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Difference between Abuse, Dependence and Addiction

Alcohol and drug use ranges on a continuum from use to dependence characterized by increasing loss of control and increasing functional impairment.  The term abuse is a broad term that refers to any maladaptive use of a psychoactive substance.  There comes a point where the use of the alcohol or drug is no longer voluntary and becomes involuntary and beyond the individual’s control.  When it reaches the stage where alcohol or drug use is no longer voluntary and interferes with daily functioning, we call it an addiction.  Dr. Alan Leshner, Director of the National Institute on Drug Abuse, stated that the condition of addiction is a “biobehavioral phenomenon” characterized by a movement from a state in which use is at least under some degree of voluntary control to a state in which use is both compulsive and uncontrollable.  He characterized addiction as a different state from abuse.

Leshner states that with addiction there are fundamental brain changes that occur with increased use.  These brain changes create a need in the individual for increased, compulsive use of the substance.  In addiction there is a loss of control and increasing use despite negative consequences.  The term dependence refers to a more severe form of abuse characterized by habitual use of a substance that is taken more frequently and in larger amounts over time, leading to increasingly negative consequences.

Historically, there have been two camps regarding the understanding of drug and alcohol addiction.  One camp, dominated by physicians, holds to the belief that addiction was based on a disease model.  It states that there is a genetic and/or biochemical basis for addictions and that the individuals cannot consistently control their drug-alcohol behavior without total abstinence.  They claim that there is no cure because addicts cannot escape the biochemical predisposition.  The other camp, dominated by psychologists, believes that alcohol and drug abuse is a learned behavior and, as such, can be unlearned, change or controlled through behavioral-learning models of treatment.

Increasingly, addiction workers in the field are coming to the realization that neither approach alone may be sufficient for treating a large number of addicts.  For some individuals there may be a biochemical basis for their addiction, for some a behavioral basis, and for still others, both may be involved.  Furthermore, these workers are recognizing that treatment isn’t based on a “one size fits all” model.  While the abstinence model may be appropriate for some individuals, a moderation approach may be effective for others.  Addiction is a multivariate disorder with no simple solutions.  By offering only one approach we put addicts in the position of either adopting the only available treatment approach, whether or not it works for them, or not receiving any treatment at all.  Most professionals in the field recognize that treatment of addiction must focus on the addictive behavior itself rather than on the cause of the addiction.

Drug Abuse

Nora Volkow, MD, of the Brookhaven National Laboratory, says:

“Classically, people thought that drug addiction was a disease that involved the centers of pleasure that people are taking the drug because it’s pleasurable.  But that is not the case.  In fact, addicted people don’t have as strong a pleasure response as people who are not addicted.  Recent data are showing us that addiction entails a basic disruption of motivational circuits.”

Not only does drug abuse affect the emotional centers of the brain, but also recent research shows that drug abuse alters cognitive activities such as decision-making, planning, and memory.  The evidence is clear that cocaine and marijuana use affect the frontal cortex, which is the center in the brain governing cognitive activity.  Such disruption in the frontal cortex might be responsible for the poor decision-making.  Recent research with a gambling task tested drug abuser’s making ability.  Not surprisingly it was found that drug abusers made poorer decisions on the gambling task than participants in a control group.

The research is mounting that the long-term affects of drug abuse are much greater than most people believe.  It is not just that these affects occur while actively using the drugs.  Rather, these affects continue after drug use is discontinued.  It takes a long time for most drugs to clear one’s system and there may be residual physical and psychological affects long after that.

Alcohol Abuse

Alcohol abuse is more insidious than drug abuse. Since having a drink is socially sanctioned, there is no overt reminder that the behavior may lead to trouble down the road. With illicit drugs merely using the substance is a reminder because it is illegal.  Having a cocktail at dinner, drinking a beer at a ballgame, and celebrating a wedding with champagne are all socially supported and even encouraged.  One can receive accolades for being able to hold one’s liquor.  Becoming “shit-faced” in college is a right of passage.  There are many models of respected people enjoying alcohol.  This is not true for other substances.  Hence, it is easy to rationalize moving from the occasional beer, cocktail, or glass of wine to daily use.

It is easy to go from the meal enhancing drink to using alcohol to self-medicate for social inhibition, depression, loneliness, anxiety, and other discomforting affects.  Because some people can develop a tolerance for higher levels of alcohol in their system, they may need higher doses in order to experience the same effects.  One drink becomes two, two becomes three.  Where one beer was good, for some people it can easily become three, four, or more during the week with a few extras on the weekend.

Unfortunately, most alcoholics are not aware that they are alcoholics until they get into some difficulty.  And when there is some warning, they often deny it.  Often the early signs are related to work performance, health problems, social problems, legal difficulties, financial problems, or marital difficulties.

Some people are born with a genetic and biochemical predisposition that leaves them more vulnerable to abusing alcohol.  They do not receive a signal from their brain that they have had enough or too much. Rather than producing sleep, nausea or other obvious physiological effect, they develop a tolerance for large amounts of alcohol.  In fact, with continued abuse they begin to crave the substance.  In addition, these people find that the alcohol temporarily comforts them by reducing shyness, anxiety, depression, and inhibition.  In a world where alcohol use is approved of and even encouraged, it becomes part of the culture.

Alcoholics do not want to think of themselves as not able to control their drinking.  They want to keep up with and be part of their social group.  Declining a drink in many situations is difficult for these people.  It is not until they have developed a dependence that interferes with work, family life, and social life that they begin to recognize that they have a problem.  But by then it is often too late.  The physiological craving for alcohol becomes so great that giving it up does not seem like an option.  The centers of the brain that regulate judgment have been so affected that it takes a crisis to motivate these individuals to seek treatment.

Signs of Abuse

The very nature of substance abuse is such that people do not want to admit that they have a problem.  People around them do not want to admit that there is a problem, and healthcare practitioners tend to either overlook or fail to investigate the possible existence of substance abuse.  Hence, the individual goes diagnosed and untreated.  There are several areas in which signs of abuse may appear.

Problems in living: financial problems including poor financial decision-making; poor judgment; legal problems including traffic tickets (e.g., DUI) and accidents; occupational difficulties such as poor performance, absence, conflict; social problems such as inappropriate behavior, missed appointments, chronic lateness.

Physical effects: increased incidence of health problems, poor dietary changes, higher tolerance for substance causing increased quantity and frequency of use; experiencing withdrawal when not using; higher incidence of nausea, dizziness, vomiting; disrupted sleep pattern.

Psychological and behavior effects: emotional instability, e.g., irritability, impatience; difficulty in abstaining from use; using substances to regulate affect, i.e., to reduce social inhibition, relieve stress, reduce anxiety or depression; denial and defensiveness when substance use is suggested.

[Please add your thoughts and experiences on this topic in the comment section of this blog.  This blog is intended as a forum for folks to raise issues, share experiences, and promote dialogue on important issues of contemporary life.   Please sign up as a Facebook Fan at www.docdreyfus.com/fanpage. For additional information about me and my practice, please visit my website at www.DocDreyfus.com.]