According to the World Health Organization (WHO), addiction is a worldwide problem. Indeed, more than 15.3 million people confront drug abuse issues internationally, and the abuse of alcohol results in 3.3 million deaths every year (World Health Organization, 2018). A British Social Trends report (2002) notes that drinking, smoking, and drug addictions are rising in the United Kingdom, especially among young people, with more than 50 percent of teenage boys consuming these substances regularly by the age of fifteen. In the United States, the incidence of addiction is so high that there are insufficient trained professionals to assist those affected by drug abuse (Brandeis University Institute for Health Policy, 1993), precipitating a crisis in treatment. “Fewer than one-fourth of the persons in need of alcohol and drug abuse services in the United States actually receive treatment” (p. 60, as cited in American Psychiatric Association, 2008). Yet, according to WHO, such rehabilitation is cost-effective, saving seven dollars in “health and social costs” for every one dollar invested in drug treatment programs (WHO, 2008). The establishment and endorsement of addiction prevention and treatment programs are somewhat compromised by debates and controversies over cause.
According to the World Health Organization (WHO), addiction is a worldwide problem. Indeed, more than 15.3 million people confront drug abuse issues internationally, and the abuse of alcohol results in 3.3 million deaths every years (World Health Organization, 2018). A British Social Trends report (2002) notes that drinking, smoking, and drug addictions are rising in the United Kingdom, especially among young people, with more than 50 percent of teenage boys consuming these substances regularly by the age of fifteen. In the United States, the incidence of addiction is so high that there are insufficient trained professionals to assist those affected by drug abuse (Brandeis University Institute for Health Policy, 1993), precipitating a crisis in treatment. “Fewer than one-fourth of the persons in need of alcohol and drug abuse services in the United States actually receive treatment” (p. 60, as cited in American Psychiatric Association, 2008). Yet, according to WHO, such rehabilitation is cost- effective, saving seven dollars in “health and social costs” for every one dollar invested in drug treatment programs (WHO, 2008). The establishment and endorsement of addiction prevention and treatment programs are somewhat compromised by debates and controversies over cause.
Defining Addiction. Addiction is “a chronic relapsing illness with onset typically occurring in the early teenage years, followed by cycles of drug use and abstinence” (Elkashef, Biswas, Acri and Vocci, 2007). The source of addiction is complex and entails interactions between biological factors (specifically genes) and environmental factors. Some research suggests that some people are born with a higher tendency to become addicted (NIDA, 2008). According to this argument, addiction is a biological disease, much like diabetes or hypertension, and acquiring the tendency (or predisposition) to addiction is as much out of a person’s control as the predisposition to some other diseases.
Alternately, the environment in which people develop (including how they are parented, their socioeconomic status of origin, peer group influences, traumatic or stressful experiences and their levels of education) produces protective or risk-enhancement effects (Elkashef, Biswas, Acri and Vocci, 2007). While many laypeople may view addictive behavior as a choice, there is a growing consensus that both biology and environment are factors in addiction.
Nonetheless, even with explanations about brain chemistry and genetic predisposition, certain images of addiction prevail: the beggar on skid row or the drunk driver. Those images are powerful, and scientific jargon does not erase them from the cover of newspapers or the lead story on the six o’clock news. Concomitantly, Alan I. Leshner (1997) notes the difficulty in addressing such stereotypes:
One major barrier [to treatment] is the tremendous stigma attached to
being a drug user or, worse, an addict. The most beneficent public
view of drug addicts is as victims of their societal situation.
However, the more common view is that drug addicts are weak or bad
people, unwilling to lead moral lives and to control their behavior
and gratifications … We need to face the fact that even if the
condition initially comes about because of a voluntary behavior
(drug use), an addict’s brain is different from a nonaddict’s brain
… Recall that as recently as the beginning of this century we
were still putting individuals with schizophrenia in prison like
asylums, whereas now we know they require medical treatments (par.
Amphetamine-type stimulants are the second most widely abused drugs worldwide, after cannabis (United Nations Office on Drugs and Crime, 2016). According to the WHO Report on the Global Tobacco Epidemic, more than one billion people worldwide smoked tobacco as of 2017 and tobacco kills nearly seven million people each year (“Tobacco fact sheet,” 2017). In many instances, people who become addicted first use substances voluntarily. As Linda S. Cook (2001) noted, most teenagers have used some substance by the time they turn eighteen. One study (Sweeting & West, 2008) on the lifetime prevalence of drug use among a cohort of people in the United Kingdom (which tracked use over twenty years), found that drug use, in general, rose from 9 percent at the age of fifteen to 58 percent by age twenty-three.
