Addiction beyond substances : gambling, food, sex and relationships
by Raju Hajela, CD, MD, MPH, CCFP, CASAM, CCSAM, FASAM, FCFP
Family, Community and Behavioural Medicince, Kingston, Ont.

The nature of addiction involves a loss of personal choice for the individual. While addiction is usually linked to substance dependence, patterns of the disease can manifest in other behaviors as well.

Addiction is a term traditionally associated with psychoactive or mood-altering substances where the person uses the substance of choice to excess, preferentially over other things and/or other aspects of their lives. Pharmacologically, it has been associated with the phenomenon of tolerance, where increasingly larger amounts of a substance are required to produce a desired result of intoxication, and with withdrawal symptoms, which occur when the blood level of the addictive substance is declining. Generally, people somewhat erroneously use the term addiction to describe a fondness for something that they like to do a lot, which can range from substances, food, or any behavior. There is often a misguided assumption that addictive behavior is driven by personal choice.

In reality, addiction is an insidious and powerful disease that takes control over a person's life, thus creating a significant amount of despair for the person affected and those around them. As much as there may be a choice component in the initiation of the use of a substance or engagement in an addictive behavior, the personal choice is increasingly lost. The emergent pattern is that of increasing desire that can never be totally fulfilled. The chase after that desire becomes associated with neglect of responsibilities, excessive time spent in the chase and/or recovering from its effects, and restriction of the normal social, occupational, or recreational activities.

This article will explore the concept of addiction, starting from the perspective of substance dependence but broadening it to various behaviors that are part of the disease of addiction with or without evident problems related to substance use.

Substance abuse, dependence, addiction: What is the difference?
Medical literature has avoided the term addiction in its diagnostic nomenclature over the last several decades, presumably to avoid any pejorative connotations. The term in widespread use is "substance abuse" and the diagnostic distinctions between substance abuse and substance dependence are not appreciated, despite being clearly spelled out in DSM IV,1 the most commonly used standard for classification of mental disorders (see Table 1).

Current research has delineated molecular sites of action for every major drug with abuse potential. For example, opioids bind to the opioid receptor; cannabis binds to the cannabinoid receptors, and cocaine blocks the reuptake of dopamine into presynaptic axon terminals. Regardless of the particular receptor complexes involved, the common denominator appears to be the reward of dopamine release in the mesolimbic system, which is essential in the perception of feelings.2,3

Clinicians in the field of addiction medicine have increasingly recognized that patients suffering from substance dependence will often engage in other behaviors in patterns similar to the use of their drug(s) of choice. As well, many patients have certain behavior patterns that have become problematic in terms of impaired control without an apparently identifiable use of a substance. Common behaviours thus identified are gambling, eating disorders, sex and love, relationships, exercise, work, Internet, shopping, etc. (see Table 2).

This has led to the development of a more unitary view of addiction that underscores the common denominator of an addicted brain displaying a surge of dopamine release in the nucleus accumbens, as mediated by the mesolimbic dopamine system regardless of the drug of choice; and a close link between these reward pathways and appetites (e.g., food, sex, money, power, relationships) has been observed. From a practical point of view, the criteria for substance dependence can be easily applied to any of the addictive behaviors (see Table 3).

It has become increasingly clear in patient care that people suffering from dependence or addiction may have one or more drugs or behaviors of choice that feed their addictive disease. In light of the growing clinical experience and convergence of concepts, the Canadian Society of Addiction Medicine adopted the following definition in 1999:4

Addiction
A primary, chronic disease, characterised by impaired control over the use of a psychoactive substance and/or behavior. Clinically, the manifestations occur along biological, psychological, sociological, and spiritual dimensions. Common features are change in mood, relief from negative emotions, provision of pleasure, preoccupation with the use of substance(s), or ritualistic behavior(s); and continued use of the substance(s) and/or engagement in behavior(s) despite adverse physical, psychological, and/or social consequences. Like other chronic diseases, it can be progressive, relapsing, and fatal.
The above definition is consistent with dependence but not abuse. Therefore, it must be appreciated that substance abuse and addiction are not interchangeable terms. Substance dependence can be used interchangeably with addiction, with the additional understanding that addiction is a disease that goes beyond the use of substance(s) to many behaviors that present problems for an individual much like psychoactive substances. The dysfunction and distortions in the psycho-social-spiritual dimensions require considerable attention, regardless of the substance(s) and/or behavior(s) of choice. The implications are that assessment and treatment need to be broadened to help people appreciate the impaired control, and establish "abstinence" so that the negative effects are minimized and healthier behaviors with clarity of thought and feelings are established. Abuse can be considered an earlier-stage problem that represents a risk for progressing to addiction.

