It is important to understand the difference between physical dependence and addiction, two phrases that are sometimes used interchangably but that may or may not refer to the same thing, depending on the context.

Tolerance and withdrawal are signs of ‘physical dependence’ on a substance.  Addiction, on the other hand, is a complicated term that has different meanings in different contexts, but generally refers to an obsession or attachment to a behavior, person, or substance.

Many people mistakenly consider physical dependence and addiction to be the same thing.

22 Comments to
It’s the Obsession, Silly!

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  1. Hello;
    Apologies for burdening you with this, as I am sure you carry enough in your real life work; but I have been feeling rather confused lately, and this article seems to point to some level of clarity. Would you mind giving me a little more?

    I am an adolescent female who got drunk for the first time at twelve – as a reaction to my most severe major depressive episode up to that point – and comes from a long line of addicts of all kind (my father being one of them): alcoholics, caffeine, drug addicts, gambling, nicotine, shopping, and others – usually a combination. Mental illness is also prevalent, something I have inherited to the highest extent (Schizoaffective Disorder, Bipolar Type; Obsessive-Compulsive Disorder; numerous Anxiety disorders; Borderline and Avoidant Personality Disorder-traits; Asperger’s Syndrome; Sensory Processing disorder; and, after numerous life events, Post-Traumatic Stress Disorder and Dissociative Disorders). We’re an interesting bunch.

    My concern comes in now, however, with my own drinking. To use terms provided in this article, I seem to obsessed. There are many times – usually when I am in a depressive, psychotic, anxious, or mixed episode – that I begin to taste the alcohol(ic beverage) on my tongue – as if it were truly there! – and begin to want it with a yearning deeper than I can truly articulate. My head runs through possible ways to obtain it; I research the safety of drinking mouthwash; as my Dad hates alcohol, request pot; and, if all else fails, search the house for some other abusable drug: NyQuil, Robitussin, etc. It drives me mad. And when I finally do get that drink? It is if I can never stop. I am in a trance, and love it.

    I know that this seems to be a generally clear situation; but it is to me. This is because, literally, I can count the amount of times I have gotten drunk on my two hands – certainly no more than ten (though I wish it had been much more) – and I only indulged Robitussin once – backing out before I had taken enough to be high at any level. Most defiantly not enough time to form any physical dependence. Oh, and I haven’t had a drink in over a year (though I know it’s illogical, in my eyes – this is really unfortunate)! Yet, it holds me tighter than before. Somehow, my brain formed those alcohol connections at frightening rates.

    My question is this: is it really possible that I, a *fourteen* year old who has gotten drunk less times than many others her age – is…an alcoholic? An actual drinking problem? If I’m trying to rationalize and deny, I don’t want to stay that way; but I need to know, in your experience, is it possible? And if it is, would your suggestion be I abstain?

    Though I am extremely open to my psychiatrist about everything – from anxiety to suicidal planning – this is one thing I really minimize. Not because of his reaction; but because I’m still so unsure about it. He has mentioned before that the way I talk about alcohol sounds like the talk of someone who drinks a lot. I know that’s true.

    With Lovel
    Ire

    • If you are truly only 14 years old (I am not sure of the meaning of your asterisks), then you are quite insightful for your age. I have sometimes wondered if counter to how most of us see our development, we actually become MORE confused as we age… your clear presentating adds weight to that idea.

      This is just my opinion, but to answer your question directly– yes, absolutely. I have heard many alcoholics and addicts over the years who described themselves as ‘addicts from birth’, and I think that others refer to something similar when the talk about an ‘addictive personality.’ You would not meet the criteria for alcoholism in the DSM, but labels have utility in some situations– and little utility in others. The relevant issue is that you have identified a trait within yourself, and (in my opinion) correctly identified the trait as one that carries potential danger.

      I would guess that alcohol has become a sort of ‘proxy’ for anything that makes life a bit less vivid. The fact that you see a psychiatrist at age 14– and the fact that you have been drunk 10 times at age 14– suggests that you may have been through more emotional pain than would be typical for other young women. You are also clearly inteliigent, and it only takes a quick look at literary figures throughout history to realize that bright, expressive people carry a heavy emotional burden. Knowing this latter fact, it only makes sense to do what you can, proactively, to keep yourself ‘safe.’ And it appears pretty clear that substances including alcohol would represent a threat to your well being.

