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=                             Addictive                              =
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                            Introduction
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Addiction is a neuropsychological disorder characterized by a
persistent and intense urge to use a drug or engage in a behavior that
produces natural reward, despite substantial harm and other negative
consequences. Repetitive drug use can alter brain function in synapses
similar to natural rewards like food or falling in love in ways that
perpetuate craving and weakens self-control for people with
pre-existing vulnerabilities. This phenomenon - drugs reshaping brain
function - has led to an understanding of addiction as a brain
disorder with a complex variety of psychosocial as well as
neurobiological factors that are implicated in the development of
addiction. While mice given cocaine showed the compulsive and
involuntary nature of addiction, for humans this is more complex,
related to behavior or personality traits.

Classic signs of addiction include compulsive engagement in rewarding
stimuli, 'preoccupation' with substances or behavior, and continued
use despite negative consequences. Habits and patterns associated with
addiction are typically characterized by immediate gratification
(short-term reward), coupled with delayed deleterious effects
(long-term costs).


Examples of substance addiction include alcoholism, cannabis
addiction, amphetamine addiction, cocaine addiction, nicotine
addiction, opioid addiction, and eating or food addiction. Behavioral
addictions may include gambling addiction, shopping addiction,
pornography addiction, internet addiction, video game addiction, and
sexual addiction. The DSM-5 and ICD-10 only recognize gambling
addictions as behavioral addictions, but the ICD-11 also recognizes
gaming addictions.


                         Signs and symptoms
======================================================================
Signs and symptoms of drug addiction can vary depending on the type of
addiction. Symptoms may include:
* Continuation of drug use despite the knowledge of consequences
* Disregarding financial status when it comes to drug purchases
* Ensuring a stable supply of the drug
* Needing more of the drug over time to achieve similar effects
* Social and work life impacted due to drug use
* Unsuccessful attempts to stop drug use
* Urge to use drug regularly

Other signs and symptoms can be categorized across relevant
dimensions:
!Behavioral Changes     !Physical Changes       !Social Changes * Angry and
irritable       * Changes to eating or sleeping habits  * Changes to
personality and attitude        * Decreased attendance and performance in
workplace or school setting     * Fearful, paranoid and anxious without
probable cause  * Frequently engaging in conflicts (fights, illegal
activity)       * Frequent or sudden changes in mood and temperament    *
Hiding or in denial of certain behaviors        * Lack of motivation    *
Periodic hyperactivity  * Using substances in inappropriate settings    *
Abnormal pupil size     * Bloodshot eyes        * Body odor     * Impaired motor
coordination    * Periodic tremors      * Poor physical appearance      * Slurred
speech  * Sudden changes in weight      * Changes in hobbies    * Changes to
financial status (unexplained need for money)   * Legal problems related
to substance abuse      * Sudden changes in friends and associates      * Use of
substance despite consequences to personal relationships


                       Substance use disorder
======================================================================
The DSM-5 discourages using the term "drug addiction" because of its
"uncertain definition and its potentially negative connotation" and
prefers the term "substance use disorder" to describe the wide range
of the disorder, from a mild form to a severe state of chronically
relapsing, compulsive pattern of drug taking.

SUD, belongs to the class of substance-related disorders, is a chronic
and relapsing brain disorder that features drug seeking and drug
abuse, despite their harmful effects. This form of addiction changes
brain circuitry such that the brain's reward system is compromised,
causing functional consequences for stress management and
self-control. Damage to the functions of the organs involved can
persist throughout a lifetime and cause death if untreated. Substances
involved with drug addiction include alcohol, nicotine, marijuana,
opioids, cocaine, amphetamines, and even foods with high fat and sugar
content. Addictions can begin experimentally in social contexts and
can arise from the use of prescribed medications or a variety of other
measures.

It has been shown to work in phenomenological, conditioning (operant
and classical), cognitive models, and the cue reactivity model.
However, no one model completely illustrates substance abuse.

Risk factors for addiction include:
* Aggressive behavior (particularly in childhood)
* Availability of substance
* Community economic status
* Experimentation
* Epigenetics
* Impulsivity (attentional, motor, or non-planning)
* Lack of parental supervision
* Lack of peer refusal skills
* Mental disorders
* Method substance is taken
* Usage of substance in youth


                           Food addiction
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The diagnostic criteria for food or eating addiction has not been
categorized or defined in references such as the 'Diagnostic and
Statistical Manual of Mental Disorders' (DSM) and is based on
subjective experiences similar to substance use disorders. Food
addiction may be found in those with eating disorders, though not all
people with eating disorders have food addiction and not all of those
with food addiction have a diagnosed eating disorder. Long-term
frequent and excessive consumption of foods high in fat, salt, or
sugar, such as chocolate, can produce an addiction similar to drugs
since they trigger the brain's reward system, such that the individual
may desire the same foods to an increasing degree over time. The
signals sent when consuming highly palatable foods have the ability to
counteract the body's signals for fullness and persistent cravings
will result. Those who show signs of food addiction may develop food
tolerances, in which they eat more, despite the food becoming less
satisfactory.

Chocolate's sweet flavor and pharmacological ingredients are known to
create a strong craving or feel 'addictive' by the consumer. A person
who has a strong liking for chocolate may refer to themselves as a
chocoholic.

Risk factors for developing food addiction include excessive
overeating and impulsivity.

The Yale Food Addiction Scale (YFAS), version 2.0, is the current
standard measure for assessing whether an individual exhibits signs
and symptoms of food addiction. It was developed in 2009 at Yale
University on the hypothesis that foods high in fat, sugar, and salt
have addictive-like effects which contribute to problematic eating
habits. The YFAS is designed to address 11 substance-related and
addictive disorders (SRADs) using a 25-item self-report questionnaire,
based on the diagnostic criteria for SRADs as per the DSM-5. A
potential food addiction diagnosis is predicted by the presence of at
least two out of 11 SRADs and a significant impairment to daily
activities.

The Barratt Impulsiveness Scale, specifically the BIS-11 scale, and
the UPPS-P Impulsive Behavior subscales of Negative Urgency and Lack
of Perseverance have been shown to have relation to food addiction.


                        Behavioral addiction
======================================================================
The term 'behavioral addiction' refers to a compulsion to engage in a
natural reward - which is a behavior that is inherently rewarding
(i.e., desirable or appealing) - despite adverse consequences.
Preclinical evidence has demonstrated that marked increases in the
expression of ΔFosB through repetitive and excessive exposure to a
natural reward induces the same behavioral effects and neuroplasticity
as occurs in a drug addiction.

Addiction can exist without psychotropic drugs, an idea that was
popularized by psychologist Stanton Peele. These are termed behavioral
addictions. Such addictions may be passive or active, but they
commonly contain reinforcing features, which are found in most
addictions. Sexual behavior, eating, gambling, playing video games,
and shopping are all associated with compulsive behaviors in humans
and have been shown to activate the mesolimbic pathway and other parts
of the reward system. Based on this evidence, sexual addiction,
gambling addiction, video game addiction, and shopping addiction are
classified accordingly.


Personality theories
======================
Personality theories of addiction are psychological models that
associate personality traits or modes of thinking (i.e., affective
states) with an individual's proclivity for developing an addiction.
Data analysis demonstrates that psychological profiles of drug users
and non-users have significant differences and the psychological
predisposition to using different drugs may be different. Models of
addiction risk that have been proposed in psychology literature
include: an affect dysregulation model of positive and negative
psychological affects, the reinforcement sensitivity theory of
impulsiveness and behavioral inhibition, and an impulsivity model of
reward sensitization and impulsiveness.


Neuropsychology
=================
The transtheoretical model of change (TTM) can point to how someone
may be conceptualizing their addiction and the thoughts around it,
including not being aware of their addiction.

Cognitive control and stimulus control, which is associated with
operant and classical conditioning, represent opposite processes
(i.e., internal vs external or environmental, respectively) that
compete over the control of an individual's elicited behaviors.
Cognitive control, and particularly inhibitory control over behavior,
is impaired in both addiction and attention deficit hyperactivity
disorder. Stimulus-driven behavioral responses (i.e., stimulus
control) that are associated with a particular rewarding stimulus tend
to dominate one's behavior in an addiction.


