Definitions Of Addiction: Historical Views Versus Today’s Views
The definitions of addiction have changed throughout the years since the classification of substance use disorders began in the early 19th century.
Addiction is a complex process. What drives people to use illicit substances or alcohol in destructive ways? What makes someone keep using despite things spiraling out of control? There are several underlying motives that encourage substance misuse. Can we use the word encourage? Maybe motivate? Regardless, one motivating factor could be the “high” one feels when they use a substance. The pursuit of pleasure. But what happens when the high is no longer achieved? What keeps them going? There are two phenomenon that are in play that can help explain: positive and negative reinforcement.
The repetition of a habit based off a relationship with a stimuli, is known as reinforcement. Reinforcement can be either classified as positive or negative. That does not equate to “good or bad” as one may think. Both reinforcement types increase drug usage in this context. Reinforcement is usually facilitated by an external stimuli or some sort of trigger, by adding to the desired effect, or removing of an aversive stimuli. The key result of any “reinforcement”, is that it maintains the behavior, in the case of addiction, the drug using process, regardless of it being positive or negative reinforcement. We will explore the difference.
For example, someone who needs to achieve higher grades in school, who studies better while using a certain drug, may continue to be reinforced to use it, as the drug use helps them study longer, and results in better grades. Alternatively, someone battling depression may discover that using a drug may provide enough relief to temporarily soothe their low or sad mood, and depending on the substance, continues using it. In the first example, adding the drug leads to (positive) better grades and reinforces further drug usage. In the later example, using the drug removes (negative) the aversive situation, depression, which reinforces further drug usage. Both result in maintaining or increasing drug usage.
So lets look at this construct further.
There are examples of positive reinforcements that can motivate each person differently. Positive reinforcements in relationship to substance abuse can include:
Let’s examine the role of positive reinforcement, or operant conditioning, in the context of addiction. For example, someone who has had a car accident visits the doctor and is prescribed and opioid for their severe pain. The individual is prescribed a certain dosage to help manage and alleviate symptoms for their pain. The relief of pain in their body allows for the individual to feel less stress, gain mobility, and enjoy a better quality of life with reduced pain. Furthermore, the euphoria the individual may feel while taking the drug may become a mood enhancer. This interaction promotes or “reinforces” the use of the opioid.
Expanding on the above storyline of someone prescribed an opioid to assist in reducing pain, they later discover they have better mood overall and continue to use opioids even after the pain subsides. In this case the use of pain medication to help their overall state of mind and outlook, that they are “happier”—the positive reinforcement of an improved mood can encourage misuse or the consuming of non-prescribed in increased amounts. Obviously, this is dangerous. The pharmacodynamics and mechanisms of action of opioids readily make someone physically dependent in a very short time, around two weeks, even at therapeutic dosages, and more with overzealous amounts. Opioids bind with opioid receptors in the brain which release endorphins and activates the brain’s reward system, with a rush of dopamine which rewards one with a good feeling. Once someone gets the high from the drug, they often develop a cycle of pursuing that high. The physical nature of opioids create changes in the brain quickly, that when one tries to stop, significant psychological and physical discomfort can occur. And once this physical dependence has been achieved, the severe discomfort of withdrawal, is often the trigger leading to a vicious cycle pursuing more opioids, and facilitating addiction. Concurrently, tolerance to the drug can nullify the strength of the effects, as tolerance has occurred once the original dosage of the drug is not enough to get the person high anymore. This is due to sensitization in the brain to the drug. This leaves the individual seeking a higher amount of the same substance, or a stronger similar class of drugs to illicit a high.
That second part of pursuing a drug to avoid or mitigate physical withdrawal leads us to explore the concept of negative reinforcement.
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There is still much research being done on negative reinforcement and drug abuse. Negative reinforcement can include someone who abuses a drug and get used to its effects, then stops and feels withdrawal, and now has to continue its usage to avoid the aversive situation. In the case of substance abuse, negative reinforcement can include:
Negative reinforcement is an often misunderstood concept. We see the word negative and feel that it has to do with an outcome, something bad happened, or resulted. Well, yes, when using drugs and alcohol within the scope of addiction, it is all negative, but in this context, we speak of the removal of an aversive stimuli or situation that further reinforces using the substance.
Example would be from our first storyline, that an individual first started using opioids for a legitimate pain condition, found the “euphoria” and mood enhancing qualities that came along with it, and now despite resolving the pain condition, continued to use to the point of physical dependency. Now what? Using now is not to really pursue pleasure anymore, it is to escape the pain, to take away, “negate”, the withdrawal. This further promotes, or reinforces, the drug usage. This is negative reinforcement. Removing (negative) the aversive stimuli or situation, by using the drug.
The irony of addiction is how it starts. It often begins by using drugs or alcohol as experimentation, while socializing, or to feel good; the pursuit of pleasure and positive reinforcement. Many times we see progression of a prescribed medicine to treat authentic medical or psychiatric condition, become diverted and used in maladaptive ways. No one knows the full extent of the relationship drugs and alcohol will ultimately have on the mind and body when they are first introduced. It’s a complex interaction of genetics versus “everything else.” There are so many variables and nuances that compound upon one another and can act as risk factors to develop a substance use disorder. So these aforementioned reinforcement models may help us understand a drug’s use progression, based on this conditioning over time, and the relationship with risk factors all placed against the backdrop of the environment. So, whether starting out using for pleasure, and developing tolerance and physical dependence, or beginning with other risk factors such as painful medical or distressing psychological conditions, ultimately, when one continues to use in this vicious cycle to escape the pain, to remove the aversive stimuli, this switches to negative reinforcement.
Fortunately, treatment for substance use disorders can break this vicious cycle. Engaging in treatment is a major step, one that can offer the tools to address the physical and psychological distress that exists with addiction, and start the journey of living a drug free life. There are ways to pursue pleasure and escape from pain, without the path of addiction.
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