Addictive disorders

Michael Polignano MD

Neurobehavioral & Cognitive Disorders

Updated 10.28.2024
Expires For CME 10.28.2027

Addictive disorders

Author: Michael Polignano MD

See Contributor Disclosures

Editor: Victor W Mark MD

Addictive disorders

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Introduction

Overview

According to a 2023 U.S. government survey, 17.1% of the U.S. population aged 12 years and older (48.5 million people) met diagnostic criteria for a substance use disorder in the past year (43). In addition to getting addicted to substances, people can become addicted to non-substance ingestion behaviors, such as gaming, shopping, sex, and gambling. Addiction is the continued, compulsive use of a substance or behavior despite harm to oneself or others. There is no brain scan or blood test to diagnose addiction. Rather, addiction is diagnosed by looking at patterns of behavior over time. The behavioral manifestations of addiction are accompanied by progressive changes to the neurocircuitry of motivation, stress, and self-control. These changes can endure long after addictive behaviors have ceased, leading to a persistent risk of relapse. Addiction should, thus, be managed as a chronic relapsing-remitting disorder. When treated, the prognosis for addictive disorders is like that of other chronic medical conditions.

Key points

	• Addiction is the continued, compulsive use of a substance or behavior despite harm to oneself or others.
	• All human beings share the neurocircuitry underlying addiction and, thus, are susceptible to compulsive overconsumption in environments that provide unrestricted access to novel, high-potency rewards.
	• The behavioral progression of addiction is associated with enduring changes to the neurocircuitry of reward seeking, emotion and stress regulation, and executive function.
	• Addiction involves biological, psychological, and social dysfunction; therefore, treatment should address biological, psychological, and sociocultural factors affecting recovery.

Historical note and terminology

For millennia, the inability to control one’s urges—a characteristic quality of addiction—has been seen as a moral failing. Condemnation of excess and promotion of temperance are recurring themes in philosophical and religious texts, and legal codes have long penalized drunkenness and sexual licentiousness. These social proscriptions on excessive consumption may have served the positive evolutionary function of limiting reward-seeking behavior that would otherwise go unchecked (14). The stigma associated with addiction-related behaviors has often been tied to other forms of social marginalization; marginalized groups, including immigrants, poor people, and people of color, have frequently and falsely been stereotyped as immoral, undisciplined, and more prone to addiction.

In his 1784 essay, “An Inquiry into the Effects of Ardent Spirits,” the American physician Benjamin Rush created a bridge from a moral to a more medical conception of addiction, arguing that even though addiction to distilled liquor was “a disease induced by an act of vice,” its sufferers nevertheless deserved the same care as those who became ill from “an accidental and innocent cause” (36).

Toward the end of the 20th century, tremendous advances in understanding the neurobiology of addiction led the National Institute on Drug Abuse and others to disseminate a model of addiction as a chronic relapsing-remitting brain disease. It was hoped that a broad understanding of the neurobiology of addiction could inform sound approaches to treatment and policy and reduce stigma associated with the disease (27).

Terminology. As part of the broader effort to de-stigmatize addictive disorders, current usage favors less stigmatizing terms describing the illness (eg, “substance use disorders” instead of “substance abuse”) and person-centered terms describing people with the illness (eg, “person with substance use disorder” not “addict”).

Clinical manifestations

Presentation and course

	• Addiction is a chronic relapsing-remitting illness marked by progressive dysfunction in psychological, interpersonal, social, and medical domains alternating with periods of improved function (“recovery”) of variable duration.
	• The disease course is characterized by a change from voluntary, adaptive use to compulsive, maladaptive use that persists despite negative consequences.
	• Evolutionarily conserved reward neurocircuitry puts all people at risk for compulsive overconsumption, but not everyone will progress to severe addiction.

No matter the addiction, whether to a substance or behavior, the progression of addiction is phenomenologically similar. Addiction is a chronic relapsing-remitting illness marked by progressive dysfunction in psychological, interpersonal, social, and medical domains alternating with periods of improved function (“recovery”) of variable duration.

The disease course is characterized by a change from voluntary, adaptive use to compulsive, maladaptive use. At first, addictive behaviors may address a need or solve a problem (26; 14). For example, someone may drink to feel relaxed and at ease socially; use stimulants to feel less depressed or be more productive; or play multiplayer video games to feel socially connected. However, when susceptible individuals repeatedly engage in addiction-related behaviors, the behaviors can become increasingly less voluntary and continue despite worsening psychological, medical, and social consequences.

Because the reward neurocircuitry underlying addiction is shared by all human beings, all people are susceptible to compulsive overconsumption, especially in our modern ecosystem that provides easy access to novel, high-potency rewards, without the barriers to overconsumption that previously existed (26; 14). In the past, rewards were scarce and of relatively low potency (eg, unprocessed food that had to be hunted or gathered). Today, we have easy access to high-potency rewards that more strongly activate reward neurocircuitry (eg, highly processed food from the grocery store rather than homegrown and harvested or home cooked; distilled spirits rather than beer or wine; nicotine in vape cartridges rather than leaf tobacco; social media rather than planned in-person gatherings; streaming pornography rather than sex with a partner), without external barriers to overconsumption that limit use. So, today, whether it’s eating one more potato chip or streaming one more episode of a favorite show, most people find themselves overdoing it occasionally.

