What Is Addiction?

“Addiction is grieving for the person who has been lost, hating the person you have become and feeling powerless to change.” ~ Belinda Tobin

Excerpt from the upcoming book ‘Addiction Is a Symptom’

Gosh it would be nice to be able to give you an absolute answer to this. I wish there was one consistent understanding across medical and social communities that could be used to focus policy and treatment approaches. However, what you soon realise when you delve into the world of addiction is that there are many different perspectives, all formed from very different levels of personal experience and areas of specialty. While I am sure that each area is seeking the best for those with addiction, this separation of effort is certainly not helpful for the [1]:

· 240 million people across the world suffering from alcohol use disorder

· 1 billion people on this planet addicted to tobacco

· 15 million people across our communities who inject unsanctioned drugs

· 1.5% of the world’s population addicted to gambling (which represents 5 million people in the US alone).

Even more alarmingly, the kinds of things people are addicted to are expanding. While numbers are hard to come by, it was reported in in 2017, that an estimated 18 million people (more than 6 percent of those aged 12 and older) misused such prescription medications such as opioids, sedatives or stimulants at least once in the past year [2]. Reports are also being published about addictions to sex and food.

In 2019 the UK’s first internet-addiction clinic opened. In the United States it is estimated that 8% of the population is addicted to the internet, which equates to over 26 million people. And the World Health Organization (WHO) has now included gaming disorder in its official list of addictions. The diagnosis for internet addiction is 6 hours a day of non-essential internet use and symptoms that have been occurring for at least 3 months.

But it gets even worse. The age of addiction is decreasing dramatically. In South Korea alone it is reported that there are at least 160,000 children aged 5 to 9 who are addicted to the internet. In Japan, there are an estimated 500,000 children aged from 12 to 18 who are addicted. And in China, approximately 10% 0r 14.5 million teenagers meet the criteria for internet addiction [3].

The definition of being addicted is being

“Physically and mentally dependent on a particular substance”.[4]

But it appears from the above information we can certainly now expand this definition of addiction to not only include a substance, but a thing or an activity as well.

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Current Viewpoints on Addiction

What the hell is going on? I thought we were meant to be the smart species. It seems like the more things we create to provide pleasure, the more things we are creating to become addicted to. It seems like everything we create to provide enjoyment is becoming a tool of pain and suffering. More importantly, why as we get cleverer scientifically, medically and technologically, are we seeing the and increase in addiction? It surely suggests we are missing a fundamental part of the addiction picture. Let’s see the pros and cons of the three most prevalent answers to what addiction is. I know this may be a bit boring, but if you are a loved one is going through treatment for addiction, it is really important to know the view that the people helping you have. Their view of what addiction is will determine the program they are recommending. Or, if you are still yet to seek professional help, it will you be a more informed consumer of the many addiction services and treatments available out there.

Addiction as a Choice

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The definition of choice is

“an act of choosing between two or more possibilities.”[5]

So technically this is correct. From an external vantage point, it would seem that a person has the ability to select to drink or not to drink. To buy the cigarettes, or not to buy the cigarettes. To pop the pill, or not to pop the pill. To pick up the device or not to walk away from the device. Certainly this was the viewpoint of Victor Frankl (psychiatrist and holocaust survivor) when he said:

“Between the stimulus and the response is a space, and in that space is your power and your freedom.”

Photo by Jon Tyson on Unsplash

This quote is so very powerful and incredibly inspirational but does not relate to the physical realities of addiction. As we will see when we being to discuss addiction as a brain disease, behaviours become hard-wired in the brain. At this point they become automatic and subconscious, and as a result, this space that Victor Frankl mentions either ceases to exist or becomes so marginal that it is almost invisible. It is not only the mind that desires what the substance or activity delivers, but the body and brain have become dependent upon it.

I think it is very difficult for anyone who has not experienced addiction to understand the pull, the craving, the obsession that becomes ingrained in the body and brain. But even more so the desire from the heart for relief from both mental pain and physical anguish.

The reality is that in addiction, the circuits in the brain that normally help us make good choices and exert our free will don’t function like they should. The space no longer exists to make logical decisions [7].

