For accurate scientific information on alcohol- and other drugs, see “Alcohol Facts” and “Drug Facts” on this website. The reader is referred to the latest diagnostic criteria (DSM) at the end of this section, which will help clarify many of the following myths.
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- “Addiction” is a valid scientific term. (MAJOR CONCEPT) The word “addiction” (in quotes in this website) is actually not a valid diagnostic word. In everyday popular use, anything can be “addicting”. From compulsive cocaine use to buying too many shoes , the word is applied uniformly, yet there is a great difference between compulsive drug use and the harmless collection of shoes. But applying the word “addiction” to anything that people really like to do tends to trivialize the horrific effects of drugs on a person’s behavior, thoughts, emotions, and psychology. In other words, it ends up stigmatizing a person who cannot stop using drugs without medical or psychotherapeutic intervention as a “bad person” or someone with poor self control. One way to differentiate serious drug overuse problems is to call them “major addictions” or Addictions (with a Big A). Other overuse situations such as with eating too much chocolate would be called a “minor addiction”, or just addictions (with a little a). For the most part Drug Addictions have the most compelling research validity (lots of studies), whereas most behavioral addictions have relatively few studies, and therefore little research validity. It is actually more accurate to call out-of-control gambling “pathological gambling” or “compulsive gambling”. Not calling it an Addiction does not mean that it does not exist; rather it is rather rare among gamblers and may not have the same biological causes in the Addiction areas of the brain as cocaine, heroin, alcohol, nicotine, and other Addictive drugs. The accurate labeling of behavioral actions as “diseases” or “not diseases” depends upon such distinctions.
- Compulsive sexual behavior is an “addiction”. While “sexual addiction” is an accepted term, there is very little about compulsive sexual behavior that is similar to the destructive overuse and dependence upon chemicals that are toxic to the body. The new DSM criteria for substance use disorders are designed to characterize “substance” (drug, chemical) pathologies, so sex cannot by definition fit these criteria. A better term (perhaps more easily covered by insurance?) is “compulsive sexual behavior”.
- Compulsive gaming behavior is an “addiction”. Let’s be careful what we call things! As with compulsive sexual behavior, gaming has very little in common with drugs that produce dependence. Is there any value in calling compulsive gaming an “addiction”? Isn’t it less stigmatizing, when it occurs in a small percentage of game-players, to label it “pathological gaming”?
- Withdrawal = “addiction”. Many people erroneously think that if a person goes through withdrawal after a long period of drug use, they are “addicted”. What about cocaine, which produces little observable withdrawal? When a person goes through withdrawal from morphine after several weeks’ treatment with the drug, does that mean they are “addicted” for life? Remember that withdrawal is only one of eleven criteria for severe substance use disorder (“addiction”), and a person must have six or more of the criteria to be diagnosed as “addicted”.
- Therapeutic pain-killers (such as morphine) produce a high rate of “addiction”. Actually, since we know that “addiction” is actually “dependence” as defined by DSM-IV (or “severe substance use disorder”, as identified by six or more of the criteria in DSM-5), we now know that the likelihood of becoming “addicted” on opioid pain-killers is actually quite low. Where the confusion comes in is when people erroneously believe that “withdrawal” is synonymous with “addiction”. (Withdrawal is also known as “physiological dependence” – confusing enough?) Most people given these pain-killers will go through withdrawal but will never want or need the drug again.
- There is a high rate of “addiction” when stimulants are used to treat ADHD (ADD). We do not yet understand why “addicting” drugs produce a lower rate of dependence (severe substance use disorder) when used therapeutically. Studies have found that few children (when accurately diagnosed) with attention deficit (hyperactivity) disorder (ADHD, ADD) become dependent upon stimulants such as Ritalin, dextroamphetamine, Adderall, etc. In fact, if such children are not treated, they tend to self-medicate with worse drugs (cocaine, alcohol) later in life.
