The term—and concept of—“addiction” is regularly frowned upon or even attacked by people in our field. But it won’t disappear, nor should it.
There are four groups or schools of thought that de-emphasize or disparage “addiction.” And their reasons for doing so all have value.
But for me, their arguments point us not to the abandonment of the term, but to its reconception in order to make it accurate and useful.
Before I elaborate, I’ll summarize these “anti-addiction” groups and their positions.
The American Psychiatric Association’s diagnostic manual, DSM (as well as its international equivalent, the International Classification of Diseases or ICD), doesn’t use the term addiction (except in a single instance, as we’ll see). Indeed, the current editions of DSM (DSM-5) and ICD (ICD-11) don’t even use the term “dependence” with substances.
DSM-5 has replaced addiction and dependence with a sliding scale of “substance use disorders” (SUD), ranked from mild to severe, that can result from using a variety of drugs. This reflects the important truth that all substance use, and any accompanying problems, occur along a nuanced spectrum.
DSM’s categorization reflects that clinicians are justifiably concerned with substance-use problems that fall short of the severe end of the spectrum. What if your drinking doesn’t qualify as addiction or “alcoholism” but still concerns or harms you? Furthermore, the most severe SUDs involve the greatest number of problems and the most impairment, but may or may not include [please, there is no separate “physical”] tolerance and withdrawal — the criteria classically used to define addiction.
At the same time, major forces in psychiatric thinking (including the head of the National Institute on Drug Abuse, Nora Volkow) wish to make clear that people who rely on long-term medication (i.e. “depend” on it) should not receive pejorative labels like “dependent” or “addicted” (think insulin, or even painkillers).
Epidemiologists are concerned with public health consequences, not with clinical classifications. Those working in the field of alcohol focus on accidents, violence, social disruptions, and chronic medical conditions (like cirrhosis) that, while alcohol-related, may not result from addiction. With illicit drug use, along with problems similar to those that occur with alcohol, infections caused by contaminated syringes and deaths caused by combining drugs are similarly separate from drug addiction, if overlapping. It is clearly possible, for example, to contract an infection from a used needle, or to die of drug poisoning, while falling far short of being addicted.
Focusing on reducing population-level harms is valuable. It also means that, for epidemiologists, addiction is a sideline interest at best, and a diversion at worst.
Instead, with alcohol, international consortia of Temperance-based researchers are concerned with specific problems and the bottom line of reducing overall consumption. Likewise, social epidemiologists dismiss drug addiction entirely as a matter of choice, or even mock it as a “pharmacological version of the belief in demon possession that has entranced western culture for centuries.”
Critics of an expanded view of addiction:
The addiction thinkers by whom I have been most influenced are Norman Zinberg, Charles Winick, Harold Mulford and Don Cahalan. I considered them all friends (all are now dead). While each accomplished important work, none thought about drugs or alcohol in the context of larger behavioral patterns. Indeed, Zinberg and Winick only addressed illicit drugs, and Mulford and Cahalan only alcohol, so that they never put drug and alcohol (let alone other) problems under a broader lens.
At best, they would say to me about my integrated model of addiction across substances and non-substance-involved activities, “Interesting idea, Stanton.” At worst, Norman Zinberg would announce at conferences where we both spoke, “Just because I read the paper every morning with a cup of coffee doesn’t mean I’m addicted!”
Norman was implying that I was cheapening the idea of addiction by extending it to love and sex, as I did in my 1975 book with Archie Brodsky*, Love and Addiction. If you call ordinary activities addictive, this critique goes, then everything is an addiction. And indeed, calling every routine activity an addiction would make the concept meaningless. We didn’t, and I don’t.
This far-reaching movement based on drug users’ self-empowerment interprets substance use and any accompanying problems or disorders in functional terms.
Harm reduction pioneers, such as Patt Denning and Jeannie Little in their book Over the Influence (2017), portray people who use drugs problematically as individuals making human attempts to lead satisfying lives—including integrating various substances into those lives—with different degrees of success.
Many harm reductionists further contend that no one merits being pathologized (and self-pathologized) as an “addict.” People with drug-related difficulties, they point out, are simply people seeking to do the best that they can in the circumstances in which they live.
I agree with these harm reductionists’ innovative thinking.
But the justified eschewal of the stigmatizing and disempowering label “addict” can sometimes extend into rejecting the very concept of “addiction”—an overreaction, in my view.
Substance use is a problem only when it causes problems. Reading the paper and drinking coffee aren’t in themselves addictions, or even problems. By the same token, neither is drinking alcohol or taking heroin. (Ironically, and with due acknowledgement to Carl Hart, few contemporary specialists have pointed this out in regards to heroin as forthrightly as Zinberg did.)