Despite the evidence some people still think that this talk about brain science is just an excuse to continue the selfish and self-destructive behaviour. I do wish it was that simple. But from my own experience, until I understood more about the impacts on the brain my inability to put my children ahead of alcohol was a constant source of shame and guilt. And this is the downside I see to this approach. In seeing addiction as a choice, it then implies that ‘addicts’ have less moral fibre and character strength than others. It suggests that ‘addicts’ are weak and selfish. These judgements on a person do nothing but keep a person down in despair and hopelessness.

The only benefit to this viewpoint is the way in which it does instil a sense of personal power and responsibility. This is an incredibly important part of healing, but only when the person is physically and mentally able to take on this responsibility and able to make conscious choices and logical decisions. You wouldn’t expect someone just recovered from cancer to get out and run a marathon. So in the same way you wouldn’t expect someone who’s decision-making ability has been compromised to immediately be able to make great decisions! I do see there is a time and a place, and some benefit to the choice model, but I don’t see it as the first step in understanding or treating the cause and effect of addiction. My reasons for this view will become more apparent through the following discussions of addiction as a disease and mental disorder.

Addiction as a Chronic Brain Disease

The great news for treatment of addiction is that there is overwhelming consensus that addiction

· Is a function of brain activity; and

· creates changes in the brain.

While the actual interplay of hormones and circuitry in the brain is very complex, addiction, very simply is supported physically by the ‘feel good’ hormone dopamine and becomes hard-wired into the brain by neuroplasticity.

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Photo by Josh Riemer on Unsplash

Here is my very basic explanation of the brain science. When you do something that gives you a good feeling, the dopamine system in the brain is turned on. Humans are pleasure-seeking creatures, and so our brains will release the hormone dopamine again as a motivator to get you to do the same activity. The more you repeat the activity, the stronger the connections become in the brain. If the activity continues to be repeated then it gets hard-wired in the brain, and through an effect called automaticity, you are soon doing this activity without even thinking about it. This effect is compounded as the tolerance level for the substance increases, and the person needs more and more to achieve the same result. The fact is in addiction changes occur in the brain that reinforce and escalate the addiction. This is the reason that some people see addiction as a brain disease.

The definition of a disease is:

“A disorder of structure or function in a human that produces specific symptoms or that affects a specific location and is not simply a direct result of physical injury”.[8]

In the case of addiction as a chronic brain disease, it is argued that the:

· specific location is the brain

· disorder is the associated neurobiological changes in the brain that create dependence and

· the symptoms are craving and withdrawal.

I was first introduced the disease model during one of my inpatient stays in rehab. We watched a movie called “Pleasure Unwoven” which presents a wonderful insight to the way the brain changes through addiction, and how addiction can be classified as a disease. After watching this movie I was so very relieved. It was like a huge burden had been taken off my shoulders. I was not a bad person; I had a brain disease!

This is one of the real benefits of the disease approach to addiction. It certainly does take away some of the stigma, but more importantly judgement associated with it. It also allows you to get some personal distance from the addiction — I am not addicted, my brain is. I know it sounds a bit silly, but when you are in the throws of the trauma and shame that comes with addiction, any distance and perspective is helpful.

This view also helps focus efforts and energy. OK, so what do I have to do to get my brain better?

Thinking of addiction as a disease also helped me understand the role of medication. Knowing the extent of chemical and structural damage that is done to the brain, I could appreciate that at least in the short-term some medication might be needed to restore proper balance and function — to ‘speed up’ if you like the process of brain repair.

In the United States there is no system of free or subsidised health care. To get a treatment covered by health insurance there needs to be a definable illness. Having addiction defined as a chronic brain disease is essential to enable access to assistance by the millions of Americans battling with addiction. I really don’t see the issue with it being called a disease if means people get the help they need.

But the disease model has its limitations. You can’t just burn off, cut out or medicate away addiction. The fact is it has become ingrained in the brain through weeks months and years of repeated behaviour. If you don’t get to the cause of the action in the first place, then there is the real risk that the behaviour will occur again, and before you know it you are back in rehab dealing with the same problems. While addiction may be a disease in itself, it is an ‘end-game’. It is caused by something else, something deeper. What is driving the search for the escape, relaxation, the pleasure, the stimulation in the first place? Treating addiction just as a disease does not get to the bigger picture and real cause of the addiction.