- Marijuana is not addicting. According to the latest (DSM) accepted diagnostic criteria, about 10% of the population can become dependent on (“addicted” to) marijuana.
- Caffeine is addicting. Scientists do not yet agree that caffeine is “addicting”, according to DSM criteria. While people have marked withdrawal symptoms from using too much caffeine, withdrawal alone is not sufficient to diagnose “addiction” (see #3 above). Also, caffeine does not appear to have the same “dysregulating” effect on the “dependence pathway” (mesolimbic dopamine system) of the brain, like cocaine or amphetamine do.
- Crack is more addicting than cocaine powder. While there are more “crack” “addicts” observed on the streets, this is probably because crack is cheaper and easier to obtain than cocaine powder. But there is no pharmacological reason why the form of a drug or the route of administration should change the “addiction” liability of a drug. In fact, science is beginning to realize that the drug is not the cause of “addiction”; rather, the susceptibility of the person to the drug determines how much “addiction” (dependence, severe substance use disorder) develops.
- Sugar is “addicting”. The term “addiction” as used by the public does not have an exact scientific meaning. Better terms are “dependence” or “severe substance abuse disorder” (as defined by DSM, see table at the end of this section). Sugar cannot satisfy enough DSM criteria; therefore sugar is not addicting, in a scientific or clinical sense. Also, scientists have not yet found “sugar receptors” in the mesolimbic dopamine system.
- Club drugs are new, not very dangerous, and affect everyone the same way. Club drugs include ecstasy, GHB, ketamine, rohypnol, methamphetamine, and LSD. We don’t have much solid research on club drugs, even though most have been around for 20-30 years or more. Emergency room reports indicate they are very dangerous, especially when mixed with alcohol. Finally, they affect everyone differently, based upon dosage taken and an individual’s sensitivity to the drug.
- Ecstasy is highly addicting. Although this may very well turn out to be true, there is no evidence that ecstasy is “addicting”. Most people don’t use it long enough to produce serious withdrawal symptoms or signs of “impaired control”. Because of this lack of data, it is not clear whether users of ecstasy will satisfy the necessary criteria for “chemical dependence” or “severe substance use disorder”.
- Drugs have equal “addiction” potential. It is logical to think that every drug is not equally addicting. “Addiction” potential is related to many factors, including the susceptibility of the individual, and the ability of the drug to act at the “addiction site” (the brain’s pleasure center).
- Everyone who uses cocaine or heroin is an addict. Science is doing its best to develop ways to diagnose those people who willfully make bad choices about their use of drugs, and those who are born with or develop pathological dependence (“addiction”) on drugs. Most people (75-85%) can use cocaine or heroin for a while and stop using when they decide to stop. Others (“addicted”) cannot stop without medical and structured therapy.
- Drug abuse leads to dependence (DSM-IV). A better phrase is “drug abuse often precedes dependence”. The myth suggests that drug abuse causes drug dependence, when in actuality they are two different drug-use conditions. In many people dependence is preceded by abuse, but some people develop dependence without going through the progression of drug use, abuse, and dependence. In addition, many people abuse drugs for many years without developing the disease of chemical dependence.
- People “addicted” to one drug are “addicted” to all drugs. While this sometimes occurs, most people who are dependent on a drug may be dependent on one or two drugs, but not all. This is probably due to how each drug “matches up” with the person’s brain chemistry. If a person has a dysregulation of (for example) heroin through a match-up with abnormal endorphin chemistry, they might or might not have a dysregulation of dopamine, which is related to cocaine dependence.
- “Substance abuse” is a scientifically valid term. The word “substance abuse” is a weak, wimpy, confusing, inaccurate, and misleading term when applied to drug problems. Is there any “substance” that is not a chemical or a drug? Do we only treat drug abusers in “substance abuse” treatment centers? Is it any wonder that policy-makers and the public look down on “addicts” and those who treat them, when it appears that many treatment centers are not sure about what they’re treating?Â (The word “abuse” as it relates to drugs has been removed from the DSM terminology. It does not appear in DSM-5.)
