Definitions of Addiction

The Dependence View of Addiction

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The term “dependence” within the conceptual framework of addiction has a confused history. However, discussing the evolution of the term is instructive. Historically, definitions of addiction began with definitions of dependence. Himmelsbach defined physical dependence as:

“ arbitrary term used to denote the presence of an acquired abnormal state wherein the regular administration of adequate amounts of a drug has, through previous prolonged use, become requisite to physiologic equilibrium. Since it is not yet possible to diagnose physical dependence objectively without withholding drugs, the sine qua non of physical dependence remains the demonstration of a characteristic abstinence syndrome.”

(Himmelsbach CK. Can the euphoric, analgetic, and physical dependence effects of drugs be separated? IV. With reference to physical dependence. Federation Proceedings, 1943, (2), 201–203).

This definition eventually evolved into the definition for physical dependence: “intense physical disturbances when the administration of a drug is suspended” (Eddy NB, Halbach H, Isbell H, Seevers MH. Drug dependence: its significance and characteristics. Bulletin of the World Health Organization, 1965, (32), 721–733). However, this terminology clearly did not capture many of the aspects of an addictive process that do not show physical signs, necessitating the creation of the term psychic dependence to capture the behavioral aspects of the symptoms of addiction:

“A condition in which a drug produces ‘a feeling of satisfaction and a psychic drive that require periodic or continuous administration of the drug to produce pleasure or to avoid discomfort’…”

(Eddy NB, Halbach H, Isbell H, Seevers MH. Drug dependence: its significance and characteristics. Bulletin of the World Health Orgaization, 1965, (32), 721–733).

Later definitions of addiction resembled a combination of physical and psychic dependence, with more of an emphasis on the psychic or motivational aspects of withdrawal, rather than on the physical symptoms of withdrawal:

“Addiction; from the Latin verb ‘addicere,’ to give or bind a person to one thing or another. Generally used in the drug field to refer to chronic, compulsive, or uncontrollable drug use, to the extent that a person (referred to as an ‘addict’) cannot or will not stop the use of some drugs. It usually implies a strong (Psychological) Dependence and (Physical) Dependence resulting in a Withdrawal Syndrome when use of the drug is stopped. Many definitions place primary stress on psychological factors, such as loss of self-control and overpowering desires; i.e., addiction is any state in which one craves the use of a drug and uses it frequently. Others use the term as a synonym for physiological dependence; still others see it as a combination (of the two).”

(Nelson JE, Pearson HW, Sayers M, Glynn TJ (eds.) Guide to Drug Abuse Research Terminology. National Institute on Drug Abuse, Rockville MD, 1982).

Unfortunately, the word dependence in this process has multiple meanings. Any drug can produce dependence if dependence is defined as the manifestation of a withdrawal syndrome upon the cessation of drug use, see above. Meeting the ICD-10 criteria for Dependence or the DSM-5 criteria for Substance Use Disorder requires much more than simply manifesting a withdrawal syndrome. For the purposes of this book, dependence (with a lowercase “d”) will refer to the manifestation of a withdrawal syndrome, and addiction will refer to Dependence as defined by the ICD-10. The terms Dependence (with a capital “D”), addiction, and alcoholism will be held equivalent for this book. The term Substance Use Disorder is defined as a problematic pattern of drug use that leads to clinically significant impairment or distress, reflected by at least two the 11 criteria within a 12 month period (see above). How this cluster of cognitive, behavioral, and physiological symptoms will be considered equivalent to “addiction” remains to be determined.

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