It is also argued that the disease model of addiction demoralises people and turns them into helpless, powerless patients. I can see this point, and if this was the only approach, I was offered I think I would feel a bit like a lab rat. I need to be recognised as a whole person and have my body, mind and spirit recognised and respected. I do want to feel like I am creating and shaping my own life, and not a slave to a regimen of psychiatry visits and medication rituals. And yet, the disease model does have its place, and it does have benefits.

Addiction as a Mental Disorder

While the brain disease view of addiction concentrates on the structural changes in the brain, the mental illness view of addiction expands to work with the thoughts, feelings and behaviours that contribute to, and result from the addiction. According to the World Health Organization, a disorder is:

“ generally characterized by some combination of abnormal thoughts, emotions, behaviour and relationships with others”.[9]

Substance use abuse and dependence are then listed as a mental disorder.

DSM is the standard classification of mental disorders in the United States and DSM-5 contains the criteria for what constitutes a substance use disorder. Substance use disorders are classified as mild, moderate, or severe, depending on how many of the diagnostic criteria a person meets. The 11 DSM-5 criteria for a substance use disorder are:[10]

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  1. Hazardous use
  2. Social or interpersonal problems related to use
  3. Neglected major roles to use
  4. Withdrawal
  5. Tolerance
  6. Used larger amounts
  7. Repeated attempts to control use or quit
  8. Much time spent using:
  9. Physical or psychological problems related to use:
  10. Activities given up to use:
  11. Craving

Photo by averie woodard on Unsplash

While the diagnostic criteria for this mental disorder are based around observable and objective behaviours of the patient, the treatment approach is a bit more holistic. As a mental illness, treatment programs also attend to the emotional instability and dysfunctions that are associated. A mental disorder approach to addiction may see a combination of:

· Psychiatry to address the physical brain changes and imbalances and treat with medication

· Psychology to help work through and correct unhelpful emotional or thought patterns that could be keeping the person stuck in addiction.

A popular therapy used for many mental disorders is Cognitive Behavioural Therapy (CBT). As the name suggests, CBT works with thoughts as the key driver of addictive behaviour. It seeks to correct faulty ways of thinking that are leading to the substance use and abuse and create more helpful and healthy patterns of thinking and behaviour. It does this by working through the following behaviour model.

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The CBT Model

Figure 1 — The CBT Model

The continued substance use is the behaviour that is targeted for change. To do this, the CBT therapist works with the person to understand the feelings that are driving the behaviour, the thoughts that are driving the feelings and the beliefs underlying the thoughts. And So this is where seeing addiction as a mental disorder has its benefits. Treating addiction as a mental disorder then is much more respectful for the patient as a whole person, and the context in which they are living. It helps them deal constructively with the situation they are in and gives them the tools to continue to help themselves in the future.

The downside of this approach though is the stigma that comes along with being seen as mentally ill. Although, slowly, as more people share their experiences, mental disorders are becoming less a source of shame, and more a celebration of resilience.

Addiction as Deep Learning

The latest viewpoint on addiction concentrates on the results bubble in the CBT model. Professor Marc Lewis believes that the result or goal that people are seeking is the most important part, and people learn the most effective and efficient way to get what they want [11]. To tackle the problem, Professor Lewis concentrates on the behaviour of addiction as a learned behaviour to reach a goal.

He sees it is as a habit that has been effective in achieving some end. Therefore, to ‘fix’ the addiction, a greater and healthier goal must be found. The drive to achieve a more meaningful and inspirational goal will help fuel the behaviours that will, over time, build new habits and new pathways in the brain. In the deep learning approach to addiction, the treatment focuses on unlearning the destructive habits and replacing them with more helpful ones that will allow them to achieve the same, or even greater goals. Compared to the mental disorder approach, there is a emphasis on the results or goals that the person is seeking and using these to motivate the creation of supportive habits.