- Anyone who uses drugs too much or too often will become “addicted”. We know “addiction” doesn’t occur in everyone, any more than diabetes occurs in everyone who eats too much sugar or food. It now appears that a person must “have what it takes” to become dependent on (“addicted to”) drugs. In many cases, genetics is the main risk factor for determining who develops the disease, although there are many other risk factors being studied.
- Drugs cause “addiction”. An interesting scientific question is: If drugs cause “addiction”, then why doesn’t everyone who uses drugs too much, too often, become “addicted”? Scientists are looking into genetic and other unknown factors that cause some people to become “addicted” while sparing others of this brain pathology.
- It takes years for someone to become addicted to a drug. There are anecdotal reports that some people become “instantly addicted” to drugs like alcohol, heroin, and cocaine, with one or only a few exposures to the drug. These people might be heavily genetically-loaded for the disease. There are also research studies showing that most people who will become addicted to cocaine do so within three years of starting cocaine use.
- Euphoria = “addiction”. Euphoria is “a sense of well-being”. Cocaine produces tremendous euphoria, whereas nicotine produces mild euphoria. Yet most experts agree that nicotine and cocaine are both highly “addicting”. Euphoria is the reason why people use drugs (“to get high”). “Addiction” occurs in some, but not all, people who experience euphoria. People who become “addicted” have a brain disease.
- “Addicts” are bad, crazy, or stupid. Evolving research is demonstrating that “addicts” are not bad people who need to get good, crazy people who need to get sane, or stupid people who need education. “Addicts” have a brain disease that goes beyond their simple overuse of drugs.
- “Addiction” is a will-power problem. This is an old belief, probably based upon wanting to blame “addicts” for using drugs to excess. This myth is reinforced by the observation that most “treatments” for alcoholism and “addiction” are behavioral (talk) therapies (including Twelve Steps). But “addiction” occurs in a subconscious area of the brain that is not under conscious control, the mesolimbic dopamine system. Also, there appears to be a pathology of the frontal lobes associated with “addiction”, and frontal lobes are where decision-making takes place in the brain. If there is a problem with the decision-making portion of the brain, can we say they have weak “will-power” when that portion of the brain is not working properly?
- “Addicts” should be punished, not treated, for using drugs. Science is demonstrating that “addicts” have a brain disease that causes them to have impaired control over their use of drugs. If we want to punish people for using drugs, we should punish those who are willfully abusing (DSM diagnosis) drugs. “Addicts” need treatment to stop their destructive use of drugs, and no amount of punishment is going to make them stop permanently.
- “Addicts” cannot be medically treated. Actually, “addicts” are medically detoxified, when appropriate, in hospitals all the time. But can they be medically treated after detox? New pharmacotherapies (medicines) are now available to help patients; e.g., those who have already become abstinent, to curb their craving for addicting drugs. These medications reduce the chances of relapse and enhance the effectiveness of existing behavioral (talk) therapies (including Twelve Steps). Such drugs include naltrexone (ReVia, Vivitrol), acamprosate (Campral), buprenorphine (Subutex, Suboxone), varenicline (Chantix), and bupropion (Zyban).
- Methadone treatment simply involves substituting one addicting drug for another. While methadone is a drug that is “addicting”, methadone has been shown to reduce the craving for the dangerous illegal drug heroin. By placing an “addict” into a controlled methadone program, clinicians can monitor their progress, encourage abstinence from heroin, help the addict find a job, and gradually reduce the methadone dose. Many people choose to take methadone in place of heroin, which is less dangerous than injecting heroin “on the street”. Also, there is some sentiment for providing free heroin to opioid-dependent people, to make them more comfortable, reducing their criminal behavior, and helping them find places for treatment. Many of these people actually want help but can’t find it.
