medical detoxification include acupuncture detoxification. A wide variety of controlled clinical trials, outcome summaries and anecdotal reports about the use of acupuncture in addiction treatment have been appearing since the 1970s in journals specializing in addictions, mental health, public health, criminal justice and acupuncture. These reports differed vastly in terms of methodology, populations studied, statistical sophistication and clinical relevance as well as in their findings about the value of acupuncture. A sub-category of this published work has focused specifically on acupuncture detoxification. Neurofeedback therapy has shown statistically significant improvements in numerous researches [2] conducted on alcoholic as well as mixed substance abuse population. In chronic opiate addiction, a surrogate drug such as methadone is sometimes offered as a form of opiate replacement therapy. But treatment approaches universal focus on the individual's ultimate choice to pursue an alternate course of action.

Therapists often classify patients with chemical dependencies as either interested or not interested in changing. Treatments usually involve planning for specific ways to avoid the addictive stimulus, and therapeutic interventions intended to help a client learn healthier ways to find satisfaction. Clinical leaders in recent years have attempted to tailor intervention approaches to specific influences that affect addictive behavior, using therapeutic interviews in an effort to discover factors that led a person to embrace unhealthy, addictive sources of pleasure or relief from pain.
Treatment Modality Matrix
Behavioral Pattern Intervention Goals
Low self-esteem, anxiety, verbal hostility Relationship therapy, client centered approach Increase self esteem, reduce hostility and anxiety
Defective personal constructs, ignorance of interpersonal means Cognitive restructuring including directive and group therapies Insight
Focal anxiety such as fear of crowds Desensitization Change response to same cue
Undesirable behaviors, lacking appropriate behaviors Aversive conditioning, operant conditioning, counter conditioning Eliminate or replace behavior
Lack of information Provide information Have client act on information
Difficult social circumstances Organizational intervention, environmental manipulation, family counseling Remove cause of social difficulty
Poor social performance, rigid interpersonal behavior Sensitivity training, communication training, group therapy Increase interpersonal repertoire, desensitization to group functioning
Grossly bizarre behavior Medical referral Protect from society, prepare for further treatment
Adapted from: Essentials of Clinical Dependency Counseling, Aspen Publishers

From the applied behavior analysis literature and the behavioral psychology literature several evidenced based intervention programs have emerged (1) behavioral maritial therapy (2) community reinforcement approach (3) cue exposure therapy and (4) contingency management strategies.[17][18] In addition, the same author suggest that Social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious.