A global problem
You won’t be surprised to learn that the use of addictive drugs of all types is a global problem. What’s surprising, however, is that few experts agree on what addiction really is, or what causes it.
Some doctors and healthcare workers view addiction as a disease, whereas others see it as a problem of behaviour or emphasise the idea of ‘addictive personality’. Yet the evidence for both concepts is inconclusive.
As we will see, our attitude to addiction is just as much shaped by cultural attitudes as by the medical evidence. But before we look at the nature of addiction, and why it affects men more than women, we should remind ourselves of the scale of the problem.
The United Nations estimates that the world is host to:
- 8 million heroin users
- 13 million cocaine users
- 30 million users of amphetamines
- 141 million cannabis users
- 227 million sedative users
- 1100 million tobacco smokers.
Over 100 million people are dependent on the tobacco trade for their livelihood.
Alcohol is thought to cause around 33,000 deaths per year in Britain, with one in four hospital admissions being related to alcohol.
Drinking is implicated in 60 per cent of suicides, 40 per cent of domestic violence cases and 40 per cent of domestic fires.
Probably the most common and problematic substance with potential for abuse, nicotine is highly addictive.
The various toxins in cigarette smoke kill many thousands of people annually.
Approximately 3 per cent of the British adult population has a gambling problem. Of these, about 500,000 have a severe problem.
Some estimates put the number of Britons addicted to over-the-counter drugs and prescription drugs to be around 2 million.
Men and addiction
Men are much more likely to be addicted to alcohol and other substances than women. Two thirds of attendees at Alcoholics Anonymous are men (although this figure was 80 per cent in 1972).
A large American study has found that men are twice as likely as women to have a substance dependence disorder, with a lifetime prevalence of almost 36 per cent for men and 18 per cent for women. In other words, over one third of the male population of the US have been dependent on alcohol or drugs at some stage of their lives.
Men in the 25 to 34 year age group were twice as likely as those in the 45 to 50 year old age group to report substance dependency. Alcohol and drug abuse are strongly associated with an increased suicide rate in men.
In a large British study men were three times more likely than women to be alcohol dependent and twice as likely to be drug dependent. Almost 8 per cent of British men and almost 5 per cent of women said that they had been drug dependent at some time in their lives, 3 per cent of men and 1 per cent of women reporting dependence during the previous year.
Marriage appears to protect men from addiction problems. Never being married or becoming single is associated with increased alcohol consumption, while getting married is associated with a drop in alcohol consumption.
‘Substance misuse’ is a term used to describe the situation when a drinker or drug user experiences mental or physical harm as a result of their habit without necessarily being addicted to the substance in question.
Substance misuse needs to be contrasted with substance dependence (also known as addiction).
Dependence occurs at a more advanced stage of the addiction process.
Doctors make a diagnosis of addiction if three or more of the following features are present.
- A strong desire or sense of compulsion to take the substance.
- Difficulties controlling the substance-taking behaviour in terms of when it occurs, and or being able to stop, and or being unable to controlthe amount consumed once started.
- A physically unpleasant withdrawal state when not consuming the substance.
- Further substance use to relieve or avoid the withdrawal state.
- Evidence of increased tolerance (increased doses are required in order to achieve effects originally produced by lower doses).
- Progressive neglect of alternative pleasures or interests because of the substance use.
- Persisting with substance use despite clear evidence of harmful consequences.
- Narrowing of a person’s ‘personal repertoire’ or lifestyle – ie taking the substance becomes more important than anything else.
The causes of addiction
There is much controversy as to the causes of addiction, not least because the exact biology of addiction is unknown.
There are a number of theories, briefly explained below, but none should be considered to be the definitive account nor is any one theory mutually exclusive of any other.
It appears that characteristics of the individual (including their personality), the properties of alcohol and drugs, and environmental factors interact to produce addiction. But it’s difficult to determine whether the individual’s personality or their environment is the primary factor in causing addiction.
Is alcoholism inherited?
A considerable body of research suggests that a tendency to alcoholism may be inherited. Alcoholism seems to be much more common in some families and this inherited type of alcoholism particularly affects men.