- “Addiction” is treated behaviorally, so it must be a behavioral problem. New brain scan studies are showing that behavioral treatments (i.e., psychotherapy) and medications work similarly in changing brain function. So “addiction” is a brain disease that can be treated by changing brain function, through several different types of treatments.
- Alcoholics can stop drinking – all they have to do is attend A.A. meetings. The key word here is “all”. A.A. doesn’t work for everyone (even for many people who truly want to stop drinking). For most people, A.A. is a lifelong working of the twelve steps, and it’s often not easy. Scientists theorize that people who “get better” in A.A. somehow learn how to overcome (or compensate for) their brain disease.
- The more a person is educated about drugs, the less likely they are to become “addicted”. This idea that “addiction” is preventable is an old one. Strong indirect evidence concerning the brain mechanisms involved in the disease tells us that “addiction” cannot be prevented. If the above myth were true, physicians, nurses, and pharmacists would have a low rate of “addiction”. Sadly, these health professionals have an incidence of “addiction” that is at least as high as the general population.
- Research is less important than treatment. Throughout history, medical diseases have always been treated before scientists learned the causes of the diseases. Through research, causes can be found, and better treatments (more effective for more sufferers, at reduced cost) can be developed. (If we had continued to develop better treatment for polio instead of trying to find the cause, today we would have computerized, miniaturized iron lungs!)
- You cannot overdose on alcohol (college students). Alcohol has a lethal dose of around 24 ounces (1.5 pints) of 40% distilled spirits for a 70-kg (150-lb) male, when the beverage is drunk rapidly (within two hours or less). The mechanism of death is respiratory depression (cessation of breathing due to toxic effects of alcohol; or aspiration of – drowning in – one’s own vomit).
- Heroin should be legalized for treatment of cancer pain. It is difficult to rationalize the legalization of heroin, since it breaks down in the body to the legal drug morphine. Increasing the dose of morphine will give the same analgesic effects as heroin.
- Stress causes “addiction”. Research on this topic is incomplete, and we know that stress can trigger relapse in a recovering person. It appears that stress can increase the chances that a person who “has what it takes” can develop “addiction”, but stress alone is probably not a primary cause of the disease.
- There is an “addictive personality”. An addictive personality is presumably something that can be seen in young people that helps predict whether they will become “addicted” later in life. Scientists have not been able to find such a personality. Another definition of “addictive personality” is that people who are “addicted” tend to be “addicted” to everything. This is also not true, based upon the presumed neurochemical causes of the disease.
- LSD causes “madness”. While LSD causes hallucinations, these are temporary and somewhat different than the hallucinations of schizophrenia. Long ago, clinicians gave LSD to human volunteers to produce psychotic symptoms, so they could test potential new anti-psychotic drugs on the volunteers. LSD in normal people, however, does not cause “madness”.
- THIQs are a cause of alcoholism. This is an old theory, which was very attractive in the early 1970s. It suggested that alcoholics, when they drink, form opiate-like THIQs (abbreviation for several artificially-formed chemicals) in the brain, to which they become “addicted”. Later research was not able to consistently find THIQs in the tissues of alcoholics compared to those of non-alcoholics. Thus, the “THIQ theory” is no longer popular among most scientists.
- “Crack babies” are a major problem. Actually, “fetal alcohol spectrum disorder” babies are a major problem. While there are babies born of mothers who use cocaine or crack during pregnancy, most of these women also use other drugs and have other prenatal problems. “Crack baby” is a pejorative, media-generated term that is not scientific. Such babies, when they are born, are more accurately described as “babies in distress”. And there is no evidence that they are born “addicted”.
- It is not possible to overdose on caffeine. Actually, the human lethal dose of caffeine is around 10 grams. But you would have to drink about 100 cups of coffee to even have a chance of this happening!
- Drinking red wine is not protective against heart attacks. There is now good scientific evidence that not only red wine, but also any type of alcohol, is probably beneficial to the heart in moderate doses (1-3 drinks per day).
