Pubdate: June 17, 1996

What Addiction Really Means

By Alan I. Leshner
Special to The Washington Post
Tuesday, June 17, 1997; Page Z09
The Washington Post

The word "addiction" calls up many different images and strong
emotions. But do we really know what we are reacting to? Too often we
focus on the wrong aspects of addiction, and that means our efforts to
deal with it can be misguided.

Any discussion about psychoactive drugs, particularly a drug such as
nicotine or marijuana, inevitably moves to the question, "Is it really
addicting?" The conversation then shifts to whether the drug is
"physically" or "psychologically" addicting.

People assume that the more dramatic the physical withdrawal symptoms,
the more serious or dangerous the drug must be. Indeed, they tend to
discount the dangerousness of substances that "just" produce
psychological addiction or have only minimal physical withdrawal
symptoms.

But 20 years of scientific research and even longer clinical
experience have taught us that focusing on this physical vs.
psychological distinction is wrong. It does not matter very much, as
an issue in either treatment or policy, whether physical withdrawal
symptoms occur. Other aspects of addiction are far more important.

First, we can medically manage the symptoms of withdrawal such as
severe stomach cramps and trembling. Even the very dramatic symptoms
of heroin addiction can now be easily treated with appropriate
medications. That means physical withdrawal symptoms are not our main
concern in treating people.

Second, and more important, many of the most addicting and dangerous
drugs do not produce severe physical withdrawal symptoms. Crack
cocaine and methamphetamine are clear examples. Both are highly
addicting, but they cause very few physical withdrawal symptoms in
people who stop using them.

What matters most is whether a drug causes what we now know to be the
essence of addiction: uncontrollable, compulsive drug seeking and use.
This is how the National Academy of Sciences' Institute of Medicine,
the American Psychiatric Association and the American Medical
Association all define addiction.

Drug cravings and the other compulsive behaviors are extremely
difficult to control, much more difficult than any physical
dependence. As the movie "Trainspotting" showed us so well, the
addict's entire life becomes focused on getting and using the drug.

Focusing on this aspect of addiction should help clarify the nature of
the drug problem. For the addict and the clinician, this more accurate
definition shifts the focus of treatment away from managing physical
withdrawal symptoms toward dealing with the far more difficult task of
getting control over drug craving, seeking and use.

Rethinking addiction should also change how we identify which drugs
are more dangerous and therefore more worthy of society's attention.

In most circumstances, for example, opiates are tremendously
addicting. However, when administered for pain, morphine is not
usually addicting. While morphine treatment can produce physical
dependence which now can be easily managed after stopping use it
typically does not cause addiction as defined here. This is why so
many cancer physicians find it acceptable to prescribe opiate
analgesics for cancer pain.

An opposite example is marijuana. People debate whether marijuana is
addicting. Well, there are some signs of physical dependence or
withdrawal in heavy users, and more dramatic withdrawal has been
demonstrated in studies on animals. But what matters much more is that
every year more than 100,000 people, many of them adolescents, seek
treatment for their inability to control their marijuana use.

It is important to emphasize that addiction as defined here can be
treated, but it is not simple. We have a range of effective addiction
treatments, although not enough. This is why we continue to invest in
research, to improve existing treatments and to develop new approaches
to help people deal with their compulsive uncontrollable drug use.

We can do a better job of serving everyone affected by drugs
addicts, their families and their communities if we base our
efforts on an accurate understanding of what matters most in
addiction.

Alan I. Leshner is director of the National Institute on Drug Abuse,
which is part of the National Institutes of Health.

(c)Copyright 1997 The Washington Post Company