Fully four hundred years ago, the acclaimed poet John Donne wrote: ‘No man is an island’. Certainly, Donne’s’ piece from 1624 applies equally in modern times, but to rely solely on that as a response to the statement ‘Why addiction affects us all’ could be considered a little trite at least, but it does provide an interesting viewpoint from which to begin the discussion.
There are several interesting positions taken on the statement that we are all affected by addiction and perhaps the best way to begin would be to sample the scientific view.
In the fields of psychology and psychiatry, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA), is recognised as the standard professional reference on mental health disorders. The DSM-5 defines addiction as a ‘chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences’. The significant part of this definition to consider initially is probably ‘disorder’ which DSM-5 defines as a conspicuous irregularity in the way a person thinks, controls their emotions, and manages their behaviour. Such a disorder would indicate an underlying - and most often distressing - dysfunction in aspects of a person’s life, whether this be psychological, biological, or developmental. This could then be taken as the established scientific view on the nature of addiction.
There are nine types of substance addictions listed by the DSM-5 within the category of ‘Substance-Related and Addictive Disorders’, and these are: alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics or anxiolytics; stimulants; and tobacco. The wide range of addictive substances, including caffeine and tobacco, means that a greater number of people are susceptible to being caught up in the net of addiction.
The ‘compulsive drug seeking’ that the DSM-5 relates to certainly acknowledges that most illicit drugs taken to excess trigger the brain’s reward circuitry, and quite evidently certain prescription drugs can act in the same way, for example the repeated use of co-codamol to control back pain.
Dopamine, the crucial brain reward circuitry activated by addictive drugs, is a neurotransmitter or chemical pathway which functions in the pleasure and reward zones of the brain. Essentially, dopamine invokes the ‘high’ that persons taking addictive substances seek, and this conclusion has been based upon a great deal of peer-reviewed work in the field. Similar ‘feel-good chemicals’ are serotonin and endorphins.
At this point it is worth noting that addiction and dependence are not always the same thing. As recently as March 2023, it was reported in The Lancet that physical dependence is much more common than addiction. This is because negative withdrawal effects occur regardless of whether drugs consumed are illicit substances or prescribed medication. As such, people who are struggling to come off medication because of punishing withdrawal symptoms, can be stigmatised as ‘addicted’ or ‘misusing drugs’. This can often be the case with antidepressants, which strictly speaking are not addictive, but which often lead to a withdrawal syndrome on reduction or cessation. Patients who avoid the intolerable withdrawal symptoms may then be seen as ‘dependent’ on the substance involved.
Since the early nineteenth century, people in recovery from dependence on illicit drugs or alcohol have often been characterised as suffering from a chronic, relapsing brain disease conveniently known as the ‘brain disease model of addiction’ or BDMA. This was in itself a more humane reaction to earlier, more punitive and scornful attitudes towards addiction. As part of a ‘second wave’ of intellectual thought aimed at the field of addiction, proponents of the BDMA will point to ‘neuroplasticity’ or changes in the brains’ structure because of the effects of neurotransmitters such as dopamine. They would argue that these changes have effects on perception, memory, and executive functions in the brain. However it is also true to say that brains are supposed to change; self-organisation of the brain is an accepted result of learning development, which causes structural reorganisation in the brain.
A positive effect of adopting the classification of addiction as a disease however is that those who use illicit drugs and alcohol are less likely to be stigmatised as morally deficient or self-indulgent.
Psychologists who question the BDMA view claim that it conflicts with the related experiences of former users of illicit substances who do not feel they were ever ‘ill’ and have somehow not been ‘cured’. Others who oppose the establishment BDMA view say that the strongest endorsement of the brain disease model comes from ‘Big Pharma’ and the burgeoning private rehabilitation sectors who stand to benefit hugely from providing pharmacological and psychosocial treatments.
A plausible, alternative view to the BDMA is that addiction may be seen as a self-medicating and natural response not only to adverse environmental or economic conditions, but also to psychological suffering including trauma, anxiety, low mood, bereavement, and loneliness.
It follows that those identified as illicit drug users effectively self-stigmatise because of exposure to negative social attitudes towards addiction. As such, this vulnerable cohort already interpret themselves as failing, have low self-esteem, and do not live up to their own standards of normality. This results in the profoundly negative self-attitude commonly known as shame. The risk here is of a destructive cycle being constructed as those affected internalise this shame, often in a state of helpless isolation, which then becomes a strong motivation to continue with the addictive behaviour as a coping mechanism.
Of course, not everyone affected by addiction will experience this self-stigmatisation; other responses to public stigma can include righteous indignation, anger, or just plain indifference.
Studies based on interviews with recovering opiate users have identified ‘normality’ as a common theme with positions taken ranging from ‘normal can be boring’ to ‘normal drug use means problems’. Certainly, based on the premise that the life of an opiate user is not easy – requiring the individual to find a dealer, buy drugs having somehow secured the necessary money, deal with poor resultant ill-health and fractured relationships, only to repeat the destructive cycle at the earliest opportunity – it is perhaps not surprising that many opiate users claim that they just want to be ‘normal’. Recovery therefore can be seen as a concerted attempt by those engaged in the process to distance themselves from their previous identity as ‘addicts’.
In the context of substance misuse, it is now widely recognised that there is no such thing as an addictive personality. More exactly, there does not exist a personality type that is prone to addiction. The path to dependence on illicit or prescription drugs involves several complex influences which may be psychological, social, familial, biological, or a combination of several of these factors. Certainly, the anxiety caused in experiencing addiction and subsequently seeking treatment can adversely affect work, daily life, and relationships. Mental illness frequently precedes drug or alcohol use, and people in this position often try drugs or alcohol to alleviate psychiatric symptoms. Simply being in the company of other people who live with addiction incurs a risk of adopting the same patterns of substance misuse.
It is certainly true that some people will become addicted to substances while others will not, so what factors influence this phenomenon? Research has shown that children who experience aggressive behaviour from within the family group are more at risk of addiction in later life. Other risks are lack of parental supervision, peer-group pressure, curiosity allied to drug experimentation, availability of drugs, cultural factors such as a ‘drinking culture’, and community poverty.
A ‘third wave’ of intellectual thought associated with addiction has now begun and is gathering momentum. Talking therapies, such as cognitive behavioural therapy, are certainly now widespread and addiction is gradually being accepted as a social construction. Of course, addiction can also apply to behaviours beyond the habitual misuse of substances, such as gambling or sex addiction. Whereas this article has focused mainly on substance misuse, the interpretation of addiction as a social construction means that these other behaviours are included in much of what has been outlined here.
Thinkers and treatment providers in the field are progressively considering contributions from those in recovery from substance misuse, and gradually stigma is being removed and improved pathways to recovery are being established for those affected by the misuse of drugs and alcohol.
All these issues considered together indicate it is likely that anyone can become addicted and as such it is certainly possible that addiction could potentially affect us all.
Perhaps the last word should be left to John Donne who concludes: ‘Therefore, send not to know for whom the bell tolls, it tolls for thee’.