- Adolescents who use drugs DO NOT have a greater chance of becoming dependent than people who start using later in life. The thinking here is that adolescent brains are still developing and might be more vulnerable to the effects of addicting drugs. There is now significant evidence that drug use in adolescents increases the risk of becoming “addicted” later in life. This is probably due to an effect of the drug on the developing brain; in particular the frontal lobes, where emotions and “executive function” arise.
- Treatment doesn’t work. People who don’t like “addicts” or their lifestyle will often point out that relapse (“falling off the wagon”, resumption of drug use after treatment) occurs, so that the treatment must not have worked. We need to remember that relapse also occurs with other diseases (diabetes, cancer, hypertension, etc.), so this is a prejudicial view about substance use disorder treatment.
- “Addiction” is an acute problem requiring only 28-day treatment. This is an old notion that suggests recovery takes place in 28-day inpatient treatment centers. We have always known that twelve-step programs are a lifetime commitment, and this is why we use the word “recovering” rather than “recovered”. More modern treatment is taking the attitude that “addiction” is a chronic medical illness that requires longer treatment and lifetime monitoring.
- Anyone who drinks too much, too often, is an alcoholic. A person “addicted” to alcohol is called an “alcoholic”. If the “too much, too often” myth were true, then most college students would be alcoholics, or alcohol “addicted”. In fact, most college students abuse (overuse) alcohol, while only 10-15% show “addiction” to alcohol at some point in their drinking careers.
- It is possible to overdose on marijuana. Marijuana has few toxic effects on major organs. Even though it has a well-established effect on mood and can cause “addiction”, there is no known lethal dose of marijuana in humans.
- It is possible to overdose on LSD. LSD is a major hallucinogen and can cause people to jump from tall buildings (for example) in their hallucinogenic state. However, there is no known lethal dose in humans. In other words, LSD can cause death through its psychological effects, but no one is known to have overdosed and died from the toxic effects of LSD on the body.
- Social drinking kills brain cells. This is an old idea in which some people thought that even one drink could kill thousands of brain cells. Alcohol can kill brain cells, but only after many years of heavy drinking. One old study involved giving alcohol daily to a dog for several weeks, then looking at damaged brain cells in the dog at autopsy. A calculation was made of the number of brain cells damaged, and this was extrapolated backwards to determine how many cells would be damaged with one drink! Obviously alcohol given over time leading to brain cell death has nothing to do with single drinks of alcoholic beverages.
- Everyone “has what it takes” to become “addicted” to drugs. If “addiction” is a chronic medical disease, then why should it be different from other medical diseases? Everyone doesn’t “have what it takes” to get sickle cell anemia, insulin-dependent diabetes, or multiple sclerosis. Also, most of us have seen someone who uses drugs so much (alcohol, nicotine, cocaine) that it “looks” like they’re trying to get “addicted”. But then they just stop.
- Alcoholics can drink socially. There are a few scientific studies that suggest this. But most of these studies look at “problem drinkers”, and do not satisfactorily differentiate between “intentional alcohol overusers” and “pathological alcohol dependence” (“severe substance use disorder”). “Overusers” can drink socially (that is, under control), whereas “addicted” individuals cannot. The obvious questions to ask are “What is the logical reason why someone whose life has been devastated by alcohol wish to drink socially?” and “How can someone who has an ‘impaired control over alcohol use’ brain disorder learn to drink under control for the rest of his/her life?”
- All drugs damage brain cells. Actually, relatively few have been shown to damage brain cells through a toxic effect. These include alcohol (high doses over a long time), “inhalants”- including paint thinner, airplane glue, correction fluid, hair sprays (all of these are organ-toxic and highly damaging to all internal organs), and methamphetamine and MDMA (shown in animal studies with high doses, but not yet in humans). The brain is marvelously resilient, and able to fend off dangerous effects of most drugs. And damage is not always permanent.