But not everyone will progress to severe addiction. Most people can modulate addictive behavior when it threatens to interfere with important parts of their lives. For example, someone might want to reduce cannabis use to be more present with their young child, and they can do so. But some people at higher risk develop severe addiction, and they find themselves unable to temper addictive behaviors despite devastating costs to relationships, jobs, health, and self-esteem.

Clinical manifestations of addiction can be conceived in terms of the “4Cs”: Craving, loss of Control over use, Compulsive use, and continued use despite negative Consequences.

Craving. Craving is a strong urge or desire to use a substance or engage in a behavioral addiction, accompanied by an intense mental preoccupation with the substance or behavior. Cravings are relieved by use of the substance or by engaging in the addictive behavior. Such relief, in which a person shifts from an uncomfortable state to a neutral or pleasurable state, negatively reinforces addictive use, increasing the probability that use will continue. For example, after recovering from the depressive “crash” that follows binge cocaine use, someone may find themselves with an intense urge to use cocaine and obsessive thoughts of using cocaine, accompanied by signs of physiologic arousal (increased heart rate, increased motor activity).

Loss of control over use. The addicted person finds themselves using more than they intend or plan to, or in situations when using is ill-advised. For example, someone with a video game addiction may intend to play for only an hour, or only on weekends, but despite their intention find themselves playing for 5 to 6 hours every day.

Compulsive use. The addicted person finds that they are unable to stop themselves from using even when they are aware of important reasons not to use or face high barriers to use. For example, someone with an opioid addiction may suspect that the only available supply is contaminated with fentanyl, and that using risks overdose, but nevertheless cannot stop themselves from using that supply.

Use despite negative consequences. A person continues to use even after having negative medical, social/relational, or legal consequences. For example, someone who drinks may find themselves continuing to drink even after being told that they have liver damage, or after having suffered the legal consequence of a DUI.

Physiologic dependence versus addiction. Continued use despite negative consequences is the hallmark of addiction and can occur with or without physiologic dependence on a substance or medication. Physical dependence is the physiologic adaptation to the presence of a drug, manifesting as tolerance, needing more of the drug over time to get the same effect, and/or withdrawal when ingestion ceases or the dose is decreased, which can occur with both addictive substances (eg, alcohol, benzodiazepines, or opioids) and non-addictive medications (eg, antidepressants), as well as addictive behaviors (eg, gambling, gaming, sex).

Tolerance. High-dose, high-frequency stimulation of the brain’s reward system results in tolerance to the rewarding effects of any addictive drug or behavior. The same dose at the same frequency does not produce the original effect, which now can be produced only with larger, more potent, and more frequent dosing. This occurs with behavioral addictions as well as with substance addictions. For example, the softcore porn that was once titillating now seems boring and tame, and more extreme images of sexual behavior are needed to produce the same level of arousal and excitement.

Withdrawal. Stopping addictive use of any substance or behavior can result in a set of withdrawal symptoms universal to addiction—irritability, anxiety, depression, insomnia —lasting days to months after last use. These symptoms of withdrawal from addictive use partially overlap but are distinct from withdrawal from specific substances or medications (eg, withdrawal from alcohol or opioids). Withdrawal from addictive use results from hypersensitivity of the brain’s stress response and “anti-reward” system that develops over time to counterbalance the hyper-activation of the reward circuitry during addictive use (20).

Table 1. Psychological and Behavioral Changes Over Time as Addiction Progresses

	Initial use	With disease progression
How using feels	Use results in feeling “good” or “high” or less bad.	Using results in feeling marginally less bad. (“I don’t get high anymore. Now I use to feel normal.”)
Motivational drive from	Positive reinforcement (using to feel good)	Negative reinforcement (using to feel less bad)
Motivational importance of using	Using does not seem more important than other rewarding activities like relationships or school.	Using feels more important than almost anything else.
Tolerance	The same dose of substance or behavior produces the same effect.	Increasingly larger, more frequent doses are needed to produce an effect.
Craving	Thoughts about using are not intrusive.	Craving and preoccupation: thoughts of using are intrusive and compelling.
Emotional baseline	Affective baseline is stable: affect returns to baseline shortly after use.	Negative affect predominates: affective baseline becomes progressively more negative over time; the norm is to feel bad.
Compulsive use	Using can be planned and may look different on different occasions. Consideration of risks and benefits can influence behavior.	The drive to use cannot be interrupted, at least not for extended periods of time. Attempts to use persist despite knowledge of negative consequences or high barriers to use.

Prognosis and complications

Complications. Complications include increased morbidity and mortality.

Morbidity. Untreated substance use disorders are associated with significant medical, psychiatric, social, and spiritual consequences.

Medical. Medical consequences include death by overdose (respiratory depression, or cardiovascular collapse); end organ damage (eg, cardiovascular disease, lung disease, Wernicke-Korsakoff syndrome, liver disease); cancers (eg, liver, breast, lung); sexual and blood-borne illnesses (HIV, hepatitis C); and traumatic injury.

Neuropsychiatric. Neuropsychiatric consequences include psychosis, cognitive impairment, depression/amotivation, anxiety, and panic.

Social. Social consequences include loss of relationships, employment, increased exposure to violent crime, financial ruin, and incarceration.

Spiritual. Spiritual consequences include loss of feelings of self-worth, loss of hope, and loss of meaning.

Mortality. In general, people with untreated substance use disorders have a mortality rate higher than people in the general population. For example, opioid users not in treatment have a mortality rate 13 to 14 times higher than the general population (05). People with untreated alcohol use disorder have a mortality rate about 3.4 times (men) and 4.6 times (women) higher than the general population (35). People who smoke tobacco have a mortality rate about three times higher than those who have never smoked (16).