Stimulus control of behavior
==============================
In operant conditioning, behavior is influenced by outside stimulus,
such as a drug. The operant conditioning theory of learning is useful
in understanding why the mood-altering or stimulating consequences of
drug use can reinforce continued use (an example of positive
reinforcement) and why the addicted person seeks to avoid withdrawal
through continued use (an example of negative reinforcement). Stimulus
control is using the absence of the stimulus or presence of a reward
to influence the resulting behavior.


Cognitive control of behavior
===============================
Cognitive control is the intentional selection of thoughts, behaviors,
and emotions, based on our environment. It has been shown that drugs
alter the way our brains function, and its structure. Cognitive
functions such as learning, memory, and impulse control, are affected
by drugs. These effects promote drug use, as well as hinder the
ability to abstain from it. The increase in dopamine release is
prominent in drug use, specifically in the ventral striatum and the
nucleus accumbens. Dopamine is responsible for producing pleasurable
feelings, as well driving us to perform important life activities.
Addictive drugs cause a significant increase in this reward system,
causing a large increase in dopamine signaling as well as increase in
reward-seeking behavior, in turn motivating drug use. This promotes
the development of a maladaptive drug to stimulus relationship. Early
drug use leads to these maladaptive associations, later affecting
cognitive processes used for coping, which are needed to successfully
abstain from them.


Evolutionary perspectives
===========================
Some scholars have proposed evolutionary explanations for addiction,
suggesting that vulnerabilities to substance or behavioural dependence
reflect by-products or dysregulated expressions of reward and learning
systems that were adaptive in ancestral environments. Classic accounts
argue that purified drugs and rapid delivery methods exploit ancient
motivational circuitry by providing "false fitness signals" that mimic
cues once linked to survival or reproduction. Other reviews emphasise
how psychoactive substances and behavioural reinforcers act on
conserved mechanisms for reward, reinforcement, and emotion, which in
modern settings can be overstimulated or maladapted. These
perspectives do not replace proximate neurobiological models, but aim
instead to situate contemporary patterns of vulnerability within a
broader evolutionary framework.


                            Risk factors
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A number of genetic and environmental risk factors exist for
developing an addiction. Genetic and environmental risk factors each
account for roughly half of an individual's risk for developing an
addiction; the contribution from epigenetic risk factors to the total
risk is unknown. Even in individuals with a relatively low genetic
risk, exposure to sufficiently high doses of an addictive drug for a
long period of time (e.g., weeks-months) can result in an addiction.
Adverse childhood events are associated with negative health outcomes,
such as substance use disorder. Childhood abuse or exposure to violent
crime is related to developing a mood or anxiety disorder, as well as
a substance dependence risk.


Genetic factors
=================
Genetic factors, along with socio-environmental (e.g., psychosocial)
factors, have been established as significant contributors to
addiction vulnerability. Studies done on 350 hospitalized
drug-dependent patients showed that over half met the criteria for
alcohol abuse, with a role of familial factors being prevalent.
Genetic factors account for 40-60% of the risk factors for alcoholism.
Similar rates of heritability for other types of drug addiction have
been indicated, specifically in genes that encode the Alpha5 Nicotinic
Acetylcholine Receptor. Knestler hypothesized in 1964 that a gene or
group of genes might contribute to predisposition to addiction in
several ways. For example, altered levels of a normal protein due to
environmental factors may change the structure or functioning of
specific brain neurons during development. These altered brain neurons
could affect the susceptibility of an individual to an initial drug
use experience. In support of this hypothesis, animal studies have
shown that environmental factors such as stress can affect an animal's
genetic expression.

In humans, twin studies into addiction have provided some of the
highest-quality evidence of this link, with results finding that if
one twin is affected by addiction, the other twin is likely to be as
well, and to the same substance. Further evidence of a genetic
component is research findings from family studies which suggest that
if one family member has a history of addiction, the chances of a
relative or close family developing those same habits are much higher
than one who has not been introduced to addiction at a young age.

The data implicating specific genes in the development of drug
addiction is mixed for most genes. Many addiction studies that aim to
identify specific genes focus on common variants with an allele
frequency of greater than 5% in the general population. When
associated with disease, these only confer a small amount of
additional risk with an odds ratio of 1.1-1.3 percent; this has led to
the development the rare variant hypothesis, which states that genes
with low frequencies in the population (<1%) confer much greater
additional risk in the development of the disease.

Genome-wide association studies (GWAS) are used to examine genetic
associations with dependence, addiction, and drug use. These studies
rarely identify genes from proteins previously described via animal
knockout models and candidate gene analysis. Instead, large
percentages of genes involved in processes such as cell adhesion are
commonly identified. The important effects of endophenotypes are
typically not capable of being captured by these methods. Genes
identified in GWAS for drug addiction may be involved either in
adjusting brain behavior before drug experiences, subsequent to them,
or both.


Stress and Addiction
======================
Stress can play a central and key role in the development and the
persistence of addiction. It can influence neurophysiological
pathways, decision-making processes, and relapse risk. Acute and
chronic stress can activate the hypothalamic pituitary adrenal gland,
which can result in elevated cortisol and corticotropin releasing
factor. These hormonal changes alter reward processing and increase
the motivational value of substances, mainly those that temporarily
reduce negative affect.

In preclinical models, repeated stress exposure aids dopamine release
in the nucleus accumbens and sensatizes the mesolimbic reward system,
increasing the reinforcing aspects of drugs. Chronic stress also
disturbs glutamatergic signaling in the pre frontal cortex, which
impairs executive fucnctions including inhibitory control and self
regulation. These changes increase the susceptibility to compulsive
drug seeking and decrease the ability to ignore conditioned cues that
are associated with substance use.

Stress can also be one of the most reliable predictors of a potential
relapse. Human neuroimaging studies show that stress induced
activation of the amygdala and reduced pre frontal cortex regulation
correlate with self reported craving and subsequent return to use.
Individuals that have a history of trauma or chronic social stress
(things like discrimination, poverty, or unstable housing) show an
increased risk for substance use disorders due to both neurobiological
sensitization and behavioral coping responses.

Stress interacts very strongly with reward circuitry and
decision-making systems, this means many treatment approaches
integrate stress reduction strategies. These include cognitive
behavioral therapy, mindfulness based interventions, and medications
targeting stress related neurochemistry.


Environmental factors
=======================
Environmental risk factors for addiction are the experiences of an
individual during their lifetime that interact with the individual's
genetic composition to increase or decrease his or her vulnerability
to addiction. For example, after the nationwide outbreak of COVID-19,
more people quit (vs. started) smoking; and smokers, on average,
reduced the quantity of cigarettes they consumed. More generally, a
number of different environmental factors have been implicated as risk
factors for addiction, including various psychosocial stressors. The
National Institute on Drug Abuse (NIDA) and studies cite lack of
parental supervision, the prevalence of peer substance use, substance
availability, and poverty as risk factors for substance use among
children and adolescents. The brain disease model of addiction posits
that an individual's exposure to an addictive drug is the most
significant environmental risk factor for addiction. Many researchers,
including neuroscientists, indicate that the brain disease model
presents a misleading, incomplete, and potentially detrimental
explanation of addiction.

The psychoanalytic theory model defines 'addiction' as a form of
defense against feelings of hopelessness and helplessness as well as a
symptom of failure to regulate powerful emotions related to adverse
childhood experiences (ACEs), various forms of maltreatment and
dysfunction experienced in childhood. In this case, the addictive
substance provides brief but total relief and positive feelings of
control. The Adverse Childhood Experiences Study by the Centers for
Disease Control and Prevention has shown a strong dose-response
relationship between ACEs and numerous health, social, and behavioral
problems throughout a person's lifespan, including substance use
disorder. Children's neurological development can be permanently
disrupted when they are chronically exposed to stressful events such
as physical, emotional, or sexual abuse, physical or emotional
neglect, witnessing violence in the household, or a parent being
incarcerated or having a mental illness. As a result, the child's
cognitive functioning or ability to cope with negative or disruptive
emotions may be impaired. Over time, the child may adopt substance use
as a coping mechanism or as a result of reduced impulse control,
particularly during adolescence. Vast amounts of children who
experienced abuse have gone on to have some form of addiction in their
adolescence or adult life. This pathway towards addiction that is
opened through stressful experiences during childhood can be avoided
by a change in environmental factors throughout an individual's life
and opportunities of professional help. If one has friends or peers
who engage in drug use favorably, the chances of them developing an
addiction increases. Family conflict and home management is a cause
for one to become engaged in drug use.


