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What is addiction?

The word addiction is derived from the Latin term for “enslaved by” or “bound to”.

The National Institute on Drug Abuse (NIDA), a U.S. federal government drug abuse and addiction research institute, defines addiction as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. Addiction occurs when a person cannot control the impulse to use drugs even when there are negative consequences—the defining characteristic of addiction. NIDA and others consider addiction a brain disease because drugs change the brain; they change its structure and how it works, especially in the brain’s natural inhibition and reward centers.

While NIDA and others continue to use the term “addiction” to describe compulsive drug seeking despite negative consequences, “addiction” is not considered a specific diagnosis in The Diagnostic and Statistical Manual of Mental Disorders (DSM 5)—a diagnostic manual used by clinicians that contains descriptions and symptoms of all mental disorders classified by the American Psychiatric Association (APA). In 2013, the APA updated the DSM, replacing the categories of substance abuse and substance dependence with a single category: substance use disorder (SUD).

The symptoms associated with SUD fall into four major groupings: impaired control, social impairment, risky use, and medical criteria (i.e., tolerance and withdrawal). Addiction medicine specialists talk about the four C’s of SUD; loss of Control over substance use, Compulsion to use, Cravings for the substance and continued use despite negative Consequences.

Under the new DSM, a person will meet the criteria for SUD if at least two of the following symptoms occur in a 12-month period:

  1. The substance is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful effort to cut down or control use of the substance.
  3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
  4. Craving, or a strong desire or urge to use the substance.
  5. Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.
  7. Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
  8. Recurrent use of the substance in situations in which it is physically hazardous.
  9. Use of the substance 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.
  10. Tolerance, as defined by either of the following:
  11. A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
  12. A markedly diminished effect with continued use of the same amount of the substance.
  13. Withdrawal, as manifested by either of the following:
  14. The characteristic withdrawal syndrome for that substance (as specified in the DSM- 5 for each substance).
  15. The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

The DSM 5 allows clinicians to specify how severe the SUD is, depending on how many symptoms are identified. Two or three symptoms indicate a mild SUD, four or five symptoms indicate a moderate SUD, and six or more symptoms indicate a severe SUD.

While most experts and professionals do not dispute the disease model of addiction, it is not without controversy. There are some professionals, some people with lived experience, and some professionals with lived experience, who do not believe that addiction is a disease. However, most of them believe it is a brain disorder or illness, just not a disease. Thus this is mainly a question of semantics. Their concern is that categorizing it as a disease disempowers people struggling with addiction and can leave them feeling hopeless. (Most of those who believe in the disease model believe that the disease model is empowering because it means a person’s symptoms are not their fault or due to weakness, but because they have a treatable disorder.) Addiction and the Brain Disease Fallacy is one US paper that discusses this issue in detail. In Unbroken Brain, Maia Szalavitz explains her belief that addiction is a learning disorder rather than a disease. In The Biology Of Desire: Why Addiction is Not a Disease, neuroscientist Marc Lewis also expresses his belief that addiction is not a disease.