Prognosis. Most people using substances or behaviors addictively will not progress to severe addiction, and most people previously meeting criteria for addiction will have some reduction in symptoms or achieve remission over time (17; 44). For example, data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III) showed that only about 34% of people surveyed who met criteria for alcohol use disorder prior to the survey continued to meet criteria when the survey was conducted; of those who achieved reduction in symptoms, most did so without treatment (44).

Progression is influenced by multiple factors, including type of drug or behavior, route of administration of drug, family history, developmental history, co-occurring psychiatric and medical illness, and socioeconomic factors.

Factors predicting more severe addiction or more chronic illness. More severe and more persistent illness is seen in people with a family history of substance use disorders; a history of extreme childhood stress/adverse childhood experiences, like exposure to abuse or an unstable home environment; polysubstance use; co-occurring psychiatric conditions; lack of social support; unstable living environment; unemployment or lack of meaningful activities; and chronic pain or other medical conditions (04; 38).

Factors predicting more favorable outcomes. More favorable outcomes are seen with earlier intervention and treatment and longer treatment duration, as well as higher socioeconomic and educational levels; stable housing; strong social support; stable employment or involvement in meaningful activities, including spiritual or religious involvement; absence of co-occurring psychiatric illness; strong coping skills (40; 09; 04; 06; 30; 38).

Thus, in general, there is a greater likelihood of a more favorable outcome when someone has (1) greater access to “natural” rewards, like strong relationships and stable employment, which can compete with the rewards of addiction; (2) fewer chronic stressors (like co-occurring medical and psychiatric illness, or unstable housing); and (3) internal psychological resources and social support that allow better coping with stress.

Biological basis

• Addictive behavior is accompanied by progressive changes to the neurocircuitry involved in (1) learning about rewards in the environment and seeking them out; (2) engaging in goal-directed behavior and inhibiting impulses; and (3) regulating affect and the response to stress.

To adapt to ongoing, high-dose, high-frequency use of addictive substances or engagement in addictive behaviors, the neurocircuitry underlying reward-related learning, motivation, impulse control, and responses to stress progressively changes, both in human and animal models, toward prioritizing addiction-related behaviors above all others. Both substance and behavioral addictions appear to involve the same brain neurocircuitry (25).

These within-system and between-system adaptations involve dysregulation of three interacting neurocircuits.

Functional systems	Associated neurocircuitry
Motivational salience and habit systems	Basal ganglia
Executive function	Prefrontal cortex
Negative emotional states	Extended amygdala
Adapted from (20)

Reward-seeking behavior. The brain’s reward system is an evolutionarily conserved system that motivates animals to seek out and learn about aspects of their environment that might improve their well-being or reproductive fitness, eg, food, habitat, or prospective mates (33). The circuit including the ventral tegmental area midbrain neurons projecting to the ventral striatum is thought to be the main one involved in reward learning (28).

Motivational changes related to reward. Because addictive substances and behaviors register as highly rewarding, repeated use, especially high-dose, high-frequency use over extended periods, can result in neuroadaptations that make the motivation to engage in addiction-related behaviors stronger and stronger. The more a susceptible person uses, the more they find themselves wanting to use. These changes have been observed in humans and other animals allowed extended access to addictive substances. For example, a landmark study with rats allowed extended access to cocaine showed that a portion of the studied animals would work harder and more persistently to obtain cocaine than other animals, suggesting increased motivation to obtain the drug (07).

Associative learning and transfer of motivation. Activation of the reward system also drives learning about the context in which rewards are acquired. For example, if someone drinks at the local bar, the sights, sounds, smells of that bar become associated with the rewarding activity of drinking alcohol. Through this associative learning, aspects of the environment where rewards are acquired can become as motivating as the reward itself, eg, seeing a drinking buddy can trigger the urge to drink as much as the drink itself. Because these learned associations persist after active addiction has ended, stimuli associated with addictive use can reactivate addictive behaviors well into abstinence (15).

Impaired ability to engage in goal-directed behavior and increased habit-driven behavior. As addiction-related behaviors are repeated, they become progressively less voluntary and more habitual, performed unconsciously in response to internal and external stimuli. In part because of this change from goal-directed to habit-driven reward seeking, addiction-related behaviors become hard to interrupt and persist even when the outcome becomes less rewarding. Neurobiologically, this shift from goal-directed to habit-driven reward seeking is hypothesized to reflect a weakening of prefrontal cortical control over behavior in favor of striatal control and, as habits form, a shift in activity from the ventral to the dorsal striatum (11).

Affective changes over time. In the beginning, addictive behavior often results in someone feeling better than they do at baseline. Early on, use may bring either pleasure (eg, feeling a “buzz” after drinking, or excited while playing videogames) or relief from pain (eg, feeling less socially anxious after drinking). With occasional use of addictive substances or behaviors, as the pleasure of using wears off, people may feel temporarily worse than they do at baseline (eg, feeling worn out after the intense activity of gaming and less motivated to resume gaming). This state of feeling worse, or less able to feel good, involves activation of what has been called the brain’s anti-reward system (22). The anti-reward system counteracts activation of the reward system to maintain emotional states within homeostatic boundaries—to maintain an affective set point.