DSM expresses this approach by assessing SUDs and their severity solely through summing the problems they cause for a person. Such problems are not a simple function of the amount of a substance used. For example, binge drinking causes many more problems, medical as well as social, than drinking the same amount of alcohol, or even a larger amount, over time.
If no notable problems accompany drug use, then an SUD diagnosis isn’t warranted. Beyond this, mild or moderate problems with a substance mean the person has a SUD, but not a severe one. But there is no clear demarcation point separating these diagnoses.
This graduated approach to assessing SUDs is not consistent with a disease model of addiction. If what can be labeled an SUD (or “addictive”) may be more or less so, then addiction isn’t a single underlying biological entity.
An addiction is a compulsive and harmful habit of any kind. As we noted earlier, DSM-5 actually does address addiction, which it had never done previously. It just doesn’t apply the term to any drugs.
What, then, does DSM categorize as an “addictive disorder?”
Just one thing: gambling.
How is it possible that only one thing in the universe is addictive? That idea is ludicrous and must surely change. (ICD-11 also recognizes sex in this category, which DSM-5 explicitly rejected, and gaming, which DSM wait-listed for future consideration.)
DSM-5 has created the category “Substance-Related and Addictive Disorders,” implying that these are two separate entities. This distinction between substance-related and addictive disorders is untenable, and will not survive the test of time.
Instead, addiction must be defined as an involvement of any type in which people compulsively engage despite serious negative impacts for them. The criteria for this diagnosis can be built on the current DSM substance-use disorder criteria, without anchoring them to specific substances or activities.
Why do so? Because this model is accurate and useful, as demonstrated by precisely analogous causes, behavioral patterns and harms. As Maia Szalavitz noted in Unbroken Brain (2016) about my and Archie Brodsky’s work in Love and Addiction, “Peele and Brodsky illustrated how unhealthy relationships—whether with drugs or with people—share the same fundamental qualities.”
That is to say, those addicted both to sex-love and to drugs seek emotional comfort and self-acceptance through repetitive, constant stimulation while losing sight of, and damaging, other activities and relationships.
These benefits outweigh the disadvantages—disadvantages that we should strive to eliminate by using the term accurately.
Ultimately, addiction should be retained as a concept for three main reasons.
First, people “get” it. Virtually everyone in the Western world understands the meaning of the term as a compulsive, damaging entanglement. And, when not influenced by disease thinking, people very often have a common-sense notion that we are driven to addiction due to negative emotional states, deprived lives and environments, and the absence of other, meaningful rewards in our worlds.
Second, it implies the need for important real-world change. Applying addiction to all damaging compulsions—including behaviors (love, eating) that we cannot eliminate from our lives—makes clear that drug demonizing and prohibition are illogical responses to drug addiction.
And, third, the inclusivity of the term emphasizes that those of us who have not experienced drug addiction have nevertheless experienced addiction somewhere in our lives (just ask people you know), militating against attitudes and policies that isolate and vilify drug users.
These benefits outweigh the disadvantages of the myths and misappropriations associated with the concept—disadvantages that we should strive to eliminate by using the term accurately.
Yes, people can read newspapers—and certainly drink coffee (caffeine is included in DSM-5 SUDs)—compulsively and addictively. A scenario in which a person were obsessed with reading the New York Times (or the Bible) all day to the detriment of their relationships and life goals is far-fetched, but possible.
Addiction can reach severe depths whenever, despite extreme negative consequences—health harms and risks, social isolation, the exclusion of other meaningful endeavors—the person is unable to quit repeating a behavior.
Even disease-concept psychiatrists like those in the American Society of Addiction Medicine are now being forced to recognize the experiential essence of the addiction syndrome. This recognition ultimately dictates that the treatment path and prevention techniques for addiction lie in creating more fulfilling lives for individuals—and taking action to encourage these societal changes.
The task remains for anti-disease model advocates to separate addiction from the bias against drugs—from the assumptions that only drugs cause addiction, that drug use is inevitably addictive, and that “addicts” are an isolated segment of the population who suffer from a specific disease that stems only from substance use.
When the focus in addiction thus shifts from the substance to the nature of people’s involvements; when it includes an understanding that addiction is not a distinctive all-or-nothing biological state; when it recognizes that, at its heart, addiction is an existential journey, then we will no longer need to fear, loathe or punish human beings who use drugs or who experience addiction.
Only then can we envision ways to overcome and prevent addiction through helping people to find purpose, develop skills and open life opportunities for themselves. Our currently dominant disease view of addiction, in the meantime, offers no inkling of how to do this and only exacerbates our problems.
It is, then, the concept of addiction that Archie and I first presented in 1975 that I rededicate here. It remains the concept that best interprets and explains the data and points to the workable, effective remedies that some clinicians and policymakers are beginning to advocate and practice. It will take a societal commitment to make them work and to produce results on a large scale.
*Archie Brodsky is a member of the board of directors of The Influence Foundation, which operates Filter.