Social control theory
=======================
According to Travis Hirschi's social control theory, adolescents with
stronger attachments to family, religious, academic, and other social
institutions are less likely to engage in delinquent and maladaptive
behavior such as drug use leading to addiction.


Age
=====
Adolescence represents a period of increased vulnerability for
developing an addiction. In adolescence, the incentive-rewards systems
in the brain mature well before the cognitive control center. This
consequentially grants the incentive-rewards systems a
disproportionate amount of power in the behavioral decision-making
process. Therefore, adolescents are increasingly likely to act on
their impulses and engage in risky, potentially addictive behavior
before considering the consequences. Not only are adolescents more
likely to initiate and maintain drug use, but once addicted they are
more resistant to treatment and more liable to relapse.

Most individuals are exposed to and use addictive drugs for the first
time during their teenage years. In the United States, there were just
over 2.8 million new users of illicit drugs in 2013 (7,800 new users
per day); among them, 54.1% were under 18 years of age. In 2011, there
were approximately 20.6 million people in the United States over the
age of 12 with an addiction. Over 90% of those with an addiction began
drinking, smoking or using illicit drugs before the age of 18.


Prefrontal Cortex Maturation and Addiction Risk
=================================================
Adolescence is a critical developmental period in which the prefrontal
cortex (which is responsible for planning, inhibitory control, and
evaluating long term consequences) experiences significant maturation.
During this period, limbic reward circuits mature earlier than
prefrontal cortex regulatory networks, creating a developmental
imbalance in which reward sensitivity is high, but cognitive control
is not fully developed yet. This mismatch contributes to higher
experimentation with substances and vulnerability to addiction.

Neuroimaging studies show that adolescents exhibit reduced prefrontal
cortex activation during decision making tasks, risk taking behavior,
and heightened dopamine reactivity compared with adults. Exposure to
substances during this early period of their life can disrupt synaptic
pruning and myelination. Ths can produce long term alterations in
executive functioning and reward processing that increase the chance
of developing a substance use disorder.


Comorbid disorders
====================
Individuals with comorbid (i.e., co-occurring) mental health disorders
such as depression, anxiety, attention-deficit/hyperactivity disorder
(ADHD) or post-traumatic stress disorder are more likely to develop
substance use disorders. The  cites early aggressive behavior as a
risk factor for substance use. The National Bureau of Economic
Research found that there is a "definite connection between mental
illness and the use of addictive substances" and a majority of mental
health patients participate in the use of these substances: 38%
alcohol, 44% cocaine, and 40% cigarettes.


Epigenetic
============
Epigenetics is the study of stable phenotypic changes that do not
involve alterations in the DNA sequence. Illicit drug use has been
found to cause epigenetic changes in DNA methylation, as well as
chromatin remodeling. The epigenetic state of chromatin may pose as a
risk for the development of substance addictions. It has been found
that emotional stressors, as well as social adversities may lead to an
initial epigenetic response, which causes an alteration to the
reward-signalling pathways. This change may predispose one to
experience a positive response to drug use.


Transgenerational epigenetic inheritance
==========================================
Epigenetic genes and their products (e.g., proteins) are the key
components through which environmental influences can affect the genes
of an individual: they serve as the mechanism responsible for
transgenerational epigenetic inheritance, a phenomenon in which
environmental influences on the genes of a parent can affect the
associated traits and behavioral phenotypes of their offspring (e.g.,
behavioral responses to environmental stimuli). In addiction,
epigenetic mechanisms play a central role in the pathophysiology of
the disease; it has been noted that some of the alterations to the
epigenome which arise through chronic exposure to addictive stimuli
during an addiction can be transmitted across generations, in turn
affecting the behavior of one's children (e.g., the child's behavioral
responses to addictive drugs and natural rewards).

The general classes of epigenetic alterations that have been
implicated in transgenerational epigenetic inheritance include DNA
methylation, histone modifications, and downregulation or upregulation
of microRNAs. With respect to addiction, more research is needed to
determine the specific heritable epigenetic alterations that arise
from various forms of addiction in humans and the corresponding
behavioral phenotypes from these epigenetic alterations that occur in
human offspring. Based on preclinical evidence from animal research,
certain addiction-induced epigenetic alterations in rats can be
transmitted from parent to offspring and produce behavioral phenotypes
that decrease the offspring's risk of developing an addiction. More
generally, the heritable behavioral phenotypes that are derived from
addiction-induced epigenetic alterations and transmitted from parent
to offspring may serve to either increase or decrease the offspring's
risk of developing an addiction.


                             Mechanisms
======================================================================
Addiction is a disorder of the brain's reward system developing
through transcriptional and epigenetic mechanisms as a result of
chronically high levels of exposure to an addictive stimulus (e.g.,
eating food, the use of cocaine, engagement in sexual activity,
participation in high-thrill cultural activities such as gambling,
etc.) over extended time. DeltaFosB (ΔFosB), a gene transcription
factor, is a critical component and common factor in the development
of virtually all forms of behavioral and drug addictions. Two decades
of research into ΔFosB's role in addiction have demonstrated that
addiction arises, and the associated compulsive behavior intensifies
or attenuates, along with the overexpression of ΔFosB in the D1-type
medium spiny neurons of the nucleus accumbens. Due to the causal
relationship between ΔFosB expression and addictions, it is used
preclinically as an addiction biomarker. ΔFosB expression in these
neurons directly and positively regulates drug self-administration and
reward sensitization through positive reinforcement, while decreasing
sensitivity to aversion.



Chronic addictive drug use causes alterations in gene expression in
the mesocorticolimbic projection. The most important transcription
factors that produce these alterations are ΔFosB, cAMP response
element binding protein (CREB), and nuclear factor kappa B (NF-κB).
ΔFosB is the most significant biomolecular mechanism in addiction
because the overexpression of ΔFosB in the D1-type medium spiny
neurons in the nucleus accumbens is necessary and sufficient for many
of the neural adaptations and behavioral effects (e.g.,
expression-dependent increases in drug self-administration and reward
sensitization) seen in drug addiction. ΔFosB expression in nucleus
accumbens D1-type medium spiny neurons directly and positively
regulates drug self-administration and reward sensitization through
positive reinforcement while decreasing sensitivity to aversion. ΔFosB
has been implicated in mediating addictions to many different drugs
and drug classes, including alcohol, amphetamine and other substituted
amphetamines, cannabinoids, cocaine, methylphenidate, nicotine,
opiates, phenylcyclidine, and propofol, among others. ΔJunD, a
transcription factor, and G9a, a histone methyltransferase, both
oppose the function of ΔFosB and inhibit increases in its expression.
Increases in nucleus accumbens ΔJunD expression (via viral
vector-mediated gene transfer) or G9a expression (via pharmacological
means) reduces, or with a large increase can even block, many of the
neural and behavioral alterations that result from chronic high-dose
use of addictive drugs (i.e., the alterations mediated by ΔFosB).

ΔFosB plays an important role in regulating behavioral responses to
natural rewards, such as palatable food, sex, and exercise. Natural
rewards, like drugs of abuse, induce gene expression of ΔFosB in the
nucleus accumbens, and chronic acquisition of these rewards can result
in a similar pathological addictive state through ΔFosB
overexpression.[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3139704/table/T1/
Table 1: Summary of plasticity observed following exposure to drug or
natural reinforcers]" Consequently, ΔFosB is the key transcription
factor involved in addictions to natural rewards (i.e., behavioral
addictions) as well; in particular, ΔFosB in the nucleus accumbens is
critical for the reinforcing effects of sexual reward. Research on the
interaction between natural and drug rewards suggests that
dopaminergic psychostimulants (e.g., amphetamine) and sexual behavior
act on similar biomolecular mechanisms to induce ΔFosB in the nucleus
accumbens and possess bidirectional cross-sensitization effects that
are mediated through ΔFosB. This phenomenon is notable since, in
humans, a dopamine dysregulation syndrome, characterized by
drug-induced compulsive engagement in natural rewards (specifically,
sexual activity, shopping, and gambling), has been observed in some
individuals taking dopaminergic medications.