However, with repeated use, especially high-frequency, high-intensity use, the brain’s reward system gets repeatedly over-activated, and the brain adapts by becoming less responsive to the same reward. The beer after work doesn’t feel as satisfying as it did before, and the mildly titillating network soap opera becomes boring. This is the development of tolerance. As tolerance develops, the brain’s reward threshold increases, and more intense stimulation is needed to activate the reward system to the same degree. This is seen in animal models of addiction in which decreases in reward sensitivity are followed by increases in drug consumption (20).

More intense stimulation of the reward system can be achieved by increasing the amount and frequency of use (from two beers on the weekend to a 12-pack nightly); by using a more potent or rapidly acting substance (from PO oxycodone to smoked fentanyl); or by engaging in more extreme versions of an addictive behavior (from 1 hour of a fantasy role play game to 7 hours of first-person shooter games). One consequence of a higher reward threshold is that “natural” rewards—like spending time with friends, or doing a good job at work, or having a romantic and sexual relationship with one’s spouse—do not sufficiently activate the reward system and are experienced as less worth pursuing.

Motivational changes related to negative affect. With repeated use also comes repeated activation of the anti-reward system and hyper-activation of the stress response. Over time, this no longer results in a temporarily negative emotional state but in a progressive lowering of the emotional set point and hypersensitivity to stressful stimuli. Feeling bad—irritable, anxious, depressed, ill-at-ease—becomes the emotional norm, a state that has been termed “hyperkatifeia” (21). At this stage, addictive use no longer moves someone’s emotional state from feeling “ok” to feeling good; now it moves someone from feeling bad to feeling less bad, to at best feeling just “ok.” At this stage of addiction, the predominant motivational drive is not to seek out rewards but to relieve emotional distress (20). The neuroadaptations that increase sensitivity to stress and make feeling bad the norm endure well after active addiction ends, contributing to the risk of relapse during abstinence.

Differential diagnosis

The differential diagnosis of substance use, substance use disorders, and behavioral addictions includes psychiatric and medical conditions that can present with similar symptoms or co-occur with addictive disorders.

Neuropsychiatric conditions. These neurologic and neuropsychiatric conditions result in disinhibition and loss of impulse control, including traumatic brain injury; CNS infectious, inflammatory, and neoplastic processes; neurogenerative diseases; and delirium.

Endocrine and metabolic disorders. These disorders include thyroid dysfunction, Cushing syndrome, and diabetes.

Medication side effects and toxicity. Even when used as prescribed, dopamine modulators, stimulants, steroids, and other medications can cause impulsivity, risk-taking, and compulsive behavior that persists despite negative consequences.

Psychiatric illnesses. Substance and behavioral addictions frequently co-occur with and can be confused with many other psychiatric illnesses. Substance use, substance withdrawal, and addictive behavior more generally should always be considered in the differential diagnosis of affective disturbances, anxiety disorders, psychosis, delirium, and constellations of behaviors typically associated with personality disorders.

Bipolar disorder. Substance use and withdrawal cause extreme fluctuations in emotional states, from euphoria during intoxication to dysphoria during withdrawal. These emotional fluctuations are often mistaken, by both patients and clinicians, for symptoms of bipolar disorder.

Major depressive disorder. Because of changes in affective neurocircuitry, long-term substance use leads to a predominance of negative affect (depression, anxiety, irritability) and negative cognitions about the self and the world, which may be mistaken for major depressive disorder.

Anxiety disorders. Sensitivity to stressful stimuli increases in addiction in response to excessive activation of the reward system, and this may result in symptoms consistent with various anxiety disorders.

Psychotic disorders. Paranoia and perceptual disturbances resulting from the use of stimulants, cannabis, hallucinogens, dissociative anesthetics, or inhalants, or from withdrawal from alcohol and other sedatives, may be confused with primary thought disorders like schizophrenia or schizoaffective disorder.

Personality disorders in adults and conduct disorder in adolescents. Substance use disorders frequently co-occur in people who meet criteria for personality disorders. Moreover, the psychological and relational dysfunction of addiction, and accompanying disregard for social norms, often mimic the symptoms of personality disorders.

Although co-occurring psychiatric disorders should always be treated together with addiction, accurate diagnosis of mood, anxiety, and personality disorders is often not possible during active use.

Substance-induced psychiatric disorders can be distinguished from primary mood, anxiety, thought, or personality disorders in several ways. If the symptoms clearly precede the use of substances and fail to remit with a period of at least 4 weeks’ abstinence (03), then the likelihood is greater that the symptoms are those of a disorder other than addiction. If symptoms continue despite multiple attempts at treatment (eg, use of SSRIs and psychotherapy for depression), this should increase suspicion that the symptoms may be related to addictive use of substances or process-based addictions.

Confusing conditions

Non-addictive use of substances. Substance use alone, regardless of amount, frequency, or type of substance, is not diagnostic of addiction, although certain patterns of use, especially high-dose, high-frequency use, are associated with increased risk of addiction.

Physiologic dependence on prescribed medications. Opioids, benzodiazepines, hypnotics, and other medications create physiologic dependence even when taken as prescribed. Dependence is not by itself diagnostic for addiction, but extended, daily use of any dependency-creating medications puts patients at higher risk of developing addiction. Prescribing should accord with clinical guidelines (eg, CDC Clinical Practice Guidelines for Prescribing Opioids for Pain) and should be carefully clinically monitored (10).

