Addictive disorders and their nature

By Professor Saunders


Image credit: Gamble by Michal Parzuchowski. Public Domain via Unsplash.

What are addictive disorders? Are they indeed disorders? The nature of problematic psychoactive substance use continues to be a matter of controversy among the public and politicians; even among health professionals there is little consensus. 

The key issue is that the nature of these conditions changes over time. On the first occasion somebody takes a substance or gambles or plays an on-line game, it is their choice. Moving from occasional use to repeated use typically involves social and psychological processes whereby further use is encouraged by a positive experience of the substance but also by the interaction of others who are drinking, smoking marijuana (read this freely available chapter), or gambling together. Substance use and related activities are “socially infectious” conditions.

Repeated use of a substance may not remain something that is a flexible behavior which can be changed when circumstances change. The reason for this is that it affects nerve circuits and nuclei in the brain. Psychoactive substances do this because they get through the blood-brain barrier and cause changes directly. In the case of gambling, gaming, and other repetitive behaviors, there is internal release within the nuclei of chemical transmitters. Repeated exposure to external substances and internal chemicals affects the vital functions of these nuclei (such as reward functions and survival responses such as the fight-flight reaction). As a result, adaptive changes occur in the nerve circuits in these nuclei, which mean they are in an altered state, which scientists call “allostasis”. The allostatic state means that a powerful internal drive develops which drives forward the use of that particular substance (or engagement in gambling or gaming ever onwards).

The driving force is the central feature of what becomes an addictive disorder. Disorder is defined as a set of symptoms and features which has a known cause or predisposing factors, and has a distinctive course or “natural history.” When the internal drive has developed, repeated substance use becomes the norm to maintain the allostatic state; no more is it a free-will decision. If substance use does not continue, the person feels its lack.

There should be an understanding of the need for the patient to abstain from the addictive substance or behavior and to rebuild their life based on that. When a powerful engine is out of control, it is essential to deprive it of fuel. On the basis of sobriety, the underlying issues (often stemming from adverse experiences in childhood or the nature of their upbringing) can be addressed so that the patient experiences a sense of healing and the ability to move forward and be in the “driving seat” of their lives.  

John B. Saunders is a Professor and Consultant Physician in Internal Medicine and Addiction Medicine at the University of Queensland, University of Sydney, St. John of God Health Care, Wesley Health Care, and South Pacific Private Hospital, Sydney, Australia.

He is one of the editors of Addiction Medicine, Second Edition, available in print and online.


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