      If you do decide to ‘just say no,’ and I strongly suggest that you do, I can assure you that you are not missing all that much. I cannot deny that there is some fun in being intoxicated in the appropriate setting, but in the grand scheme of things, there is much more to be gained– fun and otherwise— in remaining fully aware.

      Thank you for writing, and I wish you all the best going forward.

      Jeff J

  2. *but it isn’t to me

  3. Doctor,

    This article left me a bit confused on one point. The article starts by helpfully defining and making a distinction between two terms: “physical dependence” and “addiction.” Then later in the article, the term “opioid dependence” appears, seemingly as an extension of the term addiction and discussed in that context. Is opioid dependence defined as the combination of physical dependence and addiction? Is it possible, in your view, for opioid dependence to present itself as physical dependence only and not necessarily with addiction?

    • Hi Matt– I replied to your question after Kelly’s post, at least in part. As for your question about opioid dependence presenting only as physical dependence, the psychiatric definition for opioid dependence would be the criteria for ‘abuse’– such as using in spite of negative consequences– plus the addiction of tolerance or physical dependence. ‘Physical dependence’ is more a phenomena than a diagnosis. And ‘addiction’ is not really an official medical term– so it is sort of imprecise for me to use it.

  4. Yes, I am truly only fourteen. For almost a year no – I’ll be fifteen in January. As for your theory about clarity, I seem to think it’s a cycle. You go from confused (starting with birth/ early infancy), to clear (starting with late infancy – early/under two toddler-hood), and repeating like that until death. Each stage attempting to prepare us for the next. And which stages are the confused ones are different for each person, as do our definition of such adjectives.

    I can identify with the ‘addicted from birth’ sentiment. Even in my earliest years, it was always something. From candy in my younger year (to the point of illness and weight issues), to later issues with video games (to the point of isolation), internet (to the point of failing grades), caffeine (twelve pack of coke a cola in less than thirty minutes), eating disorders, and now, as it seems, with alcohol/substance. With each one, and especially with the latest, it becomes my obsession, and once I indulge, I can’t fight myself away. As I said, it’s an aggressive trance.

    I try not to compare myself to others; but it is hard to see the gap between I and my peers’ experience. Already with a natural tendency for intense feeling, the trauma of family dysfunction (addicted father; mentally ill mother), bullying, sexual abuse, and psychiatric illness have set me up for a neurotic character. Thank you for your compliment on my intelligence – it does mean a lot. As for your point that prominent literally figures also seemed to suffer greatly, I am reminded of two of my favorite poets: Edgar Allen Poe and Sylvia Plath. I can only hope that I not only attain their level of poetic genius; but I also attain a more positive completion of my life.

    Honestly, though, Thank You for taking the time to respond. I needed the validation that there was reason for me to be concerned, and be proactive about it. That I wasn’t being a Hypochondriac, or something else of the sort. That there is actual cause to bring this up with my psychaitrist.

    I will take heed to your suggestion, and try to abstain; but, I doubt it will be that simple. If I can go a year without drinking, and still experience that obsession as I drank yesterday, then I have a feeling it wouldn’t be hard to dive headfirst into it later on, or if to appear in the future. For some reason, I doubt I’ll be able to drink normally – my brain just doesn’t seemed wired for it. From where I stand – and I, of course, hope I’m wrong – this will be something I will war with for many years. And I think I might be OK with that.

    Thank You Once Again.
    It meant a lot.

    Ire

  5. For almost a year no ——>
    *For almost a year now

    I try not to compare myself to others; but it is hard to see the gap between I and my peers’ experience. —–>
    *I try not to compare myself to others; but it is hard not to see the gap between I and my peers’ experience.

  6. *as if I

  7. I have the same question as Matt. I used suboxone for 5 months, as a stepping stone to get off hydrocodone (10 yr habit). Since I started the suboxone, and even after I quit, I have had 0 (ZERO) cravings or desire to use hydrocodone for the high it gave me. Am I an addict? Why do I have to introduce myself as an alcoholic at AA meetings when I hate alcohol? (I haven’t been drunk in 25 yrs, don’t like alcohol).

    • Thank you for your comments. I am being careless when I use the term ‘addiction.’ I am not certain how the new version of the DSM (the DSM-V, coming out next year) will categorize things, but the current diagnostic verbage does not include the term ‘addiction.’ The use of substances is divided into substance USE disorders and substance INDUCED disorders. The USE disorders are substance abuse and substance dependence, and a major part of the latter diagnosis would be physical dependence or tolerance. Physical dependence alone is NOT considered a psychiatric illness, but rather is just an expected part of the use of any medication– including non-psychotropic medications.

