The term—and concept of—“addiction” is regularly frowned upon or even attacked by people in our field. But it won’t disappear, nor should it. There are four groups or schools of thought that de-emphasize or disparage “addiction.” And their reasons for doing so all have value.
Psychiatry in the latest DSM-5 claims it didn’t want to stigmatize people with the term “addiction”, so it completely muddled the difference between doing something regulated and appropriate on a regular basis (taking prescription opioids) versus binging on street drugs (heroin, amphetamines, cocaine), becoming addicted, and ending up overdosing.
The American Psychiatric Association’s diagnostic manual, DSM (as well as its international equivalent, the International Classification of Diseases or ICD), doesn’t use the term addiction (except in a single instance, as we’ll see). Indeed, the current editions of DSM (DSM-5) and ICD (ICD-11) don’t even use the term “dependence” with substances.
At the same time, major forces in psychiatric thinking (including the head of the National Institute on Drug Abuse, Nora Volkow) wish to make clear that people who rely on long-term medication (i.e. “depend” on it) should not receive pejorative labels like “dependent” or “addicted” (think insulin, or even painkillers).
Epidemiologists are concerned with public health consequences, not with clinical classifications.
With illicit drug use, along with problems similar to those that occur with alcohol, infections caused by contaminated syringes and deaths caused by combining drugs are similarly separate from drug addiction, if overlapping.
Focusing on reducing population-level harms is valuable. It also means that, for epidemiologists, addiction is a sideline interest at best, and a diversion at worst.
Likewise, social epidemiologists dismiss drug addiction entirely as a matter of choice, or even mock it as a “pharmacological version of the belief in demon possession that has entranced western culture for centuries.”
This far-reaching movement based on drug users’ self-empowerment interprets substance use and any accompanying problems or disorders in functional terms.
Harm reduction pioneers, such as Patt Denning and Jeannie Little in their book Over the Influence (2017), portray people who use drugs problematically as individuals making human attempts to lead satisfying lives—including integrating various substances into those lives—with different degrees of success.
And let’s not forget that drug use, even if illicit, does not always cause problems. And that most people “age out” of the abuse of drugs as they get older and have more responsibilities.
If what they say about opioids being so extremely addictive were true, we’d have at least half the population addicted, considering how many of us require some small surgery or suffer some painful injuries for which a short course of opioids is prescribed.
More and more data is showing that:
- Opioids are not inherently addictive (people have the addiction, not the drugs)
- Only 1-3% of people become addicted after exposure (using a prescription opioid for weeks to months to years)
- Overdoses are the result of illicit drugs or abusing drugs, not taking prescribed drugs as directed.
My Case for Addiction
Substance use is a problem only when it causes problems.
Reading the paper and drinking coffee aren’t in themselves addictions, or even problems. By the same token, neither is drinking alcohol or taking heroin.
DSM expresses this approach by assessing SUDs and their severity solely through summing the problems they cause for a person. Such problems are not a simple function of the amount of a substance used.
If no notable problems accompany drug use, then an SUD diagnosis isn’t warranted.
Beyond this, mild or moderate problems with a substance mean the person has a SUD, but not a severe one. But there is no clear demarcation point separating these diagnoses.
DSM-5 has created the category “Substance-Related and Addictive Disorders,” implying that these are two separate entities. This distinction between substance-related and addictive disorders is untenable, and will not survive the test of time.
Instead, addiction must be defined as an involvement of any type in which people compulsively engage despite serious negative impacts for them. The criteria for this diagnosis can be built on the current DSM substance-use disorder criteria, without anchoring them to specific substances or activities.
Why do so? Because this model is accurate and useful, as demonstrated by precisely analogous causes, behavioral patterns and harms
That is to say, those addicted both to sex-love and to drugs seek emotional comfort and self-acceptance through repetitive, constant stimulation while losing sight of, and damaging, other activities and relationships.
Ultimately, addiction should be retained as a concept for three main reasons.
- First, people “get” it. Virtually everyone in the Western world understands the meaning of the term as a compulsive, damaging entanglement.
And, when not influenced by disease thinking, people very often have a common-sense notion that we are driven to addiction due to
- negative emotional states,
- deprived lives and environments, and
- the absence of other, meaningful rewards in our worlds.
- Second, it implies the need for important real-world change.
Applying addiction to all damaging compulsions—including behaviors (love, eating) that we cannot eliminate from our lives—makes clear that drug demonizing and prohibition are illogical responses to drug addiction.
- And, third, the inclusivity of the term emphasizes that those of us who have not experienced drug addiction have nevertheless experienced addiction somewhere in our lives (just ask people you know), militating against attitudes and policies that isolate and vilify drug users.
Addiction can reach severe depths whenever, despite extreme negative consequences—health harms and risks, social isolation, the exclusion of other meaningful endeavors—the person is unable to quit repeating a behavior.
This recognition ultimately dictates that the treatment path and prevention techniques for addiction lie in creating more fulfilling lives for individuals—and taking action to encourage these societal changes.
When the focus in addiction thus shifts from the substance to the nature of people’s involvements; when it includes an understanding that addiction is not a distinctive all-or-nothing biological state; when it recognizes that, at its heart, addiction is an existential journey, then we will no longer need to fear, loathe or punish human beings who use drugs or who experience addiction.
Only then can we envision ways to overcome and prevent addiction through helping people to find purpose, develop skills and open life opportunities for themselves. Our currently dominant disease view of addiction, in the meantime, offers no inkling of how to do this and only exacerbates our problems.