ΔFosB inhibitors (drugs or treatments that oppose its action) may be
an effective treatment for addiction and addictive disorders.

The release of dopamine in the nucleus accumbens plays a role in the
reinforcing qualities of many forms of stimuli, including naturally
reinforcing stimuli like palatable food and sex. Altered dopamine
neurotransmission is frequently observed following the development of
an addictive state. In humans and lab animals that have developed an
addiction, alterations in dopamine or opioid neurotransmission in the
nucleus accumbens and other parts of the striatum are evident. Use of
certain drugs (e.g., cocaine) affect cholinergic neurons that
innervate the reward system, in turn affecting dopamine signaling in
this region.

A recent study in Addiction reports that GLP-1 agonist medications,
such as semaglutide, which are commonly used for diabetes and weight
management, may also reduce the risk of overdose and alcohol
intoxication in people with substance use disorders. The study
analyzed nearly nine years of health records from 1.3 million
individuals across 136 U.S. hospitals, including 500,000 with opioid
use disorder and over 800,000 with alcohol use disorder. Researchers
found that those who used Ozempic or similar medications had a 40%
lower risk of opioid overdose and a 50% lower risk of alcohol
intoxication compared to those not using these drugs.


Mesocorticolimbic pathway
===========================
Understanding the pathways in which drugs act and how drugs can alter
those pathways is key when examining the biological basis of drug
addiction. The reward pathway, known as the mesolimbic pathway, or its
extension, the mesocorticolimbic pathway, is characterized by the
interaction of several areas of the brain.
* The projections from the ventral tegmental area (VTA) are a network
of dopaminergic neurons with co-localized postsynaptic glutamate
receptors (AMPAR and NMDAR). These cells respond when stimuli
indicative of a reward are present. The VTA supports learning and
sensitization development and releases dopamine (DA) into the
forebrain. These neurons project and release DA into the nucleus
accumbens, through the mesolimbic pathway. Virtually all drugs causing
drug addiction increase the DA release in the mesolimbic pathway.
* The nucleus accumbens (NAcc) is one output of the VTA projections.
The nucleus accumbens itself consists mainly of GABAergic medium spiny
neurons (MSNs). The NAcc is associated with acquiring and eliciting
conditioned behaviors, and is involved in the increased sensitivity to
drugs as addiction progresses. Overexpression of ΔFosB in the nucleus
accumbens is a necessary common factor in essentially all known forms
of addiction; ΔFosB is a strong positive modulator of positively
reinforced behaviors.
* The prefrontal cortex, including the anterior cingulate and
orbitofrontal cortices, is another VTA output in the mesocorticolimbic
pathway; it is important for the integration of information which
helps determine whether a behavior will be elicited. It is critical
for forming associations between the rewarding experience of drug use
and cues in the environment. Importantly, these cues are strong
mediators of drug-seeking behavior and can trigger relapse even after
months or years of abstinence.
Other brain structures that are involved in addiction include:
* The basolateral amygdala projects into the NAcc and is thought to be
important for motivation.
* The hippocampus is involved in drug addiction, because of its role
in learning and memory. Much of this evidence stems from
investigations showing that manipulating cells in the hippocampus
alters DA levels in NAcc and firing rates of VTA dopaminergic cells.


Role of dopamine and glutamate
================================
Dopamine is the primary neurotransmitter of the reward system in the
brain. It plays a role in regulating movement, emotion, cognition,
motivation, and feelings of pleasure. Natural rewards, like eating, as
well as recreational drug use cause a release of dopamine, and are
associated with the reinforcing nature of these stimuli. Nearly all
addictive drugs, directly or indirectly, act on the brain's reward
system by heightening dopaminergic activity.

Excessive intake of many types of addictive drugs results in repeated
release of high amounts of dopamine, which in turn affects the reward
pathway directly through heightened dopamine receptor activation.
Prolonged and abnormally high levels of dopamine in the synaptic cleft
can induce receptor downregulation in the neural pathway.
Downregulation of mesolimbic dopamine receptors can result in a
decrease in the sensitivity to natural reinforcers.

Drug seeking behavior is induced by glutamatergic projections from the
prefrontal cortex to the nucleus accumbens. This idea is supported
with data from experiments showing that drug seeking behavior can be
prevented following the inhibition of AMPA glutamate receptors and
glutamate release in the nucleus accumbens.


Reward sensitization{{anchor|Sensitization|Drug sensitization}}
=================================================================
Neural and behavioral effects of validated ΔFosB transcriptional
targets in the
striatum[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607320/table/tbl3/
Table 3]         Target gene     Target expression       Neural effects  Behavioral
effects
c-Fos    ↓     Molecular switch enabling the chronic induction of ΔFosB
-
dynorphin        ↓     Downregulation of κ-opioid feedback loop       Increased
drug reward
NF-κB   ↑     Expansion of NAcc dendritic processes NF-κB inflammatory
response in the  NF-κB inflammatory response in the     Increased drug
reward Locomotor sensitization
GluR2    ↑     Decreased sensitivity to glutamate      Increased drug
reward
Cdk5     ↑     GluR1 synaptic protein phosphorylation Expansion of
dendritic processes      Decreased drug reward (net effect)
Reward sensitization is a process that causes an increase in the
amount of reward (specifically, incentive salience) that is assigned
by the brain to a rewarding stimulus (e.g., a drug). In simple terms,
when reward sensitization to a specific stimulus (e.g., a drug)
occurs, an individual's "wanting" or desire for the stimulus itself
and its associated cues increases. Reward sensitization normally
occurs following chronically high levels of exposure to the stimulus.
ΔFosB expression in D1-type medium spiny neurons in the nucleus
accumbens has been shown to directly and positively regulate reward
sensitization involving drugs and natural rewards.

"Cue-induced wanting" or "cue-triggered wanting", a form of craving
that occurs in addiction, is responsible for most of the compulsive
behavior that people with addictions exhibit. During the development
of an addiction, the repeated association of otherwise neutral and
even non-rewarding stimuli with drug consumption triggers an
associative learning process that causes these previously neutral
stimuli to act as conditioned positive reinforcers of addictive drug
use (i.e., these stimuli start to function as drug cues). As
conditioned positive reinforcers of drug use, these previously neutral
stimuli are assigned incentive salience (which manifests as a craving)
- sometimes at pathologically high levels due to reward sensitization
- which can transfer to the primary reinforcer (e.g., the use of an
addictive drug) with which it was originally paired.

Research on the interaction between natural and drug rewards suggests
that dopaminergic psychostimulants (e.g., amphetamine) and sexual
behavior act on similar biomolecular mechanisms to induce ΔFosB in the
nucleus accumbens and possess a bidirectional reward
cross-sensitization effect that is mediated through ΔFosB. In contrast
to ΔFosB's reward-sensitizing effect, CREB transcriptional activity
decreases user's sensitivity to the rewarding effects of the
substance. CREB transcription in the nucleus accumbens is implicated
in psychological dependence and symptoms involving a lack of pleasure
or motivation during drug withdrawal.


Neuroepigenetic mechanisms
============================
Altered epigenetic regulation of gene expression within the brain's
reward system plays a significant and complex role in the development
of drug addiction. Addictive drugs are associated with three types of
epigenetic modifications within neurons. These are (1) histone
modifications, (2) epigenetic methylation of DNA at CpG sites at (or
adjacent to) particular genes, and (3) epigenetic downregulation or
upregulation of microRNAs which have particular target genes. As an
example, while hundreds of genes in the cells of the nucleus accumbens
(NAc) exhibit histone modifications following drug exposure -
particularly, altered acetylation and methylation states of histone
residues - most other genes in the NAc cells do not show such changes.


DSM-5
=======
The fifth edition of the DSM uses the term 'substance use disorder' to
refer to a spectrum of drug use-related disorders. The DSM-5
eliminates the terms 'abuse' and 'dependence' from diagnostic
categories, instead using the specifiers of 'mild', 'moderate' and
'severe' to indicate the extent of disordered use. These specifiers
are determined by the number of diagnostic criteria present in a given
case. In the DSM-5, the term 'drug addiction' is synonymous with
'severe substance use disorder'.

