Understanding Addiction

1. Characteristics of Addiction

The way that addiction is viewed has changed significantly in many ways over the past decades. At the turn of the 20^th century, people with addictions were viewed as having moral shortcomings and weak willpower and were often separated from society rather than receiving treatment (Herron & Brennan, 2020). Starting in the 1970s, brain imaging studies demonstrated that addictions change the brain, helping dispel the stigma that addiction is a matter of morals and willpower. However, stigma and misconceptions about addictions persist today, with people mistakenly thinking that people can stop addictive behaviors simply by choosing to do so. In reality, addiction is a complex disease of the brain, and quitting an addiction usually takes more than good intentions or willpower. Addictions change the brain in ways that make quitting hard, even for those who are ready and willing to quit.

According to the National Institute on Drug Abuse, addiction is defined as a chronic disease characterized by seeking and use that is compulsive, or difficult to control, despite harmful consequences. More specifically, addictions are characterized by three cycles (Herron & Brennan, 2020):

• In the binge or intoxication stage, the drug or behavior impacts the brain’s reward circuits, creating a high or a sense of euphoria. This promotes feeling good and wanting to keep seeking the drug or behavior as a reward. A drug “high” lasts a short time, ranging from less than an hour to 12 hours, depending on the drug, dose, and route of administration. However, the changes in the brain that result from continued drug use can last much longer.
• In the withdrawal or negative affect stage, systems of the brain become more sensitive to the rewards of the drug or behavior. A person may build tolerance, which happens when repeated use diminishes the brain’s reward response, and the person needs more of the drug or behavior to get the same effect. A person may start to use the drug or behavior not just to feel good but to take away negative feelings, like stress or anxiety.
• In the preoccupation or anticipation stage, the person engages in impulsive and compulsive drug-taking or behavior without regard for the consequences. Trying to stop the drug or behavior causes cravings and a negative emotional state, creating a drive to seek the drug or behavior just to feel normal and functional.

IN CONTEXT

In the lesson titled “Mental Health”, you learned about the value of person-first language in avoiding stigma. This is important in the context of addiction, as stigma can reinforce negative stereotypes and prevent people from seeking treatment (National Institute on Drug Abuse, 2021). Some examples of person-first language in addiction contexts include the following:

• “Person with a substance use disorder” rather than an “addict” or a “drug user”
• “Drug use” or “drug misuse” rather than “drug abuse”
• “Person with an alcohol use disorder” rather than an “alcoholic”
• “Person with a gambling disorder” rather than a “problem gambler”
• “Person in recovery” rather than “a former addict”

terms to know

Addiction

A chronic disease characterized by seeking and use that is compulsive or difficult to control despite harmful consequences.

Tolerance

When a person needs more of the drug or behavior to get the same effect because repeated use has diminished the reward response of the brain.

2. Effects of Addiction on the Brain

The human brain is an extraordinarily complex and fine-tuned communications network made up of billions of cells that govern our thoughts, emotions, perceptions, and drives. Our brains reward certain behaviors such as eating or procreating—registering these as pleasurable activities that we want to repeat. Addiction taps into these vital mechanisms geared for our survival. Although not a life necessity, to a person with an addiction, the addiction becomes life itself, driving compulsive use—even in the face of dire life consequences.

Most drugs or behavioral addictions affect the brain’s “reward circuit” by flooding it with the chemical messenger dopamine. This reward system controls the body’s ability to feel pleasure and motivates a person to repeat behaviors needed to thrive, such as eating and spending time with loved ones. This overstimulation of the reward circuit causes the intensely pleasurable “high” that can lead people to take a drug again and again. Some drugs can cause up to 10 times the amount of dopamine as natural rewards, like eating. As a person continues to use drugs, the brain adjusts to the excess dopamine by making less of it and/or reducing the ability of cells in the reward circuit to respond to it. The person might take more of the drug, trying to achieve the same dopamine high. It can also cause less pleasure from non-drug behaviors, like food or social activities. This reaction sets in motion a reinforcing pattern that “teaches” people to repeat the rewarding behavior of abusing drugs.

Long-term drug use also disrupts the brain circuits involved in memory and control over behavior. Memories of the drug experience can trigger craving as can exposure to people, places, or things associated with former drug use. An area of the brain called the frontal cortical region is responsible for actions such as planning and decision-making, and drug use can affect this region (Herron & Brennan, 2020). The frontal cortical region is also one of the last brain areas to mature, making teenagers particularly vulnerable to the effects of drugs on the brain. The regions of the brain that exert control over desires and emotions are affected when a person has an addiction, compromising their behavior.

key concept

Dependence is characterized by physiological negative effects that occur when a person stops using a drug. These negative effects are called withdrawal. Common withdrawal symptoms include anxiety, insomnia, nausea, vomiting, and diarrhea. However, dependence is not a requirement for a person to have an addiction, and not all types of drugs cause significant negative physiological effects when their use is stopped. The physical symptoms of withdrawal are not mediated by the same areas of the brain involved in addiction (Herron & Brennan, 2020).

terms to know

Dependence

Physiological negative effects that occur when a person stops using a drug.

