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Addiction: Is it a matter of choice?

Addiction is a complex issue with biological, social and psychological factors

Rohit began smoking when he joined college. He was friends with a group of teenagers, all of whom smoked. Rohit wanted to fit in, and tentatively picked up the habit by smoking one or two cigarettes a day. Six months down the line, Rohit was smoking a pack a day. He lost interest in classes, assignments and grades. When he went home for the vacations, he couldn’t smoke as much as he wanted to. He began feeling irritated, nauseous and restless. He would pace around, unable to concentrate on simple tasks. He would try to sneak out of the house to smoke, just so he could avoid feeling out of sorts. He couldn’t enjoy his vacations or the time with his family – all he would think about was how he could leave the house to smoke, how he could smoke at home without getting caught, and how he could go back to college, just so that he could smoke without restrictions. His parents had no idea that Rohit was addicted to cigarettes and found out only when the college called them at the end of the year to say that Rohit hadn’t attended classes, and would have to repeat the year.

This fictional narrative has been constructed to aid the understanding of this disorder by placing it in a real life situation.

What is addiction?

is a pattern in which a person becomes dependent on a substance (alcohol, cigarettes, drugs, etc.) which gives them pleasure. When the person becomes dependent on a substance, they are unable to focus on other areas of their life, including family, friends and work responsibilities. This creates problems for the person as well as those around them.

is a brain illness with a firm biological basis, and is influenced by social as well as psychological factors.

Note: There are many misconceptions about addiction, including the belief that a person who is addicted is weak or lacks morals. It’s important to remember that addiction is caused by several genetic and environmental factors, and is not a choice alone.

How does a person get addicted to a substance? 

All addictive substances -- alcohol, nicotine-based cigarettes, and drugs -- contain chemicals that create biological changes in the user’s body. When a person takes any of these substances, the brain releases dopamine, which triggers feelings of pleasure. This makes the person want to take that substance again and again for the instant reward. The person craves for the substance when they abstain, and desperately wants to recreate the high.

As the person keeps using the substance, their body’s tolerance to it gets higher, and the withdrawal symptoms make them take it again. They may think that they cannot live without the substance, and that it is as important as food, water or oxygen. The person may increasingly find themselves focusing on the substance and end up neglecting work, responsibilities, family and friends.

According to WHO guidelines, a person is said to have an addiction if:

  • they feel compelled to imbibe the substance
  • they cannot voluntarily stop using it (or cut down on using it)
  • they focus frequently on how to get access to the next dose

Here is a list of the WHO’s diagnostic terms that are used to refer to addiction-related disorders. 

is a chronic, relapsing condition and is quite similar to other chronic illnesses such as diabetes. It requires treatment in the form of intervention and control. A round of treatment does not guarantee that a person will not be addicted again; there are chances of a relapse. A relapse does not necessarily mean that the person has failed; rather it indicates that the person needs more support to get over the substance.

Common addictive substances

In India, the most common addictive substances can be divided into three categories:

  • Legal drugs such as alcohol and tobacco/cigarettes 
  • Illicit drugs, which include recreational drugs 
  • Pharmaceutical drugs orprescription drugs

What is the difference between a habit and an addiction?

Psychiatrists use the term dependence to describe how a person who is addicted needs to use more and more of a particular substance to get the same effect. A person who needed one glass of alcohol to get a high may find, after some months, that they need at least three glasses to achieve the same effect. Dependence (also known as increased tolerance) is one of the warning signs that a habit has become an addiction.

Some of the other indicators of an addiction are:

  • When the substance takes up a lot of the person’s time and thinking (when will I have my next drink/smoke, what can I substitute it with, where can I get it from, how can I get it?)
  • symptoms when the person does not use the substance for a period of time: shivering, irritation, severe craving and other psychological and emotional effects
  • Loss of control, when the person intends to go a whole day without the substance, but loses the will to do so
  • Craving: A strong urge to imbibe the substance
  • Continued use of the substance despite knowing that it is causing physical and emotional harm to the person and those around them

What is the difference between substance abuse and addiction?

In everyday usage, the term substance abuse refers to a pattern in which a person consumes a substance indiscriminately. The person may be consuming too much of a particular substance, or at inappropriate times and places. A person who abuses a certain substance may or may not be addicted to it. They are able to make decisions on how much to use, and when to stop using the substance, and are able to function normally without using the substance for an extended period of time. However, this does not mean that the usage of the substance does not create physiological, interpersonal or social problems.

In clinical terms, addiction refers to a pattern in which a person becomes dependent on a substance.is a chronic, relapsing disorder. The usage of the substance causes changes in the brain, which makes it difficult for the user to quit using it.

Both abuse and addiction can be harmful for the individual.

Why is addiction considered a mental illness?

Repeated use of an addictive substance makes changes to the way the user’s brain functions. When a person is addicted to a substance, they may not even be aware that their needs are changing; the substance takes topmost priority. They lose control over their impulses and decisions; this is why they want to take the substance repeatedly and cannot quit even if they want to. Getting hold of the drug, alcohol or cigarette becomes most important, and they are unwilling and unable to focus on their work, family, friends or other responsibilities. This impacts their daily functioning and relationships.

The changes caused in the brain of a person with addiction, occur in the areas of the brain that are related to other mental health disorders such as depression, severe anxiety and schizophrenia. There is a high chance that a person who has an addiction may also develop one of these severe mental disorders.

Is addiction a choice?

People begin to use addictive substances due to several reasons: curiosity, peer pressure, an attempt to fit in, modeling of behaviour observed at home, or as an act of rebellion. In that case, why are some people likely to get addicted, while some others remain content with an occasional cigarette, a drink or two?

Doctors say that some people are more vulnerable than others to begin with. “Those who are extremely impulsive, get angry easily, are oppositional or rebellious, or on the other end of the scale – being extremely anxious or having low self-esteem are more likely to get addicted,” says Dr Prathima Murthy, psychiatrist, NIMHANS Centre forMedicine. Those who are at a genetic risk for addiction (having had a close relative who had addiction issues) are at great risk too.

The environment plays an important role in determining whether a person is likely to get addicted. The availability, accessibility, affordability and social norms regarding the use of addictive substances influence the person’s tendency to develop an addiction.

A person may begin using a substance due to curiosity, peer pressure or environmental influences, without knowing that they are at risk of developing addiction. People who are vulnerable to addiction also cannot understand when they have reached the ‘safe’ limits. They do not have a strong protective mechanism that tells them when to stop, and so the warning signs (like slurring or swaying after a few drinks) may be missing. This makes the person use more of the substance and cause harm to themselves.