What Is Addiction?

Slate's blog, Human Nature, ended its January 28 discussion about smokeless tobacco:

Addiction is a nasty business, deliberately enslaving people while they pretend that they "choose" the product. But if you're going to target that practice, then you'd better come and take all the coffee and Diet Coke from Slate's Washington office....

When I wrote Love and Addiction in 1975, "addiction" meant "heroin." It was outside the envelope to refer to tobacco as addictive, let alone to gambling or sex and love relationships.

No longer. The term "addiction" is up for grabs. The principal diagnostic manual in the United States, called "DSM-IV" (for which I served as an advisor), does not use the terms "addiction" or "alcoholism." Instead, it uses "dependence" for what most people would call "addiction," and "abuse" for lesser, but chronic, substance abuse.

Now, the American Psychiatric Association is engaged in a great civil war in crafting DSM-V, an enterprise that will occupy as much as a decade. The current directors of the agencies charged with studying drugs (the National Institute on Drug Abuse, or NIDA) and alcohol (the National Institute on Alcohol Abuse and Alcoholism, or NIAAA) have both voted for returning the term addiction to DSM-V.

Meanwhile the Vice President of the United States, Joseph Biden, introduced a bill to the Senate which would change the names of the NIDA to the National Institute on Diseases of Addiction, and the name of the NIAAA to the National Institute on Alcohol Disorders and Health. (Okay, so the Veep wants to add addiction to one agency's title, and remove alcoholism from the other -- go figure out Joe's thinking.)

Here are the central questions in bandying these names, and proposed changes, around:

1. Is addiction limited to illicit drugs? Quite clearly, the answer to this one is "no." In the U.S. today, narcotics addicts are more likely to take -- and to die from -- Oxycontin and related painkillers than heroin. The NIDA director, Nora Volkow, has announced that pharmaceuticals are the fastest growing drugs of abuse and addiction. Yet she wants to return to the term addiction in order to rule out dependencies on legitimately prescribed medications. A fine line?

2. Is all illicit drug "use" addictive? In other words, can people use illicit drugs recreationally? The answer to this is also obvious: the government's own National Survey on Drug Use and Health says the vast majority of users of every illicit drug (yes, even crack and heroin) do so occasionally or temporarily.

3. Is all drug abuse addictive? Biden's stupid bill seeks to replace "abuse" in the NIDA's title with addiction. But DSM-IV distinguishes between drug abuse and drug dependence. Indeed, people can even have some problems with drugs without achieving the criteria for being drug abusers. So, hold your heads: there is drug use, problematic drug use, full-scale drug abuse, and drug dependence. Is it possible that drug use forms a continuum -- like you see in all areas of human behavior?

4. What about smoking, coffee, cola drinks, and sugar? Everyone now regards smoking as an addiction. What does everyone think about coffee and colas (caffeine-based drinks)? Well, we know those radicals over at Slate think they're addictive. Wonder where they got that idea? What about all those anti-sugar kooks -- do they have a point about that substance's addictiveness?

Now for the tough question:

5. Can activities other than substance use be addictive? The NIDA isn't really about addiction -- it's about drugs. The government wants Volkow and her colleagues investigating cocaine -- okay, maybe Oxycontin -- but not eating, shopping, video games, sex, and love! Can any of the latter be addictive? I have argued that by standard criteria -- such as difficulty of quitting -- destructive love affairs are the worst addictions.

Here's my definition of addiction:

Addiction is a compelling, destructive involvement that -- because it detracts from other areas of people's lives -- forces them to rely with greater exclusivity on the addictive experience they get from the involvement, whether with drugs or anything else.

So are we ready to have a National Institute on Addiction and a DSM-V that deal with destructive involvements with pharmaceuticals, coffee, colas, video games, and love? This development at the same time requires us to draw the distinction between healthy -- or at least not unhealthy -- involvements with drugs and everything else that fails to qualify as addictive. And, of course, this still leaves us to disapprove of and to punish antisocial behavior, even if addictive, on the principle that people always have the option of quitting or controlling their actions.

Or are we just going to fiddle-faddle re-arranging the objects of our concern on that great addictive ship -- America?

Comments

[Michael Burke]

It seems to me your definition could cloud our understanding of addiction and addictive behaviors rather than add clarity. Two specific problems
1. The word destructive does not help with diagnosis or non-biased assessment of behavior. A cigarette smoker who needs to run to the convenience store to get his cigarette is not judged as behaving destructively like a person who needs to run downtown to the dealer to cop heroin. Legal and other societal persepectives all impinge upon how we evaluate destructiveness. Smoking cigarettes is more destructive to health by 100's of magnitudes compared with drinking coffee. Will cigarettes be seen as much more addicting because of this? Perceptions and misperceptions about comparitive destructiveness abound.
2. How does your definition distinguish addiction from obsessive compulsive behaviors like hand washing, or phobias like being unable to leave the home, or for that matter the increasingly morose inclinations of someone falling into a deep depression.
Definitions and diagnosis are important to helping understand etiology and to selecting effective treatments. while good balance, mental hygiene and social engagement can help general with many problems from coronary artery disease to schizophrenia, this doesn't mean that these problems should be identified as having similar etiologies and treatments.

[wendy82551]

Great article; I've read one of your books. It was like a breath of fresh air in a field rife with ideology and superstition.

It seems to me that it boils down to this: some habits are easy to break, and some habits are very, very difficult to break. The more we learn about the science of the mind, the more we realize that we are complex machines. Willpower isn't enough any more; relying on certain behaviors or substances alters our brain chemistry in complex ways. But the bottom line is that there's nothing magical about alcoholism versus nail biting: they're both habits that can be broken, not some kind of mysterious disease.

I'm not saying that it's not really, really hard, breaking bad habits. I'm just not particularly interested in "medicalizing" the process and involving the government in that whole process.