The National Institute on Drug Abuse (NIDA) believes that drug addiction exists, while the psychiatrist’s handbook, the DSM 5, doesn’t use the term. The public and their political representatives believe addiction to be a major problem. Though there’s no reason to think they understand the issue any better than the doctors who make a living off of illicit or inappropriate drug use or any other behavior they believe addictive. All of these groups seem unable to distinguish between behavior that is habitual from that which is truly addictive.
The new DSM describes a problematic pattern of use of an intoxicating substance leading to clinically significant impairment or distress with 10 or 11 diagnostic criteria (depending on the substance) occurring within a 12-month period. Those who have two or three criteria are considered to have a “mild” disorder, four or five is considered “moderate,” and six or more symptoms, “severe.” The diagnostic criteria are as follows:
- The substance is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful effort to cut down or control use of the substance.
- A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
- Craving, or a strong desire or urge to use the substance, occurs.
- Recurrent use of the substance results in a failure to fulfill major role obligations at work, school, or home.
- Use of the substance continues despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.
- Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
- Use of the substance is recurrent in situations in which it is physically hazardous.
- 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.
- Tolerance, as defined by either of the following:
- A need for markedly increased amounts of the substance to achieve intoxication or desired effect
- A markedly diminished effect with continued use of the same amount of the substance.
- Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for that substance (as specified in the DSM-5 for each substance).
- The use of a substance (or a closely related substance) to relieve or avoid withdrawal symptoms.
The public and the press regularly use the term addiction. The difficulty is that harmful use of a drug and addiction are considered to be essentially the same. They’re not. I’ll explain below. The definition of an addicting drug that I use is the same that pharmacologists have used for decades. Neither psychiatrists nor NIDA uses this definition.
For a drug to be addicting is must possess all four of the following characteristics – habituation, dependence, tolerance, and withdrawal. Thus, opioids, barbiturates, and alcohol are addicting. Cocaine, nicotine, sex, shopping, gambling, food, etc are not addicting.
Consider this article, in a computer publication of all places. – Why e-cigarettes are so addictive, according to doctors. Here’s an excerpt – “but no one can argue with the fact that nicotine is addictive. So addictive, in fact, that the National Institutes of Health call it as addictive heroin and cocaine.” Well, at least one scientifically trained observer can argue the contrary. The observation that nicotine affects brain receptors proves nothing. Water affects the brain as does almost anything you can think of, including a juicy steak. Notice the use of the word intoxicating in the DSM list above. No one I know of thinks nicotine to be intoxicating using any standard definition of the term.
If nicotine is so addicting how is that scores of millions of people have stopped smoking? Usually on their own. Nicotine does not cause withdrawal, nor does it usually cause tolerance. Smokers usually smoke the same number of cigarettes daily. Of the above list of problems associated with harmful drug use, smoking checks at most three.
Then there’s considering addiction as a disease versus the consequence of poor decisions. If a disease causes altered behavior, the afflicted person is not held responsible for his actions. Thus, a schizophrenic who commits murder is not executed nor sent to prison. He goes to a mental hospital. Many consider alcoholism a disease; yet if an alcoholic kills someone while driving drunk he goes to jail, not to a mental institution. Despite all the propaganda to the contrary, society doesn’t really think alcohol addiction is a disease.
I would argue that the disease model is inappropriately used for addiction. Many addicts, regardless of definition, are able to stop using the drug to which they are addicted on their own. One cannot voluntarily stop being schizophrenic or having tuberculosis.
The harm of an addicting drug depends on what the drug is. Chronic alcohol use may well kill you, but addiction to opiates is different. Opium is illegal because it’s harmful and it’s harmful because it’s illegal.
Consider the case of William Halsted, the founder of modern American surgery. For most of his adult life he was ‘addicted’ to both cocaine and morphine. Despite repeated attempts to get him off these drugs he continued to take them until his death – from a cause unrelated to his drug use. William Osler was among his physicians. Most of the work which made him a great surgeon was coterminous with his addiction. The reason that his drug use did not cause side effects or interfere with his professional life was that he had unlimited access to a clean, standardized, and legal (or at least not openly illegal) supply of the drugs he used. Accordingly, his cocaine morphine consumption did not impede the daily activities of his life.
This article is not intended to do anything except inform. But it is clear that the current deaths attributable to the ‘opioid epidemic’ are the result of opium derivatives or congeners being available only through illegal sources. Were opium derivatives available in sterile and standardized dosage, the only deaths attributable to their use would be secondary to accidental overdose or to suicide.
I cannot overemphasize that of all the drugs that are taken for recreational use, alcohol is the most dangerous. And its ubiquity is unmatched by any other.
Nicotine, regardless of its source, is legal as is alcohol. We know how well the banning of alcohol worked out. People have taken drugs which alter mood or perception ever since they figured out how to make or get them. The law and the medical profession are likely to have little effect on such use beyond persuasion and education. After all, look at how many people have stopped smoking as a result of education and societal pressure rather than law enforcement. Informed argument is our only hope with any kind of unwanted drug use. Separating their use from free will and declaring said use a disease or the result of an irresistible compulsion is apt to be futile and counterproductive.