Understanding the concepts of dependence, addiction, and substance use disorders

  1. aemetha
    Historically many of the terms used to describe what we most commonly refer to as addiction have been used interchangeably. The American Psychiatric Association has flirted with all of these terms at various times. Concern was raised that the terms addiction and dependence carried a negative connotation and contributed to stigma, and in its most recent revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013) it now calls the condition a substance use disorder. It would perhaps be accurate to say that addiction is a common language term, while substance use disorder refers to a very specific set of diagnostic criteria. The term dependence is even more confusing because it is commonly used to refer to something that is outside the scope of what is commonly thought of as addiction.

    Dependence is a term used to describe a developed physiological reliance upon a regularly used substance, that is manifested in a withdrawal syndrome when the substance is discontinued. The exact effects of the withdrawal syndrome vary between substances, and may vary from discomfort such as unpleasant sensations, sweating, agitation, anxiety and insomnia to extremely serious effects such as life threatening seizures. Some of the most common substances that may cause the development of dependence include opioids, benzodiazepines, barbiturates, antidepressants and alcohol. The time it takes for dependence to develop varies between individuals, and according to factors including length of regular use of the substance, the dosage of the substance, and how long the effects produced by the substance last with shorter acting substances often contributing to a more rapid development of dependence. The process in which a person works through dependence is generally referred to as detoxification.

    Addiction is a term used to describe a psychological reliance on a substance. When an addicted person is unable to procure their substance they experience an overwhelming urge to seek it out, called craving. Addiction is a condition that develops from exposure to substances and activities that the user finds pleasurable. Addiction presents with physical changes to the structures and functioning of certain parts of the brain. It is not something intangible and unprovable, but it is not usually necessary to directly observe brain activity to identify the development of addiction. Addiction is thought to be related to a neurotransmitter called dopamine. Neurotransmitters are chemicals which brain uses to communicate, and dopamine is associated with reward mechanisms. When we take part in pleasurable activities the brain rewards us by releasing dopamine, and we feel euphoric. This is why certain activities can be particularly susceptible for developing addictions; sex, food, exercise and gambling are all activities associated with reward. Substances often hijack this dopamine system, either by causing our brain to release more dopamine, or by mimicking the effect of dopamine. Over time the brain attempts to revert to a more baseline reward state, and increasingly the substance is required to feel euphoric, normal activities become less rewarding, and eventually the substance is required to simply feel normal. Many substances have a direct or indirect effect on dopamine and can be addictive, but some of the most addictive are opiates, amphetamines and cocaine. The process in which a person works through addiction is generally referred to as recovery.

    Substance use disorders, as noted in the introduction are the terms used when diagnosing a mental disorder consistent with what we call substance addiction according to the DSM-5 (American Psychiatric Association, 2013). To be absolutely correct, it should be applied only to those who have received a diagnosis of a substance use disorder from a qualified medical professional, but in reality the diagnostic criteria is quite simple and widely disseminated across the internet, and so the term has entered the common vernacular.

    How to use this information in recovery? First of all, before discontinuing a substance find out about dependence and withdrawal from your substance. Withdrawal can in some circumstances be quite dangerous, and even potentially fatal depending on the substance. In any case withdrawal is always an unpleasant experience, and having a good idea of how long it will last, and what measures you can take to cope with detoxification can help you to formulate a plan to maximise your chance of successfully completing it without relapse or serious risk to your health. Like with withdrawal from dependence, it is also a good idea to develop some sort of plan for recovery from addiction. It need not be particularly involved, but identifying what things you are going to do to cope with cravings, the general malaise that can be expected in early recovery, and any particularly stressful events can provide you with a basic resource to cope with the times you’re most likely to be tempted with relapse.

    References

    American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

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