      ‘Addiction’ is a layperson’s term, or at least it should be, as it lacks true specificity in regard to what is going on. I use the term because some people are confused by the term ‘substance dependence,’ thinking that it is something less severe than ‘addiction.’

    • It is generally accepted, Kelly, that alcoholism or any substance dependence is a life-long condition; something that people never totally ‘recover’ from. So we are ‘in recovery’ as opposed to being ‘recovered.’ People who do well on buprenorphine lose the obsession to use, but that obsession often returns if the buprenorphine is discontinued– at some point if not immediately. I like the term ‘remission’ for addicts on buprenorphine; the situation is different from the ‘maintenance’ state of people on methadone, because the partial agonism of buprenorphine has unique actions that eliminate the obsession for opioids in a way that methadone does not. From MY perspective, a person who has been addicted to opioids will always be an ‘opioid addict’; if the cravings are gone and the person is not using, I would consider the person’s addiction to be in remission.

  8. Obsession is actually one of three markers at our facility that determines if one is just abusing drugs or alcohol or has an addiction. We call it ‘compulsion’ and the other two markers are ‘control’ (once you start drinking or using you cannot set limits to how much is consumed) and ‘consequences’ (you continue to drink or use even though you experience negative consequences such as an impaired driving charge or losing your job). Consequences, not obsession (compulsion) is widely regarded as the key determinant in whether one has an addiction or not.

    The other point I want to make is that your focus on character defects is not helpful at all. This is the old ‘moral model’ of addiction (people drink or use because they have a character defect). The ‘disease model’ of addiction and the medicalization of addiction treatment arose in response to this. Addiction treatment needs to stay away from the moral model because it ends up objectifying people with addictions and prevents the client-centered approach espoused by Dr. Carl Rogers and many others in current psychotherapy circles. Talking about character defects is really a non-starter regardless of whether you’re talking about pharmacological approaches like buprenorphine or conventional talk therapy.

    • Using ‘consequences’ as a determinant of whether one has an addiction is not appropriate. By that approach, a person’s addiction is more a function of the behavior of others, than of the addict’s own obsession to use! There are plenty of suffering addicts out there who have essentially NO consequences, other than their own misery; there are other addicts with minimal use who face very severe consequences– for example 8 years in prison for sharing a couple tablets of methadone. The DSM refers to using in spite of repeated negative consequences as a marker of the addict’s obsession– and nothing more.

      As for focusing on character flaws, your point is mine– that addiction is best approached as the disease that it is, without regard to character defects. My complaint is that treatment programs talk that talk– but don’t walk the walk. Most are centered around a 12 step philosophy– and you can’t remove the character issue from the steps without completely gutting the 12-step approach. Remove the Higher Power and character defects from the steps and what’s left?

      I’m all in favor of treating addiction like we do all diseases– if you read my posts, you will see that as the underlying theme.

  9. your fundamental premise, “To summarize, by the old paradigm, addicts develop character defects from using, and treatment relies on the intensive repair of these character defects” is completely inaccurate.

    • You are free to comment more, Ellie. I’ve been ‘at the tables’ for 17 years, in treatment centers as patient and as part of the treatment team– and I have my perspective. Feel free to share yours.

  10. Then how do the 12 step programs work? Or perhaps, it just “works” for the small percentage of people for whom a placebo would work just as well?

    I have found Steps 1-3 very useful so far in my early recovery. However, after reading here, I am concerned my chance of relapse remains high in the 12 step program, and of course there are no statistics. I do know the people in the program all have stories of alcoholics and addicts with long recovery times, who suddenly relapsed.

    As far as the disease model of addiction, I saw a movie at a recovery lecture series, made by a doctor who specializes in addiction study, and is called “Pleasure Unwoven”. The theme is that addiction is a disease. The brain of addicts behaves differently when they are in active addiction, and the control aspects of the frontal cortex are overriden by the primitive part of the brain, which believes the drug is necessary for survival.

    • I firmly see addiction as a disease; it meets any criteria for a ‘disease’ that one would come up with. ALL diseases have SOME behavioral contribution– for example most lung cancers are caused by smoking– but that does not make them ‘less disease-like!’

