The Essence of Drug Addiction

By Alan I. Leshner, Ph.D., Director, National Institute of Drug Abuse, National Institutes of Health (1994-2001)
(NAPS) The word addiction calls up many different images and strong emotions. But what are we reacting
to? Too often we focus on the wrong aspects of addiction so our efforts to deal with this difficult issue can be
badly misguided.
Any discussion about psychoactive drugs, particularly drugs like nicotine and marijuana, inevitably moves to
the question but is it really addicting? The conversation then shifts to the so-called types of addiction
whether the drug is physically or psychologically addicting. This issue revolves around whether or not
dramatic physical withdrawal symptoms occur when an individual stops taking the drug, what we in the field
call physical dependence.
The assumption that follows then is that the more dramatic the physical withdrawal symptoms, the more
serious or dangerous the drug must be. Indeed, people always seem relieved
to hear that a substance just produces psychological addiction, or has only
minimal physical withdrawal symptoms.
Then they discount its dangers. They are wrong. Marijuana is a case in point
here, and I will come back to it shortly.
Defining Addiction
Twenty years of scientific research, coupled with even longer clinical experience,
has taught us that Focusing on this physical vs. psychological distinction is off
the mark, and a distraction from the real issue. From both clinical and policy
perspectives, it does not matter much what physical withdrawal symptoms occur.
Other aspects of addiction are far more important.
Physical dependence is not that important because, first, even the florid
withdrawal symptoms of heroin and alcohol addiction can be managed with appropriate medications.
Therefore, physical withdrawal symptoms should not be at the core of our concerns about these substances.
Second, and more important, many of the most addicting and dangerous drugs do not even produce very
severe physical symptoms upon withdrawal. Crack cocaine and methamphetamine are clear examples. Both
are highly addicting, but stopping their use produces very few physical withdrawal symptoms, certainly nothing
like the physical symptoms of alcohol or heroin withdrawal.
What does matter tremendously is whether or not a drug causes what we now know to be the essence
of addiction: uncontrollable, compulsive drug seeking and use, even in the face of negative health and
social consequences. This is the crux of how many professional organizations all define addiction, and how
we all should use the term. It is really only this expression of addiction uncontrollable, compulsive craving,
seeking and use of drugs that matters to the addict and to his or her family, and that should matter to
society as a whole. These are the elements responsible for the massive health and social problems caused
by drug addiction.
Alan I. Leshner, Ph.D.
Essence of Addiction
Drug craving and the other compulsive behaviors are the essence of addiction. They are extremely difficult
to control, much more difficult than any physical dependence. They are the principal target symptoms for
most drug treatment programs. For an addict, there is no motivation more powerful than drug craving. As
the movie Trainspotting showed us so well, the addicts entire life becomes centered on getting and using
the drug. Virtually nothing seems to outweigh drug craving as a motivator. People have committed all kinds
of crimes and even abandoned their children just to get drugs.
Rethinking Addiction
Focusing on addiction as compulsive, uncontrollable drug use should help cIarify everyone's perception
of the nature of addiction and of potentially addicting drugs. For the addict and the clinician, this more
accurate definition forces the focus of treatment away from simply managing physical withdrawal symptoms
and toward dealing with the more meaningful, and powerful, concept of uncontrollable drug seeking use.
The task of treatment is to regain control over drug craving, seeking and use.
Rethinking addiction also affects which drugs we worry about and the nature of our concerns. The message
from modern science is that in deciding which drugs are addicting and require what kind of societal
attention, we should focus primarily on whether taking them causes uncontrollable drug seeking and use.
One important example is the use of opiates, like morphine, to treat cancer pain. In most circumstances,
opiates are addicting. However, when administered for pain, although morphine treatment can produce
physical dependence which now can be easily managed after stopping use it typically does not cause
compulsive, uncontrollable morphine seeking and use, addiction as defined here. This is why so many cancer
physicians find it acceptable to prescribe opiates for cancer pain.
An opposite example is marijuana, and whether it is addicting. There are some signs of physical
dependence or withdrawal in heavy users, and withdrawal has been demonstrated in studies on animals.
But what matters much more is that every year more than 100,000 people, most of them adolescents, seek
treatment for their inability to control their marijuana use. They suffer from compulsive, uncontrollable
marijuana craving, seeking and use. That, makes it addicting, certainly for a large number of people.
Treating Addiction: Follow The Science
It is important to emphasize that addiction, as defined here, can be treated, both behaviorally and, in
some cases, with medications, but it is not simple. We have a range of effective addiction treatments in
our clinical toolbox although admittedly not enough. This is why we continue to invest in research, to improve
existing treatments and to develop new approaches to help people deal with their compulsive drug use.
Our national attitudes and the ways we deal with addiction and addicting drugs should follow the science
and reflect the new, modern understanding of what matters in addiction. We certainly will do a better job
of serving everyone affected by addiction addicts, their families and their communities if we focus
on what really matters to them. As a society, the success of our efforts to deal with the drug problem depends
on an accurate understanding of the problem.
Further information on drug abuse and addiction can be found on the NIDA homepage at www.nida.nih.gov.
Free publications can be ordered from the National Clearinghouse for Alcohol and Drug Information by calling
1-800-729-6686. The National Institute on Drug Abuse (NIDA)