Defining addiction, dependence and abuse

From: Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers

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Addiction versus dependence
Substance-related disorders

No clear line indicates when substance use becomes a problem that is severe enough to need treatment. However, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) includes substance-related disorders as one of the classes of mental disorders. Many clinicians use the DSM-IV’s diagnostic criteria for substance abuse and substance dependence to help screen for substance use problems. These criteria are listed below.

Addiction versus dependence

The definitions of “addiction” and “dependence” have evolved over the last few decades, and continue to be debated.

Addiction

Addiction is a primary, chronic, neurobiologic disease with genetic, psychosocial and environmental factors that influence its development and manifestations. It is characterized by behaviours that include one or more of the following:

loss of control over drug use
continued use despite harm
compulsive use and craving.

The four Cs of addiction¹

Feature	Typical statements
Loss of Control over use	“Every time I try to limit my use to only once a week, I end up using every day.” “I try to limit myself to one drink per day but once I start, I can’t seem to stop until I pass out.”
Continued use despite knowledge of harmful Consequences	“I know my drug use caused my HIV but I can’t stop using.” “I have to stop using because my life is out of control, but using is the only option for me.”
Compulsion to use	“All I do is think about how I am going to score.” “No matter what I do, I can’t get drugs out of my mind and I feel I have to use and use a lot. Once I want to use, it is like I am on autopilot and I just have to use. I’ll do anything to get drugs.”
Craving	“It’s like a physical drive or urge to use. I want it from the pit of my stomach; I get sweaty just thinking about it. At times, these urges come out of nowhere, or I get them when I meet my using buddies, pass the corner where my dealer hangs out or am feeling down.”

There are several theories of addiction, but the most compelling one views it as a multifactorial disease caused by predisposing and precipitating factors.² This view describes the disease as the interaction between host (i.e., the person who is addicted to the substance), agent (i.e., the drug) and environmental determinants (i.e., social determinants of health), affected by a vector (e.g., a person or an industry that promotes the drug and/or creates conducive conditions for its increased use and the subsequent harm associated with that use).³ And there is emerging evidence that the neurobiology of addiction provides the basis for understanding why people have great difficulty remaining abstinent, even years after withdrawal is overcome.^4–6

Physical dependence

Physical dependence is often thought to be the thing that defines addiction, but this is not always necessary or sufficient for a diagnosis of substance dependence. Nevertheless, understanding the components of physical dependence is important because discontinuation of some substances requires clinical management. The two related observable phenomena that comprise physical dependence are tolerance and withdrawal.

Tolerance

Tolerance is due to compensatory changes, such as downregulation and desensitization, in the number and sensitivity of central nervous system receptors. Over time, these changes compel a person to take more of the drug to achieve the same effect; or if the person maintains the same level and pattern of consumption, she stops experiencing the desired effect. The time it takes to develop tolerance to the various effects of a given drug differs considerably.

Withdrawal

Withdrawal is a specific syndrome that often begins within a few hours of stopping a drug. This occurs because the downregulation of receptors leads to unstable neurotransmission. These receptors take days or weeks to normalize with abstinence, creating a constellation of symptoms and signs that are opposite to the drug’s main effect.

The acute withdrawal for most drugs starts within a half-life of the drug, peaks within three to five half-lives of the drug and then resolves within a week or two at most; however, this is often followed by intense cravings for the drug, dysphoric mood and other symptoms that can lead to relapse.

Substance-related disorders

The DSM-IV-TR⁷ classifies substance-related disorders as substance use disorders (which are further categorized as either substance dependence and substance abuse) or substance-induced disorders. The criteria for substance use disorders follow.

DSM-IV-TR criteria for substance dependence

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:

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
withdrawal, as manifested by either of the following:
a. the characteristic withdrawal syndrome for the substance . . .
b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
the substance is often taken in larger amounts or over a longer period than was intended
there is a persistent desire or [there are] unsuccessful efforts to cut down or control substance use
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
important social, occupational, or recreational activities are given up or reduced because of substance use
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).

DSM-IV-TR criteria for substance abuse

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for substance dependence for this class of substance.^*

References

Graham, A.W., Schultz, T.K., Mayo-Smith, M.F., Ries, R.K. & Wilford, B.B. (Eds.). (2003). Principles of Addiction Medicine (3rd ed.). Washington, DC: American Society of Addiction Medicine.
Volkow, N.D. & Li, T.K. (2005). Drugs and alcohol: Treating and preventing abuse, addiction and their medical consequences. Pharmacology and Therapeutics, 108 (1), 3–17.
Volkow, N.D. (2005). What do we know about drug addiction? American Journal of Psychiatry, 162 (8), 1401–1402.
Hyman, S.E. (2005). Addiction: A disease of learning and memory. American Journal of Psychiatry, 162 (8), 1414–1422.
Hyman, S.E. & Malenka, R.C. (2001). Addiction and the brain: The neurobiology of compulsion and its persistence. Nature Reviews: Neuroscience, 2 (10), 695–703.
Hyman, S.E., Malenka, R.C. & Nestler, E.J. (2006). Neural mechanisms of addiction: The role of reward-related learning and memory. Annual Review of Neuroscience, 29, 565–598.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Washington, DC: Author.

Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers

General issues and background