Associated or underlying disorders

Diagnostic workup

	• Addiction is a clinical diagnosis established by persistence of use despite negative consequences rather than by quantity, frequency, or duration of use.
	• Certain patterns in frequency, quantity, and duration of use are nevertheless associated with a higher risk of having an addiction-related disorder.
	• Substance use disorders are diagnosed using DSM-5-TR criteria. In the DSM-5-TR, the only behavioral addiction with formal diagnostic criteria is gambling disorder. The ICD-11, but not the DMS-5-TR, includes diagnostic criteria for gaming disorder and compulsive sexual behavior disorder.
	• Laboratory testing and other diagnostic procedures can reveal recent substance use or medical consequences of addiction but have limited diagnostic or prognostic use for addiction itself.
	• Assessment should examine a patient’s patterns of use and history of recovery attempts and should evaluate for the risk of physiologically significant withdrawal, suicide and homicide risk, and co-occurring medical and psychiatric conditions.

Assessment of addiction is made clinically rather than through laboratory testing, imaging, or other diagnostic procedures. Assessment is based on evidence of impaired control over use; negative medical, psychological, and social consequences of use; and use that continues despite such consequences. An addiction diagnosis is not made based on amount, quantity, or frequency of use, nor is it made based solely on a history of physiologic dependence and withdrawal from prescribed medications.

Approach to the patient. People with out-of-control substance use or behaviors may feel tremendous shame and guilt about their behavior and its consequences. Moreover, because of motivational changes characteristic of addiction, patients may present with significant ambivalence about their use. Although they may want to end the negative consequences of addiction, they may also feel driven to keep using. For these reasons, they may be wary of fully disclosing their situation to others or to themselves. A straightforward, genuinely curious, but non-judgmental approach to the patient is, therefore, key to establishing trust and building a foundation for effective treatment.

Assessment data points. Thorough assessment should include a current and lifetime history of substance use; current and lifetime history of non-substance addictive behaviors; evaluation of current intoxication and potential for medically significant withdrawal from alcohol, opioids, benzodiazepines, or other CNS depressants; psychiatric history and safety assessment (suicidal/homicidal ideation); family history of substance use disorders and other addictions; and screening for co-occurring medical conditions (eg, encephalopathies, liver disease, infectious disease, cardiovascular disease), especially those that are urgent or emergent. Assessment should also explore the patient’s motivation for wanting to address addictive behaviors; their history of engagement with professional treatment and peer support programs; and their past periods of recovery. Assessment should include collateral from people close to the patient. Objective measures that can inform discussion with the patient include urine toxicology testing for recent substance use and state Prescription Drug Monitoring Program databases, which show prescribing of controlled substances.

Risky use/harmful use. Although amount and frequency of use are not diagnostic of addiction, certain patterns of use are associated with increased risk of development of addiction and other medical and psychiatric consequences of use. With alcohol, both binge drinking, defined as having more than four drinks (males) or more than three drinks (females) in about 2 hours, and heavy alcohol use, defined as consuming more than four drinks on any day or 14 per week (males) and more than three on any day or seven per week (females), are associated with a higher risk for developing alcohol use disorder and other medical and psychiatric complications of alcohol use (32).

Diagnosis of substance use disorders. The discrete diagnoses “substance abuse” and “substance dependence” found in the DSM-IV were replaced in the DSM-5 with the spectrum diagnosis of “substance use disorder,” the severity of which is determined by the number of diagnostic criteria met. Severity is specified as mild (two to three criteria met); moderate (four to five criteria met); or severe (six to 11 criteria met). The DSM-5-TR lists 10 separate substance use disorders, each with the same 11 diagnostic criteria; criteria for the different substance use disorders differ only in the name of the substance in question (Table 2).

Table 2. DSM 5-TR Diagnostic Criteria for [Substance] Use Disorder

A. A problematic pattern of [substance] use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
	1. [Substance] is often taken in larger amounts or over a longer period than was intended.
	2. There is a persistent desire or unsuccessful efforts to cut down or control [substance] use.
	3. A great deal of time is spent in activities necessary to obtain [substance], use [substance], or recover from its effects.
	4. Craving, or a strong desire or urge to use [substance].
	5. Recurrent [substance] use resulting in a failure to fulfill major role obligations at work, school, or home.
	6. Continued [substance] use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of [substance].
	7. Important social, occupational, or recreational activities are given up or reduced because of [substance] use.
	8. Recurrent [substance] use in situations in which it is physically hazardous.
	9. [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 [substance].
	10. Tolerance, as defined by either of the following:
		a. A need for markedly increased amounts of [substance] to achieve intoxication or desired effect.
		b. A markedly diminished effect with continued use of the same amount of [substance].
	11. Withdrawal, as manifested by either of the following:
		a. The characteristic withdrawal syndrome for [substance].
		b. [Substance] (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.
Specify if: In early remission: After full criteria for [substance] use disorder were previously met, none of the criteria for [substance] use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use [substance],” may be met). In sustained remission: After full criteria for [substance] use disorder were previously met, none of the criteria for [substance] use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use [substance],” may be met).
Specify if: In a controlled environment: This additional specifier is used if the individual is in an environment where access to [substance] is restricted.
Specify current severity: Mild: Presence of two to three symptoms Moderate: Presence of four to five symptoms Severe: Presence of six or more symptoms

Diagnosis of behavioral addictions. The behavioral addictions with formal diagnostic criteria are gambling disorder in DSM-5-TR, gaming disorder in ICD-11, and compulsive sexual behavior disorder in ICD-11. The criteria are shown below in Tables 3, 4, and 5. Other behavioral addictions, although lacking formal diagnostic criteria, can be clinically evaluated in terms of the 11 DSM-5-TR criteria for substance use disorders, where the problematic behavior is considered instead of the substance. More broadly, addiction of any kind can be assessed in terms of the 4Cs of Craving (preoccupation/anticipation of use), out-of-Control use, and Compulsive use that continues use despite negative Consequences.