In active addiction, the relationship between the drug(s) and/or behavior(s) of choice takes precedence over any other relationship, including oneself. Impaired control makes the concept of willpower meaningless. Self-deception feeds denial, rationalization, minimization, and covert deceptive manipulation of others.5 Anger in those around the addict resulting from the manipulation and apparently overt lying can actually increase the resistance. The addict can use "mistreatment" by others as justification of their addictive behavior. Appeasement, excusing or covering up by others also feeds the disease. The term "codependency" is often used to describe the phenomenon whereby significant others around an addict become more and more preoccupied with the thoughts, feelings, and behaviors of the addict in attempts to maintain control over various aspects of their life. The challenge is to reflect reality to the affected person and draw appropriate boundaries without trying to control the person's behavior. Codependency can be considered to be in the diagnostic category of abuse, whereas more extreme reactions and entrenched behavior patterns in this regard represent relationship addiction.

Dimensions of addiction
The biophysiological dimension of addiction is characterized by a genetic predisposition, altered biochemical pathways and neurotransmitters that are being identified by more recent brain research. These include the opioid pathways, cannabinoid receptor system, NMDA and glutamate receptor pathways, and serotonin, dopamine and norepinephrine neurotransmitters.2,3 The psychological dimension is characterized by distortions in thinking, feelings, and perception. The social dimension dysfunction results in neglected responsibilities, increasingly narrowing of activities, and associations that perpetuate addiction. The spiritual dysfunction is characterized by loss of values, meaning, and purpose in life. As the disease progresses, there is increasing distortion in beliefs, unmanageability, pre-occupation, ritualization, compulsivity, and despair (see Figure 1).

The entire world we live in, for every human being, is characterized by desire. It is desire that can turn engagement in a behavior for fulfillment into excess or abuse. When craving, ritualization, compulsivity, and obsession for "more" takes on a life of its own, we know that the disease of addiction has taken hold. The dance of powerlessness and unmanageability play out over a personally distorted perspective of power and control within the addict. The recognition of this central theme led Bill W. and Dr. Bob S. to establish the 12-Steps of Alcoholics Anonymous (AA),6 where the first step involves an admission of powerlessness over alcohol and unmanageability of one's life. The problems related to anger, fear, shame, and resentments were well recognized, as were problems related to sexual conduct. Since then, AA has inspired the establishment of Narcotics Anonymous (NA), Overeaters Anonymous (OA), Cocaine Anonymous (CA), Marijuana Anonymous (MA), Gamblers Anonymous (GA), Sex and Love Addicts Anonymous (SLAA), Sexaholics Anonymous (SA), etc. The robustness of the 12-Steps and the unitary view of addiction are evident in that only one word differs for each of these groups in their Step One, where alcohol is replaced by the particular substance or behavior of choice. NA uses the word addiction and emphasizes that the disease is much more important to talk about, rather than a particular drug or associated rituals.

The addicted patient acts with a rigid set of beliefs and boundaries that allows the person to organize the world by being angry with themselves and projecting or displacing the anger onto others. Eating, binging, purging, or starving are all automatic, self-destructive responses that function to create numbing and allow escape from intolerable feelings. A behavior that may have started in response to some trauma, takes on a life of its own. Gamblers take risks that create the illusion of power and control where in reality, chance leads to alternating between euphoria and anguish that ultimately turns to despair deep in one's soul. Increasing unmanageability is manifested in the form of over-control or under-control, acting-in or acting out, living in the extremes and deepening the shame of not being able to stay in balance (see Figure 2 and Figure 3).

Challenges in assessment, diagnosis, treatment
The greatest challenge in assessment and diagnosis of addiction is to look beyond the ruse the patient may be creating, often unknowingly, to avoid talking about the real issues. This avoidance, minimization and/or rationalization are often called denial. Colloquially, it is also referred to as "Don't Even know I Am Lying!" Routine questions about the relationship between the person, recreational drugs, and other addictive behaviors are important for family physicians since they get to know their patient more intimately. Open-ended questions about what a person may be doing to cope with life and the extent of unmanageability are essential. It is also important to recognize, that despite providing the physician with ample evidence, the patient may yet be unwilling to look at reality. Even in the resistant patient, someone in precontemplation, it is essential to document the evidence with the offer for help if/when the person is more willing. The physician's task is to document the evidence and periodically bringing it up for review if/when the patient is willing. It is also essential to link any further consequences of addiction to problems that the patient may present with in subsequent visits. Cajoling, shaming or detailed discussion about treatment with someone in precontemplation is not fruitful and only leads to increasing frustration for both patient and doctor.

