Rethinking Addiction

Research Blogging / by Dave Munger /

What makes someone an addict? The clinical definition of drug “dependence” is flexible, but may still mislabel individual choices as disorders.

A member of my family died as a result of her alcohol abuse in her early 20s, leaving two children to be raised by their father. Clearly her addiction was horrible, and if it could have been prevented, many people would have been spared a lot of anguish.

But consider the case of an independently wealthy man, living alone, with no dependents. He sits around his mansion all day, playing video games and freely sampling from his vast storehouse of illicit drugs. He’s just enjoying himself and he’s not directly hurting anyone. Is he a society-menacing addict?

That’s the scenario presented by “DrugMonkey,” an NIH-funded biomedical research scientist who blogs anonymously at ScienceBlogs so that he can candidly assess the research of his peers. Two weeks ago he discussed an August study published in the journal Addiction that attempts to define clinical dependence on the rave-fave drug “Ecstasy,” or MDMA. We often think of true addicts as street junkies who prostitute themselves or steal from others to support their habits, but in reality there’s a wide variety of behaviors associated with abusing mind-altering substances. They can range from the casual drinker who sometimes has a few too many martinis, to the pothead who still lives in his mother’s basement, to a talk-show host zoned out on antidepressants.

The American Psychiatric Association’s DSM-IV-TR is the reference most doctors use to diagnose mental disorders, and it offers two definitions of problems relating to recreational drug use. The first, “substance abuse,” simply suggests that abuse is any use of a substance that leads to physical, mental, social, or legal harm to oneself or to others. The second, “substance dependence,” is what we more commonly think of as addiction and includes a list of seven criteria, only three of which are needed to qualify.

Technically, our wealthy drug user could be classified as an addict: He has developed a tolerance for the drugs, he feels withdrawal symptoms if he stops using them, and he often uses more than he planned. Are most MDMA users more like this benign hobbyist or more like street junkies who have clearly measurable detriments to society? DrugMonkey tells us about a study of 593 individuals who had used MDMA at least five times. The researchers, led by Linda B. Cottler, found that about three-quarters of these individuals showed the symptoms of abuse or addiction.

That sounds pretty bad, but DrugMonkey notes that only 17 percent of users report a “persistent desire/unsuccessful effort to cut down or control use.” Among this group, the median number of pills consumed during their lifetime was just 50, which, again, hardly seems like a persistent problem. On the other hand, 68 percent of users reported “withdrawal” symptoms and 87 percent said they continued to use the drug despite physical or psychological problems.

So while many MDMA users can be clinically classified as abusers or addicts, it’s unclear that MDMA use is a problem on the order of heroin or crystal meth. Heroin, reports the UK’s Transform Drug Policy Foundation, has cost thousands of lives and caused huge crime problems in Britain alone. The issue is so bad that the Foundation and others are now recommending providing heroin itself as a “treatment” for the worst abusers. Better they get quality- and quantity-controlled, government-provided drugs than live a life of crime to buy illicit, possibly poisonous drugs from dangerous gangsters.

DrugMonkey makes the argument that a drug problem is actually different from clinical drug dependence. A single mom working a job with a no-tolerance policy for absenteeism could have a much bigger problem on her hands after one bout with MDMA than our hypothetical wealthy carefree addict.

Indeed, partially because APA’s definition of drug dependence is so flexible, researchers have begun to apply similar reasoning to other “addictive” behaviors. I reported earlier this year on a study in Psychological Science claiming that 7.9 percent of US kids are “addicted” to video games. Dutch psychiatrist Walter van den Broek uncovered a similar study purporting to show that 4 percent of Australian undergraduates were “dependent” on the internet. Van den Broek isn’t buying it: He doesn’t agree that the scale the researchers used adequately defines dependence.

Perhaps the real problem is attempting to lump all these behavioral problems into the basket of clinical dependence. No one denies that some children play too many video games or that MDMA abuse is a serious problem for some individuals. But does it make sense to classify a college kid spending too much time on Facebook in the same category as a woman who lives on the street and sells her body to support a heroin habit? Can our definitions of addiction and our social deterrents against it actually cause more harm than they prevent? Researchers, students, and advocates continue to debate this issue on their blogs. There’s more discussion about addiction on ResearchBlogging.org.

Originally published September 23, 2009

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