Table 3. DSM-5-TR Criteria for Gambling Disorder

A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period:
	1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
	2. Is restless or irritable when attempting to cut down or stop gambling.
	3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
	4. Is often preoccupied with gambling (eg, having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).
	5. Often gambles when feeling distressed (eg, helpless, guilty, anxious, depressed).
	6. After losing money gambling, often returns another day to get even (“chasing” one’s losses).
	7. Lies to conceal the extent of involvement with gambling.
	8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.
	9. Relies on others to provide money to relieve desperate financial situations caused by gambling.
B. The gambling behavior is not better explained by a manic episode.
Specify if: Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods of gambling disorder for at least several months. Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple years.
Specify if: In early remission: After full criteria for gambling disorder were previously met, none of the criteria for gambling disorder have been met for at least 3 months but for less than 12 months. In sustained remission: After full criteria for gambling disorder were previously met, none of the criteria for gambling disorder have been met during a period of 12 months or longer.
Specify current severity: Mild: four to five criteria met Moderate: six to seven criteria met Severe: eight to nine criteria met

Table 4. ICD-11 Diagnostic Criteria for Gaming Disorder

Essential (required) features
	• A persistent pattern of gaming behavior (“digital gaming” or “videogaming”), which may be predominantly online (ie, over the internet or similar electronic networks) or offline, manifested by all of the following:
		-- Impaired control over gaming behavior (eg, onset, frequency, intensity, duration, termination, context);
		-- Increasing priority given to gaming behavior to the extent that gaming takes precedence over other life interests and daily activities; and
		-- Continuation or escalation of gaming behavior despite negative consequences (eg, family conflict due to gaming behavior, poor scholastic performance, negative impact on health).
	• The pattern of gaming behavior may be continuous or episodic and recurrent but is manifested over an extended period of time (eg, 12 months).
	• The gaming behavior is not better accounted for by another mental disorder (eg, manic episode) and is not due to the effects of a substance or medication.
	• The pattern of gaming behavior results in significant distress or impairment in personal, family, social, educational, occupational, or other important areas of functioning.
Specifiers for online or offline behavior
	• 6C51.0 Gaming Disorder, predominantly online: This refers to gaming disorder that predominantly involves gaming behavior that is conducted over the internet or similar electronic networks (ie, online).
	• 6C51.1 Gaming Disorder, predominantly offline: This refers to gaming disorder that predominantly involves gaming behavior that is not conducted over the internet or similar electronic networks (ie, offline).

Table 5. ICD-11 Diagnostic Criteria for Compulsive Sexual Behavior Disorder (6C72)

Essential (required) features
	• A persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior, manifested in one or more of the following:
		-- Engaging in repetitive sexual behavior has become a central focus of the individual’s life to the point of neglecting health and personal care or other interests, activities, and responsibilities.
		-- The individual has made numerous unsuccessful efforts to control or significantly reduce repetitive sexual behavior.
		-- The individual continues to engage in repetitive sexual behavior despite adverse consequences (eg, marital conflict due to sexual behavior, financial or legal consequences, negative impact on health).
		-- The person continues to engage in repetitive sexual behavior even when the individual derives little or no satisfaction from it.
		-- The pattern of failure to control intense, repetitive sexual impulses or urges and resulting repetitive sexual behavior is manifested over an extended period of time (eg, 6 months or more).
		-- The pattern of failure to control intense, repetitive sexual impulses or urges and resulting repetitive sexual behavior is not better accounted for by another mental disorder (eg, manic episode) or other medical condition and is not due to the effects of a substance or medication.
		-- The pattern of repetitive sexual behavior results in marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviors is not sufficient to meet this requirement.
Additional clinical features
	• Compulsive sexual behavior disorder may be expressed in a variety of behaviors, including sexual behavior with others, masturbation, use of pornography, cybersex (internet sex), telephone sex, and other forms of repetitive sexual behavior.
	• Individuals with compulsive sexual behavior disorder often engage in sexual behavior in response to feelings of depression, anxiety, boredom, loneliness, or other negative affective states. Although not diagnostically determinative, consideration of the relationship between emotional and behavioral cues and sexual behavior may be an important aspect of treatment planning.
	• Individuals who make religious or moral judgments about their own sexual behavior or view it with disapproval, or who are concerned about the judgments and disapproval of others or about other potential consequences of their sexual behavior, may describe themselves as “sex addicts” or describe their sexual behavior as “compulsive” or using similar terms. In such cases, it is important to examine carefully whether such perceptions are only a result of internal or external judgments or potential consequences or whether there is evidence that impaired control over sexual impulses, urges, or behaviors and the other diagnostic requirements of compulsive sexual behavior disorder are actually present.

