Addiction Has No Standard Definition, But That's Ok For Now

Addiction is confusing.  It is confusing to seasoned professionals.  Let’s just admit it. 

It is not a specified diagnosis under the DSM or ICD; it’s only broadly referential to a sometimes amorphous categorization.

• Under the DSM-IV in 1994, only one vote separated the task force on substance abuse from using the term “addiction” instead of “dependence.”

Society doesn’t help give any clarity.  One of my favorite taco joints in Dallas’s tagline is, “Welcome to your new addiction.” That misses the point.  People say all sorts of wild, off-handed things.  "I’m addicted to sparkling water," “I’m so addicted to this band." Addiction is not an adjective.
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Take a look at a broad array of definitions (some even from reputable research organizations), which emphasize sometimes different things:

• “Addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences.” -NIH’s National Institute on Drug Abuse
• “Abnormally dependent on some habit….” -Dictionary.com
• “The state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma.” -Dictionary.com
• “…Continued use/act….becomes compulsive and interferes with ordinary life….” -Psychology Today
• “Addiction is a primary, chronic disease.” -American Society of Addiction Medicine (ASAM)
• “Compulsive substance use despite harmful consequences” -American Psychiatric Association
• “Addiction is a psychological and physical inability to stop consuming a chemical, drug, activity, or substance, even though it is causing psychological and physical harm.” -Medical News Today
• “Cannot control” - HBO
• “Addiction involves craving for something intensely, loss of control over its use, and continuing involvement with it despite adverse consequences.” -Help Guide with Harvard Health
• “Addiction is a condition in which a person engages in the use of a substance or in a behavior for which the rewarding effects provide a compelling incentive to repeatedly pursue the behavior despite detrimental consequences.” -Psychology Today
• “…can’t stop….even when you know the drug is causing harm.” - NIH’s Drugabuse.gov

Clarity through the confusion
While still in the middle of a ‘call to arms’ in clarifying Addiction is, we ultimately have a very stable understanding of the symptoms/criteria of problematic behaviors, and most of the time, how to treat them.

• Let’s look at the premier addiction society’s- The American Society for Addiction Medicine (ASAM)- short definition (which, by the way, only lists “characteristics” vs. actual criteria).  
  • "Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.  Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death."
  • The long definition is impressive, but complex. 

Substance Use and Addictive behaviors do exhibit many consistencies despite the actual substance or reward behavior pursued, and they respond to similar treatments.  Regardless of the organization, the following are usually consistent details across definitions:

• craving a substance or behavior
• with loss of control
• despite significant adverse consequences,
• with an inability to abstain or moderate.  

"Types" of Addicts
There is an extensive history of attempts to categorize addiction, through “typologies.”  Prior to scientific research, which began with E.M. “Bunky” Jellinek, there were many attempts to understand the mystery of addiction, but mostly from an observational or anecdotal standpoint.  

• AA in 1939- we see Dr. William D. Silkworth at Towns Hospital attempting to typify addictive struggles.  AA offered a new solution, albeit targeted towards the most severe “hopeless” cases. They differentiated between:
  • “Real alcoholic” who is “hopeless” d/t loss of all control (AA, pp. 20-21)
  • “Hard drinker”
  • “Moderate drinkers”
• The Jellinek Curve was created shortly after in the 1940’s. (Accessed from  https://www.in.gov/judiciary/ijlap/files/jellinek.pdf)
• Since then, there are many other attempts to classify the differences that exist and to account for the heterogeneity that exists.

We don’t have any consensus yet, but why is it important to know what type or level or continuum a person is on?  At a minimum, we need to understand where a person falls on a continuum if we are to treat effectively.  

Here is one continuum of use problems (Adapted from Earleywine, M. (2016). Substance use problems (pg. 2). Göttingen: Hogrefe.):

• Abstinence
• Initiation
• Infrequent, non-problematic use
• Regular, non-problematic use
• Problems, subclinical
• Abuse (early problems clinically)
• Dependence
• Disorder (mild)
• Disorder (moderate)
• Disorder (severe)

Effective Treatment
As I like to say, "Don’t drive your lawnmower on the freeway."  Just like you wouldn’t do this (I hope), don’t assume that therapy alone, or a doctor alone, or worse, doing nothing- alone- will be enough “horsepower” to get you where you need to go.  

Effective treatment requires applying the factors necessary to get the job done.  The person who abuses a substance occasionally on weekends will need to be treated different than the person who is “hooked” on something.

Two categories of professional treatment exist, with incorporation of several additional supportive factors:

1. Behavioral
2. Pharmacotherapy

Besides treatment, supportive factors often include, but are not limited to:

1. Drug Testing / Accountability for using and acting out
2. Support groups / meetings
3. Family and friend involvement
4. Fun and enjoyment
5. Service of others and engaging life with purpose
6. General health and well-being

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My plea:
Take addiction seriously.  Don't know whether your are addicted or not?  Find out. 

Addiction is a complex- bio-psycho-social-spiritual- issue.  Problems with drugs, alcohol, or behaviors on a spectrum of addiction cause substantial disability, even death.  And here's the kicker- people who have problems with these often experience lapses in judgement and poor insight into having a problem.

Start with a strong assessment by a competent professional who is trained and experienced.  Look for evidence based treatments (think CBT or Motivational Interviewing). Advocate for truth and be assertive.  Ask hard questions of your provider. When providers get shifty or start to recommend some unusual treatment when you need a first line treatment, exercise caution.

I'm Justin K. Hughes, MA, LPC, and I specialize in the treatment of Addiction through CBT and Motivational Interviewing (MI).  As always, please like or follow me, using whatever platform you prefer.  Also, subscribe for meaningful content regularly!