Withdrawal

Negative effects such as anxiety, insomnia, nausea, vomiting, and diarrhea that occur as a result of drug dependence.

3. Why Addiction Occurs

When does drug use become drug addiction? It rarely happens with the first use of a drug. Drug use and drug addiction can be thought of as points along a continuum. Any use of a mind-altering drug or the inappropriate use of medication (either prescription or over-the-counter drugs) is potentially problematic use, but the point at which this becomes drug addiction is less clear. Different people may reach the point of addiction at different stages, and research is ongoing as to the nature of addiction.

key concept

Drugs that change the brain by altering perception, consciousness, mood, and behavior are termed psychoactive drugs. These are the types of drugs that we typically associate with potentially problematic use and addiction. While a person may take a drug regularly for a chronic condition, like using an inhaler for asthma or injecting insulin for diabetes, not all drugs are psychoactive drugs, and therefore not all drugs have the same type of addiction potential.

No single factor can predict whether a person will become addicted to drugs. The risk for addiction is influenced by a combination of factors that include individual biology, social environment, and age or stage of development. The more risk factors an individual has, the greater the chance that taking drugs can lead to addiction. Consider the following risk factors:

1. Biology. The genes that people are born with––in combination with environmental influences––account for about half of their addiction vulnerability. Additionally, gender, ethnicity, and the presence of other mental disorders may influence the risk for drug abuse and addiction.
2. Environment. A person’s environment includes many different influences, from family and friends to socioeconomic status and quality of life in general. Factors such as peer pressure, physical and sexual abuse, stress, and quality of parenting can greatly influence the occurrence of drug abuse and the escalation of addiction in a person’s life.
3. Development. Genetic and environmental factors interact with critical developmental stages in a person’s life to affect addiction vulnerability. Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it will progress to more serious abuse, which poses a special challenge to adolescents. Because their brains are still developing in the areas that govern decision-making, judgment, and self-control, adolescents may be especially prone to risk-taking behaviors, including trying drugs of abuse.

term to know

Psychoactive Drugs

Drugs that change the brain by altering perception, consciousness, mood, and behavior.

4. Behavioral Addictions

In addition to drugs, behaviors can also promote the qualities of addiction. Research suggests that behaviors that produce the same types of short-term reward effects in the brain can make a person want to continue engaging with the behaviors, even when negative consequences result (Grant et al., 2010). However, the main difference with behavioral addiction is that the person is driven by the feelings associated with the behavior rather than using a substance (Alavi et al., 2012).

Some common types of behavioral addictions are gambling, internet-related addictions such as video gaming or internet use, exercise addiction, shopping addiction, and sex addiction. Doing a behavior regularly because it makes you feel good or is a habit is not an addiction. However, a behavior becomes an addiction when it goes beyond being a habit and becomes an obligation or compulsion, leading to problems functioning in everyday life, such as at work or in social situations (Alavi et al., 2012).

EXAMPLE

Exercise is a positive behavior with many physical and mental health benefits, as you’ve learned. Many people make exercise a daily part of their routine because of these benefits, and some people training for specific goals, like running a marathon, will devote significant amounts of time to exercise, likely sacrificing other activities. However, behaviors begin crossing the line into addiction when the behavior becomes the most important activity in a person’s life, dominating their thoughts, feelings, and behavior, and leading to conflicts with others (Griffiths, 1996). Like drug addiction, the aspects of tolerance and withdrawal can also occur with behavioral addictions.

You’ve learned about the DSM-V as the authoritative resource for diagnosing mental health disorders and sleep disorders, and the DSM-V is also used for diagnoses related to addiction. The DSM-V first recognized gambling disorder as a behavioral addiction but does not officially recognize all the behaviors listed above as behavioral addictions. However, it’s important to consider that even if a behavior doesn’t fit all the criteria for addiction, it can still cause negative effects from being done compulsively. Research on technology use, like the internet and cell phones, explains that technology uses impulses, such as wanting to check email or browse social media (Eyal, 2014). These impulses can then turn into compulsions where we end up spending significant amounts of time on the behavior, detracting from other activities that are worthwhile to us.

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REFERENCES

Eyal, N. (2014). Hooked: How to build habit-forming products. Penguin. ISBN: ‎9781591847786.

Grant, J. E., Potenza, M. N., Weinstein, A., & Gorelick, D. A. (2010). Introduction to behavioral addictions. The American Journal of Drug and Alcohol Abuse, 36(5), 233–241. doi.org/10.3109/00952990.2010.491884

Griffiths, M. (1996). Nicotine, tobacco and addiction. Nature, 384(6604), 18-18. doi.org/10.1038/384018a0

Herron, A.J. & Brennan, T.K. (2020). The ASAM Principles of Addiction Medicine, Third Edition. Wolters Kluwer. ISBN: 9781975107956

National Institute on Drug Abuse. (2021). Words matter: preferred language for talking about addiction. National Institutes of Health. nida.nih.gov/research-topics/addiction-science/words-matter-preferred-language-talking-about-addiction