Individuals may inherit a higher tolerance for alcohol (they need more drink than others to achieve the same effect), or they may inherit an increased chance of becoming dependent.
One author has described two types of alcoholism, one of which specifically affects men and may be inherited (though this idea is not accepted by everyone).
Type I or ‘milieu limited’
- Affects men and women.
- There’s loss of control of drinking.
- Parents will be non-abusers (or only mild abusers).
- There is no association with criminality.
- Usually mild in severity.
- Comes on after the age of 25.
- The environment modifies the problem.
- Not thought to be inherited.
Type II or ‘male limited’
- Affects men.
- There is an inability to abstain.
- Parents tend to be heavy abusers.
- It is associated with criminality and novelty seeking.
- Usually a moderate/severe problem.
- Comes on before the age of 25.
- The environment is irrelevant.
- Thought to be inherited.
The cognitive model of addiction
Cognition is the process by which we attain knowledge and awareness of the world, and it has been argued that addiction is not inherited but is a learned behaviour.
The more one consumes the more likely one is to be become addicted. Addiction can thus happen to anyone.
The cognitive approach to addiction assumes that:
- addictive behaviour is ‘learned’
- addiction is not a disease
- the behaviour can thus be ‘unlearned’.
Is there an addictive personality?
The phrase ‘addictive personality’ is used so commonly in our culture that few of us question whether an addictive personality type really exists, yet many doctors and psychiatrists believe that the term means little or nothing. Certainly, there is little evidence for an addictive personality as such.
Personality is complex and the role of personality in addiction is uncertain.
It’s difficult to disentangle the effects of personality on addiction from the effects of addiction on personality.
There’s no single addictive personality. However, there are a number of personality types that have been associated with addiction, and they are outlined below. The strongest evidence exists for ‘antisocial personality’.
The immature personality
Some people never really become mature adults. They may remain unduly close to their parents. They often boast about those few things that they have actually accomplished, are unable to form close relationships with others, and are self-centred.
The anti-social personality
These people are unable to accept frustration. They live for, expect and must have easy and continuous gratification. They often eat a lot, chew sweets and smoke, as well as drink heavily. They drink for two reasons – to reduce the personal discomfort that results from frustration and to provide instant and dependable gratification. They are impulsive and do not learn from their mistakes.
The self-punitive personality
Some outwardly docile people are actually repressing aggressive tendencies. This results in inner tension and alcohol helps to relieve this tension. Often alcohol releases the aggression.
The stressed or anxious personality
Some people find stress more difficult to deal with than others. They may use alcohol in an attempt to cope.
The passive-aggressive personality
This term refers to someone with an outwardly calm and acquiescent shell that hides inner anger. They find it impossible to deal with anger-inducing situations.
Many addicts do not have these personality types, and of course if you recognise yourself above it does not automatically follow that you are at increased risk of addiction.
It’s important to remember that no personality is immune to addiction. Proneness to alcoholism is better recognised by examining someone’s existing drinking habits than by assessing their personality.
Modern, well-organised studies do not support a role for personality in addiction. Most of the theories outlined above are not well supported by scientific evidence.
Does psychiatric illness lead to addiction?
Psychiatric factors can be important.
Addiction causes psychiatric problems but, at least in some cases, psychiatric problems can come first.
Many alcoholics state that they drink because they are depressed. If one goes into their life history the opposite is generally the case: they are depressed because they drink. There is a sub-group, however, who do indeed start to drink heavily to ward off depression.
Society and addiction
Societal or environmental factors are important.
Factors that increase or reduce the availability of alcohol may influence the incidence of alcoholism, eg if the cost of alcohol is increased or alcohol is made more difficult to purchase the rates of alcoholism usually go down.
Cultural factors and addiction
Cultural factors are also important.
In some societies consuming alcohol or other substances is less acceptable than in others. People in some occupations are more likely to develop alcohol problems, eg publicans, seamen, barmen and those in the armed forces. Many of these occupations are more likely to involve men than women.
Drug addiction is particularly associated with unemployment, poverty and urban decay. It is more common in men than women.
Is addiction a disease or illness?
Most people with addiction problems feel that they have a disease. Alcoholics Anonymous (AA), Narcotics Anonymous and Gamblers Anonymous all see addiction as a disease.