Management

	• Addiction involves biological, psychological, and social dysfunction; therefore, treatment should be conceived in bio-psycho-social terms, not simply in terms of biological interventions.
	• Severe addiction is a chronic relapsing-remitting illness, and longer courses of treatment are associated with better outcomes.
	• The overall goals of treatment should be to (1) improve a patient’s ability to access natural rewards and (2) reduce vulnerability to stress- and cue-driven relapse.
	• Substance withdrawal symptoms should be medically managed, but withdrawal management is not addiction treatment. Withdrawal management without addiction treatment is associated with increased morbidity and mortality from addiction.
	• Pharmacologic interventions should be used, when possible, but management of addiction is generally more effective when medications are used together with behavioral approaches.
	• Only opioid use disorder, alcohol use disorder, and tobacco use disorder have FDA-approved pharmacologic treatments.
	• Mutual support groups like Alcoholics Anonymous and facilitated engagement with such groups are evidence-based interventions for addiction.
	• Promising developments in biological interventions include neuromodulatory treatments, like transcranial magnetic stimulation, as well as agents affecting satiation, in particular, GLP-1 agonists.

Treat withdrawal and treat addiction. Substance withdrawal should be medically managed as appropriate, but treatment of acute withdrawal is not treatment of addiction. Among opioid users, treating withdrawal without treating addiction has been associated with increased addiction-related morbidity and mortality. That may be in part because during early abstinence, tolerance to the damaging respiratory depressant effects of opioids rapidly decreases while relapse risk remains high (42).

Treat addiction as a chronic, bio-psycho-social condition. Addiction arises from a complex interplay of biological, psychological, sociocultural, and environmental factors and causes dysfunction in multiple domains of an affected person’s life. Therefore, treatment should include a mix of biological, psychological, and social interventions reflecting the patient’s bio-psycho-social circumstances and severity of illness. Treatment typically includes a combination of evidence-based interventions, including professionally delivered behavioral therapy, peer support, and pharmacotherapy. Effective treatment should address not only addictive use, but associated medical, psychological, social, and spiritual concerns.

For many patients, addiction is a chronic condition and should be managed as such (29). Neuroadaptions that lead to dysfunction in reward valuation, emotion regulation, and stress tolerance can persist for months or years after use has ended, as can the motivational salience of addiction-related cues. This is associated, clinically, with the observation that relapse risk extends well beyond the period of acute withdrawal.

Thus, treatment duration matters. Multiple studies involving different forms of addiction and different treatment modalities have shown an association between longer treatment and better outcomes (06)

General goals for treatment. The primary drivers of relapse to addictive use are exposure to stimuli (the “people, places, and things”) associated with addictive use or to stressful life situations (46). Treatment should, therefore, address these principal causes of relapse and support the ability to access non-addictive rewards.

Limit access to addictive rewards and associated cues. Exposure to addictive rewards and the associated stimuli—the people (eg, drinking friends), places (eg, bars), and things (eg, cans of beer) associated with using—can trigger the urge to use, and cue-driven craving is a significant source of relapse to active addiction. Thus, reducing exposure to stimuli associated with using and adding barriers to access can support recovery. So, steps like blocking porn sites, quitting social media, finding non-drug-using companions, or getting rid of ashtrays and lighters, can help reduce cue-induced relapse.

Improve the ability to self-regulate. Addiction involves the impaired ability to inhibit impulses and to manage stress. Behavioral therapies, including cognitive behavioral therapy, can increase top-down cortical control and improve stress management skills. A regular routine helps build alternative habits. Newer biological therapies like transcranial magnetic stimulation may also improve prefrontal functioning (18).

Improve the ability to access natural rewards. Persistent psychiatric illness, such as major depressive disorder, social anxiety, PTSD, and personality disorders, can make it harder to access the natural rewards that accrue from supportive relationships and from engaging in meaningful life activities like work or school. Chronic medical illness, particularly when accompanied by chronic pain, can also interfere with the ability to access natural rewards. Thus, co-occurring psychiatric illness and medical illness should be treated.

Treatment approaches for particular substance use disorders

Opioid use disorder. Naloxone, a mu-opioid receptor antagonist that can reverse the effects of opioid overdose, has been shown to reduce overdose deaths when used by laypersons (48). It should be provided to anyone using opioids or who is in regular contact with someone who uses opioids. Naloxone is available as an over-the-counter medication, and many areas provide free naloxone kits and overdose education (https://www.naloxoneforall.org/).

Medications for opioid use disorder approved by the FDA are methadone, buprenorphine/buprenorphine-naloxone, and extended-release naltrexone. Use of these is associated with reductions in non-prescribed opioid use and opioid-related overdoses, improved physical and psychological wellbeing, and reduced all-cause and overdose mortality (41; 24; 37; 08). When behavioral therapies are used with medications for opioid use disorder, treatment outcomes, including retention in treatment and improved quality of life, may be improved. However, medication for opioid use disorder should be offered to patients whether or not they are willing to engage in behavioral treatment (02).

It is a misconception that medications for opioid use disorder are intended to be used short-term to transition patients away from addictive use. Early discontinuation of medications for opioid use disorder is associated with increased risk of return to opioid use, overdose, and all-cause mortality (41; 31; 47). For example, data from a 2023 study found an increased risk of opioid overdose among patients who discontinued buprenorphine treatment after 91 to 180 days compared with patients who discontinued treatment after a year or more (13). Patients should be advised of the risks associated with discontinuing medications for opioid use disorder, including increased risk of relapse and overdose.

