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What is addiction?

The American Society of Addiction Medicine (ASAM) defines addiction in the following manner: "Addiction is a disease characterized by continuous or periodic impaired control over the use of drugs or alcohol, preoccupation with drugs or alcohol, continued use of these substances despite adverse consequences related to their use, and distortions in thinking, most notably denial." Addicts typically begin by experimentation, evolve into regular but controlled use, and ultimately find themselves in periodic episodes of loss of control over the use of alcohol that causes impairment in various areas of their lives, either physically or socially. Despite these negative consequences, they continue to use. The issue of loss of control is a controversial one, as addicts to one degree or another are able to exhibit control over their use with a variety of reinforcers; however, the reinforcers, whether they are negative or positive, have much less impact than alcohol itself in modifying the behavior of an addict. For example, for most people, one physical accident from alcohol use requiring an emergency room visit would be negatively reinforcing — that is, it is enough to modify their drinking behavior to avoid future accidents. For an alcoholic, the visit to the emergency room is merely a pattern of frequent visits.

Preoccupation with obtaining and using alcohol refers to the fact that the addictive substance plays a central part in their inner lives, whether or not they are actively using it. Thus, maintaining abstinence is only one element in one's treatment, as the major struggle continues internally. This internal struggle includes, but is not limited to, denial. Also included are the litany of excuses for continued use, the blaming of others, particularly family members and caregivers, for their failure to maintain abstinence, and the frequently cited identification with some other emotional problem that really needs to be addressed rather than the alcoholism itself. The negative consequences play little if any role in modifying the continued use, which is the final aspect of addiction. From ASAM's perspective, addiction and dependence can be used interchangeably. The varying concepts of physiological dependence, psychological dependence, and addiction are more thoroughly explored in Question 14.

Addictive behaviors may include gambling, sex, drugs, and all of the variations on those themes, which recently include the use of the Internet and involvement with pornography. From that simple definition, it appears that no biological or pathophysiological process must be invoked. The addiction may result from the involvement or the pursuit of an activity, rather than on what direct effect the pursuit of the activity may have on the brain. How can gambling or the Internet have the same effects on the brain as opiates or alcohol? There is no receptor specific for gambling or the Internet like there is for opiates or alcohol. Somehow the behavior and the pursuit of an activity take on a life of their own, to the exclusion of all other responsible activities. If that is the case, then how can addiction be a disease? This is the subject of our next question.

Susan's comment:

Unfortunately, Bens blood alcohol levels have been more than 400 or 500 several times. He always amazes those who treat him because he is so lucid. Although he exhibits intoxicated behavior, he is not "falling down drunk" and does not exhibit any signs of respiratory distress. One time,

however, he was in the high 500s and was comatose after arrival at the emergency room. Thankfully, he began to improve immediately with treatment.

Although I understand that he needs to be sober before treatment, I always worry that one day we wont be "crying wolf" and that something important might be missed with the overall diagnosis of "severe ETOH intoxication." Thus, I still continue to bring him to the emergency room. Sometimes I get tired of apologizing; however, many trips have been made to the same place for the opposite condition: complications from alcohol withdrawal. There is certainly a marked difference in the attitude of medical personnel at the times when he is clearly sick rather than drunk. Although I sometimes sense that caregivers believe that Ben "deserves" the punishing symptoms of withdrawal, for the most part, they are sympathetic to his plight and mine. Needless to say, I have become acquainted with people on the ER staff, who often say to me when I either bring him myself or follow the ambulance, "I dont know how you do it." Most of the time my response consists of two questions. First, I ask, "Do you have children?" When they nod their head, which most do, I simply ask, "Wouldn't you?" The look of disapproval that is in their eyes seems to give way to a bit more understanding after that.

After Ben is stable and while we are awaiting the results of the blood tests, I sometimes go back to my nearby office to fill in my co-workers who have watched this process so many times. Someone says, "Doesn't he realize what he's doing to you?" I reply, "First, he's got to realize what he's doing to himself."

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