Professionals mostly feel that the situation is more complex than this. It must be recognised that viewing addiction as a disease helps many people to overcome their problem. Unfortunately, some people see themselves as passive victims of their illness, believing that ‘there is nothing I can do’.
The AA approach is to accept that one is ‘powerless over alcohol’ and to put oneself in the hands of ‘God, as we understand him’. The evidence for biological and genetic factors being important in addiction bolsters the illness argument, but there is also evidence for social and psychological factors being important.
Low levels of serotonin – a brain chemical – appear to be an important cause of addiction.
‘Drugs of solace’ may increase serotonin levels and depressed people take them for this reason.
Alcohol raises serotonin levels in the short term, but the levels fall in chronic alcoholics. Ecstasy produces the same effect. Cigarettes may increase serotonin levels, adding to their addictive properties. Gambling problems also seem to be associated with low levels of serotonin.
Low levels of serotonin may be the result of inheritance, but low status in society also seems to reduce serotonin levels. Drug and alcohol abuse is more common in people from lower socio-economic backgrounds.
Studies in animals demonstrate that they will self-administer substances – such as alcohol, cocaine, amphetamines, nicotine, barbiturates and some benzodiazepines.
Therefore, these drugs are described as rewarding or reinforcing. The fact that drugs and alcohol are rewarding does not explain why some people become addicted but not others, but it does lend weight to the argument that addiction is an illness or disease.
How to recognise if you have an alcohol dependence problem
Ask yourself the following four questions (the CAGE questionnaire).
- Have you ever felt that you should Cut down on your alcohol consumption?
- Have you ever felt Annoyed when others criticised your alcohol consumption?
- Have you ever felt Guilty about your alcohol consumption or the consequences of alcohol consumption?
- Have you ever had an Eye opener in the morning?
If you answer ‘yes’ to two or more of these questions, it’s possible that you are drinking too much and should seek help.
Treatment for addiction problems
The obvious answer to addiction is to stop taking the consumed substance, but of course this is far from easy.
If you have any concerns consult your doctor, who has a range of treatment options at his disposal.
The important thing to remember is that help is available. Probably the most important source of help (it reaches the greatest number of people) is Alcoholics Anonymous. The 12-step approach of AA is useful for many people though not for everyone.
Someone who has been consuming alcohol heavily may require admission to the medical ward of a local hospital in order to ensure safe withdrawal.
Coming off alcohol quickly can result in delirium tremens, which can be a fatal condition and must be treated carefully. A drug called chlordiazepoxide can be given to help with withdrawal.
Those who are not drinking as heavily may be able to reduce their intake at home with or without chlordiazepoxide. But while stopping drinking is relatively easy, staying off drink is much more difficult.
In most parts of the country Community Addiction Teams now exist. Nurses visit people in their own homes or see them in a local clinic and provide support and advice.
A number of new types of medication are now available that reduce the craving for substances, such as alcohol and nicotine, and can be helpful for those who are already determined to give up. Without this motivation to change, tablets will not help.
There is a range of other self-help groups and support groups throughout the country. The numbers of these groups can be found in the phone book.
Treatment for drug dependence
Dependence on opiate drugs, such as heroin, is a serious problem. There is a high risk of contracting a serious illness, such as hepatitis B or AIDS, and a high risk of death by overdose or through accidental injection of toxins that have found their way into the heroin supply.
If you are injecting heroin you should seek help immediately through your local GP. In most parts of the country methadone can be prescribed as a substitute for heroin. In some parts of the country needle exchange schemes are available – so that even if you continue to inject heroin, you can at least do so in some safety. Good treatment services are available in many regions, which help people to come off drugs.
Whether you consider your addiction to be a disease or simply a manifestation of your character, it’s important to realise that you have options. You’re not doomed to a life of addiction simply because you’ve been an addict in the past.
You should also remember that you don’t have to face your addiction alone – your GP is there to help you get over it.
Useful telephone numbers
- Al-Anon 020 7403 0888.
- Alcohol Concern 020 7264 0510.
- Alcoholics Anonymous 0845 769 7555.
- Foundation66 020 7234 9940.
- Drinkline 0800 917 8282.