The DSM-5 introduced a new diagnostic category for behavioral
addictions. Problem gambling is the only condition included in this
category in the fifth edition. Internet gaming disorder is listed as a
"condition requiring further study" in the DSM-5.

Past editions have used physical dependence and the associated
withdrawal syndrome to identify an addictive state. Physical
dependence occurs when the body has adjusted by incorporating the
substance into its "normal" functioning - i.e., attains homeostasis -
and therefore physical withdrawal symptoms occur on cessation of use.
Tolerance is the process by which the body continually adapts to the
substance and requires increasingly larger amounts to achieve the
original effects. Withdrawal refers to physical and psychological
symptoms experienced when reducing or discontinuing a substance that
the body has become dependent on. Symptoms of withdrawal generally
include but are not limited to body aches, anxiety, irritability,
intense cravings for the substance, dysphoria, nausea, hallucinations,
headaches, cold sweats, tremors, and seizures. During acute physical
opioid withdrawal, symptoms of restless legs syndrome are common and
may be profound. This phenomenon originated the idiom "kicking the
habit".

Medical researchers who actively study addiction have criticized the
DSM classification of addiction for being flawed and involving
arbitrary diagnostic criteria.


ICD-11
========
The eleventh revision of the International Classification of Diseases,
commonly referred to as ICD-11, conceptualizes diagnosis somewhat
differently. ICD-11 first distinguishes between problems with
psychoactive substance use ("Disorders due to substance use") and
behavioral addictions ("Disorders due to addictive behaviours"). With
regard to psychoactive substances, ICD-11 explains that the included
substances initially produce "pleasant or appealing psychoactive
effects that are rewarding and reinforcing with repeated use, [but]
with continued use, many of the included substances have the capacity
to produce dependence. They have the potential to cause numerous forms
of harm, both to mental and physical health." Instead of the DSM-5
approach of one diagnosis ("Substance Use Disorder") covering all
types of problematic substance use, ICD-11 offers three diagnostic
possibilities: 1) Episode of Harmful Psychoactive Substance Use, 2)
Harmful Pattern of Psychoactive Substance Use, and 3) Substance
Dependence.


Addictions Neuroclinical Assessment
=====================================
The Addictions Neuroclinical Assessment is used to diagnose addiction
disorders. This tool measures three different domains: executive
function, incentive salience, and negative emotionality. Executive
functioning consists of processes that would be disrupted in
addiction. In the context of addiction, incentive salience determines
how one perceives the addictive substance. Increased negative
emotional responses have been found with individuals with addictions.


Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS)
===========================================================================
This is a screening and assessment tool in one, assessing commonly
used substances. This tool allows for a simple diagnosis, eliminating
the need for several screening and assessment tools, as it includes
both TAPS-1 and TAPS-2, screening and assessment tools respectively.
The screening component asks about the frequency of use of the
specific substance (tobacco, alcohol, prescription medication, and
other). If an individual screens positive, the second component will
begin. This dictates the risk level of the substance.


CRAFFT
========
The CRAFFT (Car-Relax-Alone-Forget-Family and Friends-Trouble) is a
screening tool that is used in medical centers. The CRAFFT is in
version 2.1 and has a version for nicotine and tobacco use called the
CRAFFT 2.1+N. This tool is used to identify substance use, substance
related driving risk, and addictions among adolescents. This tool uses
a set of questions for different scenarios. In the case of a specific
combination of answers, different question sets can be used to yield a
more accurate answer. After the questions, the DSM-5 criteria are used
to identify the likelihood of the person having substance use
disorder. After these tests are done, the clinician is to give the "5
RS" of brief counseling.

The five Rs of brief counseling includes:
# REVIEW screening results
# RECOMMEND to not use
# RIDING/DRIVING risk counseling
# RESPONSE: elicit self-motivational statements
# REINFORCE self-efficacy


Drug Abuse Screening Test (DAST-10)
=====================================
The Drug Abuse Screening Test (DAST) is a self-reporting tool that
measures problematic substance use. Responses to this test are
recorded as yes or no answers, and scored as a number between zero and
28. Drug abuse or dependence, are indicated by a cut off score of 6.
Three versions of this screening tool are in use: DAST-28, DAST-20,
and DAST-10. Each of these instruments are copyrighted by Dr. Harvey
A. Skinner.


Alcohol, Smoking, and Substance Involvement Test (ASSIST)
===========================================================
The Alcohol, Smoking, and Substance Involvement Test (ASSIST) is an
interview-based questionnaire consisting of eight questions developed
by the WHO. The questions ask about lifetime use; frequency of use;
urge to use; frequency of health, financial, social, or legal problems
related to use; failure to perform duties; if anyone has raised
concerns over use; attempts to limit or moderate use; and use by
injection.


Abuse liability
=================
Abuse or addiction liability is the tendency to use drugs in a
non-medical situation. This is typically for euphoria, mood changing,
or sedation. Abuse liability is used when the person using the drugs
wants something that they otherwise can not obtain. The only way to
obtain this is through the use of drugs. When looking at abuse
liability there are a number of determining factors in whether the
drug is abused. These factors are: the chemical makeup of the drug,
the effects on the brain, and the age, vulnerability, and the health
(mental and physical) of the population being studied. There are a few
drugs with a specific chemical makeup that leads to a high abuse
liability. These are: cocaine, heroin, inhalants, marijuana, MDMA
(ecstasy), methamphetamine, PCP, synthetic cannabinoids, synthetic
cathinones (bath salts), nicotine (e.g. tobacco), and alcohol.


Potential vaccines for addiction to substances
================================================
Vaccines for addiction have been investigated as a possibility since
the early 2000s. The general theory of a vaccine intended to
"immunize" against drug addiction or other substance abuse is that it
would condition the immune system to attack and consume or otherwise
disable the molecules of such substances that cause a reaction in the
brain, thus preventing the addict from being able to realize the
effect of the drug. Addictions that have been floated as targets for
such treatment include nicotine, opioids, and fentanyl. Vaccines have
been identified as potentially being more effective than other
anti-addiction treatments, due to "the long duration of action, the
certainty of administration and a potential reduction of toxicity to
important organs".

Specific addiction vaccines in development include:

*NicVAX, a conjugate vaccine intended to reduce or eliminate physical
dependence on nicotine. This proprietary vaccine is being developed by
Nabi Biopharmaceuticals of Rockville, MD. with the support from the
U.S. National Institute on Drug Abuse. NicVAX consists of the hapten
3'-aminomethylnicotine which has been conjugated (attached) to
'Pseudomonas aeruginosa' exotoxin A.
* TA-CD, an active vaccine developed by the Xenova Group which is used
to negate the effects of cocaine. It is created by combining
norcocaine with inactivated cholera toxin. It works in much the same
way as a regular vaccine.  A large protein molecule attaches to
cocaine, which stimulates response from antibodies, which destroy the
molecule.  This also prevents the cocaine from crossing the
blood-brain barrier, negating the euphoric high and rewarding effect
of cocaine caused from stimulation of dopamine release in the
mesolimbic reward pathway.  The vaccine does not affect the user's
"desire" for cocaine--only the physical effects of the drug.
*TA-NIC, used to create human antibodies to destroy nicotine in the
human body so that it is no longer effective.

As of September 2023, it was further reported that a vaccine "has been
tested against heroin and fentanyl and is on its way to being tested
against OxyContin".


                             Treatment
======================================================================
To be effective, treatment for addiction that is pharmacological or
biologically based need to be accompanied by other interventions such
as cognitive behavioral therapy (CBT) and dialectical behavioral
therapy (DBT); individual and group psychotherapy, behavior
modification strategies, twelve-step programs, and residential
treatment facilities. The transtheoretical model (TTM) can be used to
determine when treatment can begin and which method will be most
effective. If treatment begins too early, it can cause a person to
become defensive and resistant to change.


                            Epidemiology
======================================================================
Due to cultural variations, the proportion of individuals who develop
a drug or behavioral addiction within a specified time period (i.e.,
the prevalence) varies over time, by country, and across national
population demographics (e.g., by age group, socioeconomic status,
etc.). Where addiction is viewed as unacceptable, there will be fewer
people addicted.