- Babies born of mothers who use drugs during pregnancy are born “addicted”. No, “addiction” requires a fully developed nervous system and the presence of the drug to produce the disease. First, not all babies are susceptible to the disease even if they are exposed to a drug. Second, when drug-exposed babies are seen to have withdrawal or other signs of distress at birth, people readily assume that the babies are “addicted”. In actuality, such babies as they grow usually do not seek drugs, nor do they lose control over their use of drugs (the primary sign of “addiction”) in any greater proportion than non-drug-exposed babies.
- Scientists found the gene for alcoholism forty years ago. Some people remember the hoopla surrounding the announcement in the early 1980s that the DRD2 gene was the cause of alcoholism. This finding stimulated a lot of research, most of which was not able to conclude that this gene is related to alcoholism any more than to other psychiatric diseases. As of this writing, the DRD2 finding is controversial, and now groups of geneticists working on alcohol are finding that genes related to other neurotransmitters (GABA, serotonin) are more likely to be related to the causes of alcohol dependence.
- Alcohol given in the form of “airshots”, Everclear, or Jello shots are safe. What’s wrong with a glass of fine wine at dinner, a cold beer after a baseball game, or a glass of brandy after a nice meal? Is it really necessary to use alternative ways to get alcohol into our bodies, especially by targeting young people or others who are likely to abuse alcohol? The problem with these forms of alcohol administration is that there is no research behind their safety, and the risks of such use (overdose, increased alcohol toxicity) greatly outweigh their benefits (profit for those who sell or market them).
- People can drink themselves into alcoholism. “Alcoholism” is popularly thought to be a situation where people drink too much, too often, for too long, and they negatively affect their own lives and those of others through their drinking. In this sense, the above statement is correct. On the other hand, “alcoholism” is technically the disease of “severe alcohol use disorder”. The disease has little to do with overdrinking and frequency of drinking, for some people appear to become “addicted” quickly and quite easily, whereas others who drink a lot over a long period of time never fulfill the diagnostic criteria for “dependence” (DSM-IV) or “severe alcohol use disorder” (DSM-5).
Diagnostic Criteria for Substance Use Disorders
Criteria for Drug Abuse and Dependence (DSM-IV, 1994; Revision, 2000)
Chemical (Drug) Abuse
I. A maladaptive pattern of drug use leading to impairment or distress, presenting as one or more of the following in a 12-month period:
- recurrent use leading to failure to fulfill major obligations
- recurrent use which is physically hazardous
- recurrent drug-related legal problems
- continued use despite social or interpersonal problems
- The symptoms have never met the criteria for chemical dependence.
Chemical (Drug) Dependence
- A maladaptive pattern of drug use, leading to impairment or distress, presenting as three or more of the following in a 12-month period:
- tolerance to the drug’s actions
- drug is used more than intended
- there is an inability to control drug use
- effort is expended to obtain the drug
- important activities are replaced by drug use
- drug use continues despite knowledge of a persistent physical or psychological problem
- Two types of dependence can occur:
A) with physiological dependence (including either items 1 or 2), or
B) without physiological dependence (including neither items 1 nor 2).
Source: Adapted from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition – Text Revision, 2000.
Criteria for Substance-Use Disorder (DSM-5, 2013)
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
- recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
- recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
- continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
- tolerance, as defined by either of the following:
a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect
b. markedly diminished effect with continued use of the same amount of the substance
(Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)
- withdrawal, as manifested by either of the following:
a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
- the substance is often taken in larger amounts or over a longer period than was intended
- there is a persistent desire or unsuccessful efforts to cut down or control substance use
- a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
- important social, occupational, or recreational activities are given up or reduced because of substance use
- the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
- Craving or a strong desire or urge to use a specific substance.
Mild: 2-3 criteria positive
Moderate: 4-5 criteria positive
Severe: 6 or more criteria positive
Early Remission (> 3 to <12 months without meeting SUD criteria, except craving)
Sustained Remission (> 12 months without meeting SUD criteria, except craving)
On Maintenance Therapy (with samples of agonists)
In a controlled environment