Stimulant use disorders (including amphetamine and cocaine use disorders). Contingency management, a behavioral intervention that uses tangible rewards (eg, gift cards) to reinforce abstinence, is by far the most effective intervention for reducing stimulant use, and in combination with other evidence-based behavioral therapies like cognitive-behavioral therapy, is recommended as a first-line treatment for patients with stimulant use disorders (01). A concern about contingency management has been that effects wane after the treatment period. However, a meta-analysis comparing long-term outcomes of patients receiving contingency management to those receiving other behavioral therapies concluded that contingency management showed long-term benefit in reducing objective measures of use, beyond those of other evidence-based treatments like cognitive–behavioral therapy (12).

To date, medications have shown limited effectiveness in treating stimulant use disorders. Guidelines recommend considering bupropion and topiramate off-label to treat cocaine use disorder. For amphetamine use disorders, mirtazapine and the combination of bupropion and extended-release naltrexone, as well as psychostimulants for both cocaine use disorder and amphetamine use disorder, are recommended (01).

Alcohol use disorder. Alcohol use disorder is typically managed with a combination of behavioral interventions and medications. The FDA-approved medications for alcohol use disorder are naltrexone, acamprosate, and disulfiram.

Tobacco use disorder. The U.S. Preventive Services Task Force recommends that all adults be screened for tobacco use. Those using tobacco should be counseled to stop using and should be offered behavioral interventions and, if not pregnant, FDA-approved cessation medications (45). The combination of behavioral treatment and medication is more effective for reducing smoking and achieving cessation than medication alone. Behavioral interventions of at least eight sessions are more effective than briefer interventions. The two most effective pharmacotherapies are varenicline and combined nicotine replacement therapy (a combination of long-acting and short-acting nicotine replacement products) (45).

Treating behavioral (and substance) addictions: the Three Circles model. When addiction involves vital aspects of human life, like eating or sex, complete abstinence from all related behaviors can be impossible or highly undesirable. In treating behavioral addictions, the Three Circles model used in Sex Addicts Anonymous (SAA) can help people distinguish behaviors that are harmful from those that are adaptive (39). The model can be used in recovery from any addiction to behaviors or substances.

Inner circle. This contains the core addictive behaviors that the individual does want to abstain from, behaviors that lead to negative consequences in their life.

Examples. For sexual behaviors: visiting sex workers, engaging in unsafe sexual practices, or using pornography compulsively. For eating: eating highly processed “junk food” or eating in secret. For substances: using the substance in any amount.

Middle circle. These are often "slippery slope" behaviors or situations that increase the risk of relapse to inner circle behaviors.

Examples. For sexual behaviors: fantasizing or flirting inappropriately. For eating: keeping inner circle foods at home or eating to cope with emotions. For substances: spending time with people who use or keeping substances in the home.

Outer circle. This circle contains behaviors and activities that support recovery and overall well-being.

Examples might include attending support group meetings, exercising, meditating, spending time with supportive friends and family, sexual behavior within a committed relationship, eating regular balanced meals, and mindful eating.

This approach, which can be applied to behavioral or substance addictions, is personalized and recognizes that ongoing recovery involves not just abstaining from core addictive behaviors or substances but practicing behaviors that are satisfying and meaningful.

Outcomes

In general, the course and outcomes for substance use disorders is like that of other chronic relapsing-remitting diseases, including diabetes, hypertension, and asthma (29).

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Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Michael Polignano MD

Dr. Polignano of Stanford Medicine has no relevant financial relationships to disclose.
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Editor

Victor W Mark MD

Dr. Mark of the University of Alabama at Birmingham has no relevant financial relationships to disclose.
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Addictive disorders

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Clinical Categories

Neurobehavioral & Cognitive Disorders

Addictive disorders

Addictive disorders

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Table 1. Psychological and Behavioral Changes Over Time as Addiction Progresses

Prognosis and complications

Biological basis

Differential diagnosis

Confusing conditions

Associated or underlying disorders

Diagnostic workup

Table 2. DSM 5-TR Diagnostic Criteria for [Substance] Use Disorder

Table 3. DSM-5-TR Criteria for Gambling Disorder

Table 4. ICD-11 Diagnostic Criteria for Gaming Disorder

Table 5. ICD-11 Diagnostic Criteria for Compulsive Sexual Behavior Disorder (6C72)

Management

Treatment approaches for particular substance use disorders

Outcomes

Special considerations

Pregnancy

Anesthesia

References

Contributors

Author

Editor

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Also in This Category

Metal neurotoxicity

Vascular cognitive impairment

Automatic-voluntary dissociation

Wilson disease

Pre-mild cognitive impairment

PART (Primary age-related tauopathy)

Anti-LGI1 encephalitis

Hypothyroidism

Addictive disorders

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Table 1. Psychological and Behavioral Changes Over Time as Addiction Progresses

Prognosis and complications

Biological basis

Differential diagnosis

Confusing conditions

Associated or underlying disorders

Diagnostic workup

Table 2. DSM 5-TR Diagnostic Criteria for [Substance] Use Disorder

Table 3. DSM-5-TR Criteria for Gambling Disorder

Table 4. ICD-11 Diagnostic Criteria for Gaming Disorder

Table 5. ICD-11 Diagnostic Criteria for Compulsive Sexual Behavior Disorder (6C72)

Management

Treatment approaches for particular substance use disorders

Outcomes

Special considerations

Pregnancy

Anesthesia

References

Contributors

Author

Editor

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Metal neurotoxicity

Vascular cognitive impairment

Automatic-voluntary dissociation

Wilson disease

Pre-mild cognitive impairment

PART (Primary age-related tauopathy)

Anti-LGI1 encephalitis

Hypothyroidism

This is an article preview.
Start a Free Account
to access the full version.