Asia
======
The prevalence of alcohol dependence is not as high as is seen in
other regions. In Asia, not only socioeconomic factors but biological
factors influence drinking behavior.

Internet addiction disorder is highest in the Philippines, according
to both the IAT (Internet Addiction Test) - 5% and the CIAS-R (Revised
Chen Internet Addiction Scale) - 21%.


Australia
===========
The prevalence of substance use disorder among Australians was
reported at 5.1% in 2009.  In 2019 the Australian Institute of Health
and Welfare conducted a national drug survey that quantified drug use
for various types of drugs and demographics. The survey found that in
2019, 11% of people over 14 years old smoke daily; that 9.9% of those
who drink alcohol, which equates to 7.5% of the total population age
14 or older, may qualify as alcohol dependent; that 17.5% of the 2.4
million people who used cannabis in the last year may have hazardous
use or a dependence problem; and that 63.5% of about 300000 recent
users of meth and amphetamines were at risk for developing problem
use.


Europe
========
In 2015, the estimated prevalence among the adult population was 18.4%
for heavy episodic alcohol use (in the past 30 days); 15.2% for daily
tobacco smoking; and 3.8% for cannabis use, 0.77% for amphetamine use,
0.37% for opioid use, and 0.35% for cocaine use in 2017. The mortality
rates for alcohol and illicit drugs were highest in Eastern Europe.
Data shows a downward trend of alcohol use among children 15 years old
in most European countries between 2002 and 2014. First-time alcohol
use before the age of 13 was recorded for 28% of European children in
2014.


United States
===============
Based on representative samples of the US youth population in , the
lifetime prevalence of addictions to alcohol and illicit drugs has
been estimated to be approximately 8% and 2-3% respectively. Based on
representative samples of the US adult population in , the 12-month
prevalence of alcohol and illicit drug addictions were estimated at
12% and 2-3% respectively. The lifetime prevalence of prescription
drug addictions is around 4.7%.

43.7 million people aged 12 or older surveyed by the National Survey
on Drug Use and Health in the United States needed treatment for an
addiction to alcohol, nicotine, or other drugs. The groups with the
highest number of people were 18-25 years (25.1%) and "American Indian
or Alaska Native" (28.7%). Only about 10%, or a little over 2 million,
receive any form of treatments, and those that do generally do not
receive evidence-based care. One-third of inpatient hospital costs and
20% of all deaths in the US every year are the result of untreated
addictions and risky substance use. In spite of the massive overall
economic cost to society, which is greater than the cost of diabetes
and all forms of cancer combined, most doctors in the US lack the
training to effectively address a drug addiction.

Estimates of lifetime prevalence rates in the US are 1-2% for
compulsive gambling, 5% for sexual addiction, 2.8% for food addiction,
and 5-6% for compulsive shopping. The time-invariant prevalence rate
for sexual addiction and related compulsive sexual behavior (e.g.,
compulsive masturbation with or without pornography, compulsive
cybersex, etc.) within the US ranges from 3-6% of the population.

According to a 2017 poll conducted by the Pew Research Center, almost
half of US adults know a family member or close friend who has
struggled with a drug addiction at some point in their life.

In 2019, opioid addiction was acknowledged as a national crisis in the
United States. An article in 'The Washington Post' stated that
"America's largest drug companies flooded the country with pain pills
from 2006 through 2012, even when it became apparent that they were
fueling addiction and overdoses."

The National Epidemiologic Survey on Alcohol and Related Conditions
found that from 2012 to 2013 the prevalence of Cannabis use disorder
in U.S. adults was 2.9%.


Canada
========
A Statistics Canada Survey in 2012 found the lifetime prevalence and
12-month prevalence of substance use disorders were 21.6%, and 4.4% in
those 15 and older. Alcohol abuse or dependence reported a lifetime
prevalence of 18.1% and a 12-month prevalence of 3.2%. Cannabis abuse
or dependence reported a lifetime prevalence of 6.8% and a 12-month
prevalence of 3.2%. Other drug abuse or dependence has a lifetime
prevalence of 4.0% and a 12-month prevalence of 0.7%. 'Substance use
disorder' is a term used interchangeably with 'a drug addiction'.

In Ontario, Canada between 2009 and 2017, outpatient visits for mental
health and addiction increased from 52.6 to 57.2 per 100 people,
emergency department visits increased from 13.5 to 19.7 per 1000
people and the number of hospitalizations increased from 4.5 to 5.5
per 1000 people. Prevalence of care needed increased the most among
the 14-17 age group overall.


South America
===============
The realities of opioid use and opioid use disorder in Latin America
may be deceptive if observations are limited to epidemiological
findings. In the United Nations Office on Drugs and Crime report,
although South America produced 3% of the world's morphine and heroin
and 0.01% of its opium, prevalence of use is uneven. According to the
Inter-American Commission on Drug Abuse Control, consumption of heroin
is low in most Latin American countries, although Colombia is the
area's largest opium producer. Mexico, because of its border with the
United States, has the highest incidence of use.


                             Etymology
======================================================================
The word 'addiction' derives from the Latin "'addico'", meaning
"giving over" with both positive connotations (devotion, dedication)
and negative ones (being enslaved to a creditor in Roman law). This
dual meaning persisted in traditional English dictionaries,
encompassing both legal surrender and personal devotion to habits.
Later, 19th century temperance movements narrowed the definition of
addiction to just drug-related disease, ignoring behavioral addictions
and the possibility of positive or neutral addictions. This
restrictive view opposes the current understanding of addiction.

'Addiction' and 'addictive behavior' are polysemes denoting a category
of mental disorders, of neuropsychological symptoms, or of merely
maladaptive/harmful habits and lifestyles. A common use of the term
'addiction' in medicine is for neuropsychological symptoms denoting
pervasive/excessive and intense urges to engage in a category of
behavioral compulsions or impulses towards sensory rewards (e.g.,
alcohol, betel quid, drugs, sex, gambling, video gaming). Addictive
disorders or addiction disorders are mental disorders involving high
intensities of addictions (as neuropsychological symptoms) that induce
functional disabilities (i.e., limit subjects' social/family and
occupational activities); the two categories of such disorders are
'substance-use addictions' and 'behavioral addictions'.

The etymology of the term 'addiction' throughout history has been
misunderstood and has taken on various meanings associated with the
word. An example is the usage of the word in the religious landscape
of early modern Europe. "Addiction" at the time meant "to attach" to
something, giving it both positive and negative connotations. The
object of this attachment could be characterized as "good or bad". The
meaning of addiction during the early modern period was mostly
associated with positivity and goodness; during this early modern and
highly religious era of Christian revivalism and Pietistic tendencies,
it was seen as a way of "devoting oneself to another".


The suffixes "-holic" and "-holism"
=====================================
In contemporary modern English "-holic" is a suffix that can be added
to a subject to denote an addiction to it. It was extracted from the
word alcoholism (one of the first addictions to be widely identified
both medically and socially) (correctly the root "alcohol" plus the
suffix "-ism") by misdividing or rebracketing it into "alco" and
"-holism". There are correct medico-legal terms for such addictions:
dipsomania is the medico-legal term for 'alcoholism'; other examples
are in this table:

Colloquial term Addiction to    Medico-legal term
chocoholic      chocolate
danceaholic     dance   choreomania
rageaholic      rage
sexaholic       sex     hypersexuality, satyriasis, nymphomania
sugarholic      sugar   saccharomania
workaholic      work    ergomania


                              History
======================================================================
Modern research on addiction has led to a better understanding of the
disease with research on the topic dating back to 1875, specifically
on morphine addiction. This furthered the understanding of addiction
being a medical condition. It was not until the 19th century that
addiction was seen and acknowledged in the Western world as a disease,
being both a physical condition and mental illness. Today, addiction
is understood both as a biopsychosocial and neurological disorder that
negatively impacts those who are affected by it, most commonly
associated with the use of drugs and excessive use of alcohol. The
understanding of addiction has changed throughout history, which has
impacted and continues to impact the ways it is medically treated and
diagnosed.