The patient in contemplation or preparation for changing their life is much more receptive to discussion about treatment possibilities. Every physician must appreciate that people will stay in dysfunctional systems because they are familiar, whereas healthier choices may be so unfamiliar that they generate a lot of fear and shame. More exploratory discussion, about potential obstacles and pitfalls to avoid, is very important. The physician must avoid "shoulding" on the patient. Deeper understanding of the patient's circumstances is necessary to come up with options to try rather than becoming focused on "right" or "wrong" ways. Relapse prevention and learning from relapse involve continual vigilance and review of thoughts, feelings and behaviors associated with people, places, and things that are part of the dysfunctional system.

Fellowship with people who have first-hand knowledge of the anguish of addiction is a necessary element of recovery. It is extremely important to appreciate that it takes 2-5 years of action for recovery behaviors to have a strong foundation. The time is also needed to address fear, anger, and shame, so that life events can be examined with greater honesty and clarity. The combination of individual and group psychotherapy, combined with strong community networks of support (often in the form of 12-Step programs) are associated with the best recovery outcomes. Interestingly enough, some patients who are too focused on their drug or behavior of choice will act out in other aspects of addiction and continue to suffer more, despite some basic grounding in recovery concepts. The chronic disease aspect also means that the relapse and/or substitution risks remain for a lifetime.

Medication
The use of medications, even for seemingly therapeutic purposes, can present difficulties to someone with the disease of addiction. Beyond the treatment of acute withdrawal or an acute procedural intervention, benzodiazepines, specifically, are contra-indicated for individuals in recovery. Prescription of antidepressants in the presence of active addiction can be very problematic because they often do not produce the anticipated benefit and/or reinforce looking for a "pill" solution rather than taking an honest account of what behaviors require change. As specified in the DSM IV, a psychiatric diagnosis cannot be made accurately in the presence of active psychoactive substance use. Similarly, behavioral aspects of addiction can mimic psychiatric syndromes that settle with appropriate recovery action. True concurrent disorders (i.e., one or more Axis I diagnoses in addition to addiction) require more detailed evaluation and patient monitoring. Judicious use of psychotropic medication is essential in these circumstances, keeping in mind that the act of taking a pill can be a trigger to the addicted individual7. Opioids are another class of medication that are psychoactive and can trigger addiction. Although opioid tolerance and/or withdrawal are not enough for a diagnosis of addiction and themselves do not cause addiction, prolonged use can complicate and unmask features in a patient that add up to addiction after someone has started chronic opioid therapy. Hence, a thorough addiction assessment and ongoing monitoring are needed for chronic pain patients on opioids. Chronic pain patients who also suffer from addiction require much stricter controls around their opioid prescriptions.

Spirituality
Spiritual aspects, clarification of values and meaning in life, are essential to a well-grounded recovery program. The recovering person must become aware of how they can affect change and when they require exernal assistance and awareness of power greater than themselves. Initially, "higher power" can be other recovering people who ultimately assist in connecting with the natural rhythms of life and the rest of the universe. Personal spiritual growth leads the person to become much more aware of the impact their behavior has on their lives and on those around them in the short-and long-term. Increased connectedness leads to more interdependence, an appreciation of everything life has to offer, and the attitude of gratitude. The Serenity Prayer "God, grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference" becomes a touchstone for living life in recovery, one day at a time.

References

1American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM IV). Washington: American Psychiatric Press, 1994.

2Leshner, Alan I. Understanding Drug Addiction: Implications for Treatment. Hospital Practice 1996;Oct 15.

3Dupont, Robert L. The Selfish Brain: Learning from Addiction. Washington: American Psychiatric Press, 1997.

4Hajela, Raju (ed). Definitions in Addiction Medicine. Kingston, Ont: Canadian Society of Addiction Medicine, 2000.

5Twerski, Abraham J. Addictive Thinking: Understanding Self-Deception. Center City, Minn: Hazelden Foundation, 1997.

6Alcoholics Anonymous World Services, Inc. The Big Book (4th ed'n), New York:, AA World Services, 2002.

7Alcohol use and abuse in patients with psychiatric illness. Toronto: The Medicine Group Ltd., 1997:1-3.

For figures and tables, please refer to the original article at http://www.cma.ca/index.cfm/ci_id/5565/la_id/1.htm.