In simple terms, definition. The difference between addiction and dependence can be difficult to grasp, mainly because there is no set clinical (or otherwise) definitions of these terms. Quite often the words are used interchangeably or even discarded.
When the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was completed there was a change in the substance use disorders section and the current nomenclature concerning the use of the terms ‘dependence’ and ‘addiction’.
‘Dependence’, while used for decades to refer to unrestrained drug-seeking behaviour, took on an alternative connotation concerning the physiological alteration that takes place when substances, acting on the central nervous system are ingested with rebound when that substance is discontinued abruptly. These two differing definitions have led to misperceptions and may have informed current clinical practices relating to under-treatment of pain, as doctors fear forming an ‘addiction’ by prescribing opioids. To address this problem, the DSM-V has altered the name of the chapter to, Substance-Related and Addictive Disorders.
However, the waters are muddied further by those scientists, academics and clinicians, who do not regard it as settled that addiction is a, ‘chronic relapsing brain disease’ and there is dissatisfaction with the ‘official’ DSM portrayal of addiction and a desire, in terms of a more realistic, genuinely scientific account of this ubiquitous problem.
The difficulty comes with two polarised views of addiction, and the interminable dispute between them. First of all, there is the ‘moral view’. This view emerged from the pre-industrial era, in that what we would now call addictive behaviour is freedom of choice (meant here to represent all the other seemingly autonomous choices we all make every day and are fully responsible for).
At the opposite end of the spectrum is the ‘disease view’. This view took root in the early 19th century and culminated in its latest expression; the brain disease model of addiction. This frames addictive behaviour as involuntary and therefore against the will of the person: ‘addicts’ do not use because they choose to; they are compelled to. This characterisation of addiction is now so commonplace among professionals and scientists that to challenge this view is seen as heresy. However, there is a mass of evidence against the view that addictive behaviour is compulsive in a straightforward sense and that a ‘middle ground’, one between wholly free choice and no choice at all must be advanced, prevailing over both the moral and disease stages, in an understanding of addiction, one day converging on a unifying framework with which to study and treat addiction.
Before any task of re-definition can take place however, a fundamental definition must be wrought. For a long time now, the general public and professionals alike have extended the use of the term substance addictions, above and beyond a ‘wide range of repetitive activities’, to the point where it is a clichéd term often meaning little more than, ‘something people spend a lot of time doing’, as a caveat, there are good grounds for viewing some forms of repetitive and harmful non-substance behaviours, such as problem gambling, as ‘behavioural addictions’ but criterion for differentiating those behaviours thought of as addictions, from those that are not. This could take the form of; a person with specified behaviours is addicted if they have shown repeated and continuing failures to refrain from or reduce dramatically, these behaviours despite resolutions to do so (resolutions defined as, contrary-inclination-defeating intentions).
This definition covers what almost all clinicians and academics in the field would regard as the main problem in treating addiction; an initial change in behaviour can be relatively easy to achieve, the main difficulty is in maintaining change over time. The hallmark of addiction, therefore, is neither in the moral view or the disease view, but simply in its relapsing nature.