      I have spent a great deal of thought on the ‘scientific basis’ for twelve step programs. They DO work, for SOME substances more than others. People seem to think that if AA works for alcohol, it should work for everything. But some substances are more addictive than others– and some substances find a deeper place of ‘meaning’ in an addict’s personhood. Addicts see crack use as ‘going somewhere.’ They see opioid use as ‘returning home.’ The spiritual dimension of AA may be appropriate for turning a person away from crack, but do little for a person addicted to opioids.

      I tend to see step programs as ‘maintenance treatment’– similar to pharmacologic maintenance treatment– in that when a person stops attending AA, relapse often follows. Medication holds the addict’s mind in an artificial state; AA meetings hold the addict’s mind in an artificial state.

  11. I must agree with Dr. Junig here. In all of my experience, even though the treatment establishment espouses and claims to adhere to the medical/disease model of addiction, the treatment providers still actually – secretly? – yet not so secretly adhere to the moral model of addiction.

    If they did not, addicts would be treated the same as an individual with any other disease, and patients in addiction treatment would not be referred to the twelve-steps mode, while, espousing the “medical model” on one side, clearly falls within the jurisdiction of the “moral model”, as even a cursory examination of any of the steps will show you.

    By the way, consequences of use are a product of obsession, not the other way around, and not separate; they are two phenomena of the same underlaying etiology. If the addict had no obsession, he would quit using when the consequences became negative; if the addict had negative consequences but no obsession, any college kid who has blacked out or passed out drunk, or been arrested for pot smoking even a single time in his or her life is an addict.

    This is clearly not the case. It is obsession that drives the desire to use again repeatedly in the face of ever increasing negative consequence, instead of “toning down” one’s use.

    Thank you,

    Lucciano Marchese PhD DPharmSci

  12. Do you consider suboxone and AA/NA as alternative maintenance treatments? Both work as long as they are used, but neither provides a permanent cure.

    I was in AA/NA in the 1980′s and had several years clean and sober. Then I thought I was cured, and forgot to stay away from substances. A few yrs later, I drank a bit of wine after dinner, then fell in love with Tylenol 4 after a root canal, but took only 1/day for several yrs. Then, to my great luck, or so I thought, I read in the WSJ about internet pharmacies where you could get pain meds from your computer. And I started on 20 hydrocodones/day and eventually worked up to 40/day.

    However, I turned down many chances to get on stronger meds, such as morphine, oxycontin, etc. I once had a fentanyl patch in the hospital and ripped it off within an hour because again, I did not like to be “out of it”. I liked to keep a little buzz going, and then was unable to handle the withdrawals.

    So contrary to what AA/NA teach, my addiction did not progress, but became lighter. I used to freebase cocaine (and shot up a few times) and get very drunk regularly in the 80′s, and then as I got older my drug and alcohol use was much lighter.

    • Our experiences sound similar in some ways. I was a huge ‘AA’er’ for many years, then started enjoying wine after dinner (I was an opioid addict; I had never been that interested in alcohol, other than truly liking a glass of wine with a nice dinner). But once I started having the wine, AA meetings fell by the wayside, and a few years later I relapsed on codeine. Unlike you, my experience was the typical AA-described path– I went crazy with the opioids at a pace much greater than before my 7-year period of sobriety.

      Yes– I consider them both a form of ‘maintenance’. Actually I prefer the term ‘remission’, as in both cases, the forces of addiction are halted– not ‘maintained’, as they are with agonist therapy (for those who don’t know about the actions fo buprenorphine, they are profoundly different than the actions of methadone– both at the receptor level and as for their effect on addiction). Both buprenorphine and meetings relieve the obsession to use– buprenorphine by neurochemical receptor actions, and meetings by reminding and reinforcing our powerlessness. Both, if used properly, will eliminate the obsession for opioids… but both stop working if they are not used regularly.

  13. I am wondering how to help someone with an opiate addiction, who is in recovery but is struggling .. what is the best thing to do for them? be there for them, force them to throw out things they have, stop being there for them and tell them when they’ve stopped you’ll be there for them .. how do you help someone you care about who is dealing with this addiction with out pushing them away?

  14. I don’t think that you can realistically help someone until you are not afraid of pushing them away. During active addiction, addicts ‘use’ friendships– they do not participate in them. Sadly, the consequences, including loneliness, are what often push an addict toward getting help.

    That doesn’t mean that you have to leave– it means that you need to have someone ELSE treating the addict, rather than you. Someone who can stand up to the threat of ‘losing’ the person.

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