What is addiction?

There is a great deal of confusion about what constitutes a state of "addiction". The Diagnostic and Statistical Manual of the American Psychiatric Association does not use this term at all. In the DSM, substance abuse problems are divided into two areas:

  • Abuse: Is any maladaptive use or abuse of a substance. Any problem that can be attributed to substance use can be diagnosed as substance abuse.
  • Dependence: Maladaptive use of any substance which also involves biological adaptation to it. Biological adaptation is characterized by three primary clusters of symptoms:
    • Physical dependence - if you experience withdrawal symptoms or discomfort when you stop using a drug, it is likely you have physical dependence.
    • Elevated tolerance - most addicts need more of the substance to get the same effect, or the effect wears off quickly. This may be present early in the course of their addiction, or it may become more apparent as the disease progresses. "He can hold his liquor" is often a sign of high tolerance.
    • Loss of control - this refers to a group of symptoms which suggest that the ability to stop is impaired; the "off" switch just doesn't work properly. This includes such symptoms as drinking more than you intended to, missing responsibilities, giving up other activities because of drug use, etc. In AA they have a saying, "One drink is too many, and a thousand isn't enough"; it is also clear that for many people "just say no" is not really possible.

I generally use the term "addiction" to refer to those with substance dependence, not just abuse.

A few things need to be emphasized about these symptoms.

  • All three of these symptoms appear to have strong biological, genetic roots. They are not signs of poor character, psychological disorders, or weak moral fiber. This is important to understand, as so many people avoid getting help out of shame over their condition.
  • There are many ways that addiction presents itself. Not everyone has all three symptoms. For example, a person with elevated tolerance and physical dependence may never actually get drunk, but they may never go a day without drinking. Another person, who doesn't have physical dependence, may not use cocaine for weeks at a time, but when they do they are unable to stop or limit their use.
  • Addiction is frequently progressive. It tends to get worse over time, especially if one continues to drink or use drugs. Even if you stop for some period of time, the dysfunction is still there.
  • The more severe the addiction, the more likely that complete abstinence from all substances will be necessary for stable recovery.
  • Addiction is a chronic disease. It doesn't go away over time. Like diabetes, it is a chronic condition which requires ongoing responsibility on the part of the patient if he or she is going to lead a stable life. Like diabetes (or asthma or other such diseases) you didn't create it through your behavior, but without doing something about it, your life will gradually go downhill. Also, the recovery rates for most chronic illnesses are similar, and depend on your compliance with a program of recovery.

A significant area of debate has been, "Is addiction a disease?" For many of us, the truth of this statement is obvious. For others, this represents a cop-out, an avoidance of personal responsibility. Again, the more severe the level of the addiction, the more likely that the term "disease" applies. I believe that the term is literally true for those who have substance dependence. For those people, the biological components of the illness are clear and inescapable. For those who have struggled to attain and maintain abstinence and have been unable to do so; for those who are unable to say "no" to that first drink; for those who have been to rehab multiple times - for these people the clear explanation for their disorder is best seen as a disease. And with the acknowledgement of the disease comes a responsibility to do something about it; rather than a cop-out, this acknowledgement requires a commitment to a new way of living and thinking.