                         Addiction and art
======================================================================
The arts can be used in a variety of ways to address issues related to
addiction. Art can be used as a form of therapy in the treatment of
substance use disorders. Creative activities like painting, sculpting,
music, and writing can help people express their feelings and
experiences in safe and healthy ways. The arts can be used as an
assessment tool to identify underlying issues that may be contributing
to a person's substance use disorder. Through art, individuals can
gain insights into their own motivations and behaviors that can be
helpful in determining a course of treatment. Finally, the arts can be
used to advocate for those suffering from a substance use disorder by
raising awareness of the issue and promoting understanding and
compassion. Through art, individuals can share their stories, increase
awareness, and offer support and hope to those struggling with
substance use disorders.


As therapy
============
Addiction treatment is complex and not always effective due to
engagement and service availability concerns, so researchers
prioritize efforts to improve treatment retention and decrease relapse
rates. Characteristics of substance abuse may include feelings of
isolation, a lack of confidence, communication difficulties, and a
perceived lack of control. In a similar vein, people suffering from
substance use disorders tend to be highly sensitive, creative, and as
such, are likely able to express themselves meaningfully in creative
arts such as dancing, painting, writing, music, and acting. Further
evidenced by Waller and Mahony (2002) and Kaufman (1981), the creative
arts therapies can be a suitable treatment option for this population
especially when verbal communication is ineffective.

Primary advantages of art therapy in the treatment of addiction have
been identified as:
* Assess and characterize a client's substance use issues
* Bypassing a client's resistances, defenses, and denial
* Containing shame or anger
* Facilitating the expression of suppressed and/or complicated
emotions
* Highlighting a client's strengths
* Providing an alternative to verbal communication (via use of
symbols) and conventional forms of therapy
* Providing clients with a sense of control
* Tackling feelings of isolation

Art therapy is an effective method of dealing with substance abuse in
comprehensive treatment models. When included in psychoeducational
programs, art therapy in a group setting can help clients internalize
taught concepts in a more personalized manner. During the course of
treatment, by examining and comparing artwork created at different
times, art therapists can be helpful in identifying and diagnosing
issues, as well as charting the extent or direction of improvement as
a person detoxifies. Where increasing adherence to treatment regimes
and maintaining abstinence is the target; art therapists can aid by
customizing treatment directives (encourage the client to create
collages that compare pros and cons, pictures that compare past and
present and future, and drawings that depict what happened when a
client went off medication).

Art therapy can function as a complementary therapy used in
conjunction with more conventional therapies and can integrate with
harm reduction protocols to minimize the negative effects of drug use.
An evaluation of art therapy incorporation within a pre-existing
Addiction Treatment Programme based on the 12 step Minnesota Model
endorsed by the Alcoholics Anonymous found that 66% of participants
expressed the usefulness of art therapy as a part of treatment. Within
the weekly art therapy session, clients were able to reflect and
process the intense emotions and cognitions evoked by the programme.
In turn, the art therapy component of the programme fostered stronger
self-awareness, exploration, and externalization of repressed and
unconscious emotions of clients, promoting the development of a more
integrated 'authentic self'.

Despite the large number of randomized control trials, clinical
control trials, and anecdotal evidence supporting the effectiveness of
art therapies for use in addiction treatment, a systematic review
conducted in 2018 could not find enough evidence on visual art, drama,
dance and movement therapy, or 'arts in health' methodologies to
confirm their effectiveness as interventions for reducing substance
misuse. Music therapy was identified to have potentially strong
beneficial effects in aiding contemplation and preparing those
diagnosed with substance use for treatment.


As an assessment tool
=======================
The Formal Elements Art Therapy Scale (FEATS) is an assessment tool
used to evaluate drawings created by people suffering from substance
use disorders by comparing them to drawings of a control group
(consisting of individuals without SUDs). FEATS consists of twelve
elements, three of which were found to be particularly effective at
distinguishing the drawings of those with SUDs from those without:
Person, Realism, and Developmental. The Person element assesses the
degree to which a human features are depicted realistically, the
Realism element assesses the overall complexity of the artwork, and
the Developmental element assesses "developmental age" of the artwork
in relation to standardized drawings from children and adolescents. By
using the FEATS assessment tool, clinicians can gain valuable insight
into the drawings of individuals with SUDs, and can compare them to
those of the control group. Formal assessments such as FEATS provide
healthcare providers with a means to quantify, standardize, and
communicate abstract and visceral characteristics of SUDs to provide
more accurate diagnoses and informed treatment decisions.

Other artistic assessment methods include the Bird's Nest Drawing: a
useful tool for visualizing a client's attachment security. This
assessment method looks at the amount of color used in the drawing,
with a lack of color indicating an 'insecure attachment', a factor
that the client's therapist or recovery framework must take into
account.

Art therapists working with children of parents suffering from
alcoholism can use the Kinetic Family Drawings assessment tool to shed
light on family dynamics and help children express and understand
their family experiences. The KFD can be used in family sessions to
allow children to share their experiences and needs with parents who
may be in recovery from alcohol use disorder. Depiction of isolation
of self and isolation of other family members may be an indicator of
parental alcoholism.


Advocacy
==========
Stigma can lead to feelings of shame that can prevent people with
substance use disorders from seeking help and interfere with provision
of harm reduction services. It can influence healthcare policy, making
it difficult for these individuals to access treatment. For designing
and implementing effective and evidence-based stigma prevention and
intervention, it is important do both, identify persons who are more
likely to be stigmatized (e.g., male or those addicted to drugs
believed to be "stronger") and target those more likely to stigmatize
(e.g., those with lacking or limited familiarity with addiction or
more conservative individuals).

Artists attempt to change the societal perception of addiction from a
punishable moral offense to instead a chronic illness necessitating
treatment. This form of advocacy can help to relocate the fight of
addiction from a judicial perspective to the public health system.

Artists who have personally lived with addiction or undergone recovery
may use art to depict their experiences in a manner that uncovers the
"human face of addiction". By bringing experiences of addiction and
recovery to a personal level and breaking down the "us and them", the
viewer may be more inclined to show compassion, forego stereotypes and
stigma of addiction, and label addiction as a social rather than
individual problem.

According to Santora the main purposes in using art as a form of
advocacy in the education and prevention of substance use disorders
include:
* Addiction art exhibitions can come from a variety of sources, but
the underlying message of these works is the same: to communicate
through emotions without relying on intellectually demanding/gatekept
facts and figures. These exhibitions can either stand alone,
reinforce, or challenge facts.
* A powerful educational tool for increasing awareness and
understanding of addiction as a medical illness. Exhibitions featuring
personal stories and images can help to create lasting impressions on
diverse audiences (including addiction scientists/researchers,
family/friends of those affected by addiction etc.), highlighting the
humanity of the problem and in turn encouraging compassion and
understanding.
* A way to destigmatize substance use disorders and shift public
perception from viewing them as a moral failing to understanding them
as a chronic medical condition which requires treatment.
* Provide those who are struggling with addiction assurance and
encouragement of healing, and let them know that they are not alone in
their struggle.
* The use of visual arts can help bring attention to the lack of
adequate substance use treatment, prevention, and education programs
and services in a healthcare system. Messages can encourage
policymakers to allocate more resources to addiction treatment and
prevention from federal, state, and local levels.

The Temple University College of Public Health department conducted a
project to promote awareness around opioid use and reduce associated
stigma by asking students to create art pieces that were displayed on
a website they created and promoted via social media. Quantitative and
qualitative data was recorded to measure engagement, and the student
artists were interviewed, which revealed a change in perspective and
understanding, as well as greater appreciation of diverse experiences.
Ultimately, the project found that art was an effective medium for
empowering both the artist creating the work and the person
interacting with it.

Another author critically examined works by contemporary Canadian
artists that deal with addiction via the metaphor of a cultural
landscape to "unmap" and "remap" ideologies related to Indigenous
communities and addiction to demonstrate how colonial violence in
Canada has drastically impacted the relationship between Indigenous
peoples, their land, and substance abuse.

A project known as "Voice" was a collection of art, poetry and
narratives created by women living with a history of addiction to
explore women's understanding of harm reduction, challenge the effects
of stigma and give voice to those who have historically been silenced
or devalued. In the project, nurses with knowledge of mainstream
systems, aesthetic knowing, feminism and substance use organized
weekly gatherings, wherein women with histories of substance use and
addiction worked alongside a nurse to create artistic expressions.
Creations were presented at several venues, including an International
Conference on Drug Related Harm, a Nursing Conference and a local
gallery to positive community response.