Many addicts go through a cycle of abuse and recovery that is difficult to explain. As Leshner (2008) observes:
Many people equate addiction with simply using drugs and therefore
expect that addiction should be cured quickly, and if it is not,
treatment is a failure. In reality, because addiction is a chronic
disorder, the ultimate goal of long-term abstinence often requires
sustained and repeated treatment episodes (p. 10).
This cycle of repeated treatment and relapse is difficult for individuals with addiction, their families, and the general public to understand and can also be viewed as an excuse for an addict’s behavior. Davies (1997) notes that the biological source of addiction may be accepted for the wrong reasons, as a means to absolve people who behave badly because the disease is out of their control.
Neurobiology. The biological explanation for addiction is based on research linking addiction to significant changes to brain chemistry caused by repeated substance use. Different kinds of drugs produce particular responses in precise areas of the brain, although the mechanisms underpinning these responses vary, as do the outcomes (Elkashef, Biswas, Acri & Vocci, 2007). For instance, Leshner (1997) notes:
Virtually all drugs of abuse have common effects, either directly or
indirectly, on a single pathway deep within the brain …
Activation of this system appears to be a common element in what
keeps drug users taking drugs. Not only does acute drug use modify
brain function in critical ways, but prolonged drug use causes
pervasive changes in brain function that persist long after the
individual stops taking the drug … The addicted brain is
distinctly different from the nonaddicted brain, as manifested by
changes in brain metabolic activity, receptor availability, gene
expression, and responsiveness to environmental cues … That
addiction is tied to changes in brain structure and function is what
makes it, fundamentally, a brain disease (p. 45).
According to Nora Volkow (2008), director of the National Institute on Drug Abuse (NIDA), the recognition of addiction as a biological disease has not only changed the way of thinking about addiction for the scientific community but also the options for treatment.
When science began to study addictive behavior in the 1930s, people
addicted to drugs were thought to be morally flawed and lacking in
willpower. Those views shaped society’s responses to drug abuse,
treating it as a moral failing rather than a health problem, which
led to an emphasis on punitive rather than preventative and
therapeutic actions … addiction is a disease that affects
both brain and behavior. We have identified many of the biological
and environmental factors and are beginning to search for the
genetic variations that contribute to the development and
progression of the disease (Volkow, 2008, n.p.).
Genetics. In addition to biochemical factors and the cycle of addiction outlined above, according to D. Ball, M. Pembrey, and D. Stephens (2005), genetics is also a causal factor linked to addiction. For instance, they note:
Twin and adoption studies show that genetics contributes (along with
environment) to our vulnerability to different types of addiction,
probably via genes that regulate the metabolism of psychoactive drugs
and the brain neurotransmitter systems on which they act (as cited in
Hall, 2006, p. 1530).
To clarify any confusion about genetics, though, Hall (2006) makes the distinction that,
…it is not the case that if you have ‘the gene’ you will become
addicted and if you do not then you will not. Instead, addiction is
most likely to be a polygenic disorder that results from interactions
between the environment and the effects of a large number of genes
… that affect a variety of personal characteristics such as:
drug metabolism, levels of brain neurotransmitters and transporters,
preparedness to use drugs, school performance, susceptibility to
peer influence, and so on (2006, p. 1530).
Biology & Environment. Focusing on the combination of biology and environment, J. Shedler And J. Block (1990) conducted a longitudinal study to look at drug use in relation to psychological characteristics. Specifically, they assessed both ego and cognitive development during seven different interviews with each of the 101 participants at ages three, four, five, seven, eleven, fourteen, and eighteen years (p. 195). Shedler and Block note that at the age eighteen interview:
Of the 101 subjects for whom information about drug use was
available, 68 percent had tried marijuana … 39 percent … reported
using marijuana once a month or more, and 21 percent reported using it
weekly or more than weekly (p. 196).