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I can see how the view of addiction as a learned behaviour is very helpful. It removes another layer of stigma and sees the problem more of adaptation than personal deficit. Addiction then is a function of:

  • Not being focused on the right goals; and/or
  • Forming dysfunctional habits to achieve these goals.

Photo by Ali Kazal on Unsplash

In my mind though, the deep learning view of addiction does not go far enough. Professor Lewis acknowledges that addiction is driven my deep despair and personal suffering. It is preceded by feelings of disconnection, alienation, despair and stress.

My question is why are people feeling this way in the first place? I think if we can understand the answer to this question, then we can have a more complete pathway to treatment and healing from addiction.

Is Addiction All of These Things?

All of these theories of what addiction is have been formed from numerous years of observation, research and in some cases personal experience. Therefore, I am really averse to disregard any of them. What about instead if they are all correct? From what I can see, they all have a place in explaining what addiction is, and in my very naïve viewpoint seem to relate together as follows:

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Perhaps addiction is all of these things?

Figure 2 — How the current addiction models fit together

I call this my naïve view of the world, because as Professor Alison Ritter says, addiction in reality a “complex cultural, social, psychological and biological phenomenon.” [11]. And yet, while this may be the truth, it does not help anyone struggling with addiction, or their carers. A model is needed to explain what is happening for that person and to help them understand the pathway to healing.

Addiction Is A Symptom

In addition to showing how current models of addiction fit together, the above diagram also makes one critical situation clear. No matter what model you use to explain what addiction is, it all feeds back to a situation that has been reacted to through the use of substances or continued harmful activity. The definition of a symptom is:

“An indication of the existence of something, especially of an undesirable situation”.[12]

It is exactly that, an undesirable situation, that has given rise to the addiction. Therefore, by definition, addiction is not an end in itself. It may be a disease, it may be a disorder, but ultimately it is a symptom of an undesirable situation.

Unfortunately though, this insight raises even more questions. What is the undesirable situation, and why do people undertake such harmful behaviours to ‘escape’ from it? Stay tuned, because I will tackle this question next and present my theory as to what the undesirable situation is that leads to addiction.

To Think About:

· What view(s) of addiction to you tend to relate to the most? Why do you support these views?

· What view(s) of addiction to you tend to relate to the least or downright don’t believe in? Why do you reject these views?

· What do you think the undesirable situation was (or is) that has led to your use of harmful substance or activity? What situation ‘drove’ you to the substance or activity in the first place?

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May you come to know and care for the great wisdom that resides within you.
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Photo by averie woodard on Unsplash

[1] Global statistics on addictive behaviours: 2014 status report. Linda R. Gowing Robert L. Ali Steve Allsop John Marsden Elizabeth E. Turf Robert West John Witton. First published: Addiction 11 May 2015

[2] https://www.drugabuse.gov/publications/research-reports/misuse-prescription-drugs/what-scope-prescription-drug-misuse

[3] https://www.thecabinchiangmai.com/blog/why-is-internet-addiction-growing-in-asia/

[4] https://www.lexico.com/definition/addicted

[5] https://www.google.com/search?safe=active&sxsrf=ALeKk03_xd_i0kAmWaiLPWkWTZcu_TkDBA:1603665803392&q=Dictionary&stick=H4sIAAAAAAAAAONQesSoyi3w8sc9YSmZSWtOXmMU4-LzL0jNc8lMLsnMz0ssqrRiUWJKzeNZxMqFEAMA7_QXqzcAAAA&zx=1603665808846#dobs=choice

[6] https://addictioneducationsociety.org/dr-kevin-mccauley-pleasure-unwoven/

[7] https://addictioneducationsociety.org/addiction-is-a-disease-of-free-will/

[8] https://www.lexico.com/definition/disease

[9] https://www.who.int/mental_health/management/en/

[10] https://www.verywellmind.com/dsm-5-criteria-for-substance-use-disorders-21926

[11] https://ndarc.med.unsw.edu.au/blog/why-addiction-isnt-disease-instead-result-deep-learning

[12] https://www.lexico.com/definition/symptom

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