Based on this data, the researchers created the following three categories of participants—frequent users, abstainers, and experimenters (p. 197) and they were able to make comparisons based on information they collected over the fifteen-year period of the study.
Throughout most of the study, frequent users displayed characteristics that were unique when compared to subjects in the other two categories. For instance, frequent users were identified as:
- Not dependable or responsible
- Not productive
- Unable to delay gratification
- Rebellious and nonconforming
- Feeling cheated and victimized by life
- Having fluctuating moods (Shedler & Block, 1990, p. 197).
When compared with subjects who had experimented with marijuana, the subjects in the frequent user group were identified as having adverse characteristics at the age eighteen interviews. Furthermore, “the frequent users appear to be relatively maladjusted as children. As early as age 7, the picture that emerges is of a child unable to form good relationships, who is insecure, and who shows numerous signs of distress” (p. 200). As children, these subjects exhibited similar characteristics as when they were eighteen.
In addition to assessing the child participants in the study, Shedler and Block also assessed the participants’ mothers and observed that “compared with the mothers of experimenters, both the mothers of frequent users and the mothers of abstainers were perceived to be cold, critical, pressuring, and unresponsive to their children’s’ needs” (p. 205). Such research suggests that how a person is treated by his or her primary caregiver when he or she is a child will most likely affect the way he or she behaves in later life, although it is not certain how that behavior will manifest. What is clear from this research, however, is that “the relative social and psychological maladjustment of the frequent users predates adolescence, and predates initiation of drug use” (p. 200). It is probable that the drug use leading to addiction is most likely the symptom of a greater issue.
Blame & Biology. One of the problems with addiction is that many people do not understand it and place blame on those who are addicted. Attribution theory explains the rules that people use to infer the causes of behavior. While people tend to attribute their own behaviors to their social circumstances (or environment) they attribute other people’s behaviors (especially socially problematic behaviors) to personality or biology (Davies, 1997).
John Monterosso, Edward B. Royzman, and Barry Schwartz (2005) tested attribution theory in a study to determine if people would be more willing to accept negative behavior if it was the result of physiology (biological make-up) rather than experience (environmental factors) (p. 139). Almost two hundred subjects participated with an almost even split between university undergraduates (n=96) and middle-class white adults in a suburban area (n=100) (p. 142). The participants were presented with several written scenarios that depicted characters intentionally behaving in negative ways. Each scenario randomly offered one of two explanations for the character’s behavior, and participants were asked to determine whether they thought the behavior was voluntary. For instance, in one scenario, a man killed a store clerk in an argument. The explanation given for this behavior was that either he had an exceptionally high quantity of a particular neurotransmitter or had a history of being severely abused as a child (Monterosso, Royzman & Schwartz, 2005, p. 143). The researchers were not surprised by their findings:
Observers judged actors as less responsible for misdeeds explained
physiologically than for those explained experientially …
Physiological explanations resulted in … less judged volition,
greater sympathy, greater blame mitigation, more positive treatment,
and a greater expressed likelihood by the participants that they
would also behave in the undesirable way if the antecedent were true
of them (Monterosso, Royzman & Schwartz, 2005, p. 150).
Specifically, one of the participants explained, “I don’t think it can be willpower or character if it is a brain thing” (Monterosso, Royzman & Schwartz, 2005, p. 153). In other words, the characters in the scenarios were considered less responsible for their actions—even when they murdered someone—when a physiological basis rather than an environmental basis was cited as the reason for their actions. In addition, subjects in the study felt sympathy for the characters based on the circumstance of biology.
Treating Addiction. There are three main approaches to treating addiction: behavioral (cognitive behavioral therapy or motivational enhancement), pharmacologic, and immunologic therapies, such as vaccines, especially for stimulant use disorders and nicotine addiction (Elkashef, Biswas, Acri & Vocci, 2007).
Research in the field of genetics suggests that there are biological underpinnings to drug abuse disorders, and, concomitantly, biological markers that can be identified (for instance, through brain imaging techniques) and used to plan more precise treatment regimes (Schumann, 2007). However, the routine use of genomic medicine is limited until future research further develops a proper methodology. In the meantime, there is no magic treatment for substance addiction, and while many people find success with twelve-step programs, in-patient programs, out-patient programs, or a combination of any of these, no program offers individuals suffering from addiction or their families a guarantee of sobriety.