Biopsychosocial Model
=======================
While regarded biomedically as a neuropsychological disorder,
addiction is multi-layered, with biological, psychological, social,
cultural, and spiritual (biopsychosocial-cultural-spiritual) elements.
A biopsychosocial-cultural-spiritual approach fosters the crossing of
disciplinary boundaries, and promotes holistic considerations of
addiction. A biopsychosocial-cultural-spiritual approach considers,
for example, how physical environments influence experiences, habits,
and patterns of addiction.

Ethnographic engagements and developments in fields of knowledge have
contributed to biopsychosocial-cultural-spiritual understandings of
addiction, including the work of Philippe Bourgois, whose fieldwork
with street-level drug dealers in East Harlem highlights correlations
between drug use and structural oppression in the United States.


Biological Factors
====================
Some biological influences of the biopsychosocial model include
genetic heretability, neuroadaptations in reward circuitry, and
changes in neurotransmitter systems. Some examples of
neurotransmitters that are affected include: dopamine, GABA, and
glutamate. Twin and family studies show that heretability accounts for
approximately 40-60% of the variance that we seen in addiction risk.
Chronic substance exposure seems to produce long-term changes in the
mesolimbic dopamine system.This includes altered activity in the
ventral tegmental area and nucleus accumbens, which contribute to
things like incentive salience, craving, and compulsive drug seeking
behavior. These biological factors contribute to things like the
initial vulnerability and the development of drug seeking behaviors.
It does this by altering factors like reward sensitivity, stress
reactivity, and executive control systems. These adaptations,
specifically ones impacting the responsivity dopaminergic responsivity
and prefrontal regulation, interact with psychological traits and
social experiences. Examples are interacting with impulsivity, coping
style, or chronic stress exposure. Together, these interactions
increase the motivational value of drug cues. It also increases the
chance that dopaminergic activity will drive compulsive use. This
makes biology just one component of a broader system that shapes
addiction.


Psychological Factors
=======================
This includes learning processes, impulsivity, reward sensitivity, and
the use of substances as coping mechansims for negative affect or
trauma. Conditioning based models show that environmental cues can
acquire motivational significance and potentially trigger craving and
relapse, even after periods of long abstinence. Psychological factors
primarily shape how people perceive, react to, and regulate internal
states. This shows how these factors influence the use of substances
as coping strategies or sources of reinforcement. These processes
interact with vulnerabilities in both biological and social contexts
by making each one strengthen the other. Biological sensativities make
a person more strongly react to social challenges. These social
challenges repeatedly activate and increase biological sensitivity. A
cycle in created were both types of vulnerabilities keep reinforcing
each other. These include: impaired inhibitory control, heightened
reward drive, stress and trauma. These interactions determine whether
substance use will evolve into damaging patterns (compulsie drug
seeking behaviors, loss of control of drug use, reliance on substance
for coping) that are characteristic of addiction.


Social and Environmental Factors
==================================
Social and environmental influences include family dynamics, early and
adverse experiences, socioeconomic status, peer networks, and cultural
norms. Longitudinal studies show that adverse childhood experiences
can significantly increase the chance of substance use later in life.
This is mainly due to the interaction with neurodevelopmental stress
pathways. Together, these levels of analysis highlight addiction as a
complex and dynamic condition emerging from the interaction of several
aspects including: neurobiological processes, individual psychological
traits, and broader social environments. This model is widely used in
contemporary clinical practice and public health because it accounts
for a lot of variability in addiction trajectories, relapase patterns,
and treatment outcomes across several individuals. Social factors
exhibit their greatest influence on things like exposure to
substances, motivation, and the probability of a potential escalation
or relapse. Social factors act through mechanisms like chronic stress,
peer modeling, socioeconomic constraints, and the availability of
substances. Social factors act through mediums like chronic stress,
which dysregulates the HPA axis and sensitizes neural cicuits involved
in threat detection. Substance availability can increase the chance of
repeated exposure and reinforcement. This will strengthen habit
circuits and lower the threshold for dependence on the substance.
Environmental pressures interact with biological predispositions and
psychological coping mechanisms to show that addictive behavior will
emerge from the combined effects of social context, brain function,
and individual psychological processes.


Cultural model
================
The cultural model, an anthropological understanding of the emergence
of drug use and abuse, was developed by Dwight Heath. Heath undertook
ethnographic research and fieldwork with the Camba people of Bolivia
from June 1956 to August 1957. Heath observed that adult members of
society drank 'large quantities of rum and became intoxicated for
several contiguous days at least twice a month'. This frequent, heavy
drinking from which intoxication followed was typically undertaken
socially, during festivals. Having returned in 1989, Heath observed
that while much had changed, 'drinking parties' remained, as per his
initial observations, and 'there appear to be no harmful consequences
to anyone'. Heath's observations and interactions reflected that this
form of social behavior, the habitual heavy consumption of alcohol,
was encouraged and valued, enforcing social bonds in the Camba
community. Despite frequent intoxication, "even to the point of
unconsciousness", the Camba held no concept of alcoholism (a form of
addiction), and no visible social problems associated with
drunkenness, or addiction, were apparent.

As noted by Merrill Singer, Heath's findings, when considered
alongside subsequent cross-cultural experiences, challenged the
perception that intoxication is socially 'inherently disruptive'.
Following this fieldwork, Heath proposed the 'cultural model',
suggesting that 'problems' associated with heavy drinking, such as
alcoholism - a recognised form addiction - were cultural: that is,
that alcoholism is determined by cultural beliefs, and therefore
varies among cultures. Heath's findings challenged the notion that
'continued use [of alcohol] is inexorably addictive and damaging to
the consumer's health'.

The cultural model did face criticism by Sociologist Robin Room and
others, who felt anthropologists could "downgrade the severity of the
problem". Merrill Singer found it notable that the ethnographers
working within the prominence of the cultural model were part of the
'wet generation': while not blind to the 'disruptive, dysfunctional
and debilitating effects of alcohol consumption', they were products
'socialized to view alcohol consumption as normal'.


Subcultural model
===================
Historically, addiction has been viewed from the etic perspective,
defining users through the pathology of their condition. As reports of
drug use rapidly increased, the cultural model found application in
anthropological research exploring western drug subculture practices.

The approach evolved from the ethnographic exploration into the lived
experiences and subjectivities of 1960s and 70s drug subcultures. The
seminal publication "Taking care of business", by Edward Preble and
John J. Casey, documented the daily lives of New York street-based
intravenous heroin users in detail, providing insight into the dynamic
social worlds and activities that surrounded their drug use. These
findings challenge popular narratives of immorality and deviance,
conceptualizing substance abuse as a social phenomenon. The prevailing
culture can have an influence on drug taking behaviors, along with the
physical and psychological effects of the drug. To marginalized
individuals, drug subcultures can provide social connection, symbolic
meaning, and socially constructed purpose that they may feel is
unattainable through conventional means. The subcultural model
demonstrates the complexities of addiction, highlighting the need for
an integrated approach. It contends that a biosocial approach is
required to achieve a holistic understanding of addiction.


Critical medical anthropology model
=====================================
Emerging in the early 1980s, the critical medical anthropology model
was introduced, and as Merrill Singer offers 'was applied quickly to
the analysis of drug use'. Where the cultural model of the 1950s
looked at the social body, the critical medical anthropology model
revealed the body politic, considering drug use and addiction within
the context of macro level structures including larger political
systems, economic inequalities, and the institutional power held over
social processes.

Highly relevant to addiction, the three issues emphasized in the model
are:
* Self-medication
* The social production of suffering
* The political economy (Licit and Illicit Drugs)

These three key points highlight how drugs may come to be used to
self-medicate the psychological trauma of socio-political disparity
and injustice, intertwining with licit and illicit drug market
politics. Social suffering, "the misery among those on the weaker end
of power relations in terms of physical health, mental health and
lived experience", is used by anthropologists to analyze how
individuals may have personal problems caused by political and
economic power. From the perspective of critical medical anthropology
heavy drug use and addiction is a consequence of such larger scale
unequal distributions of power.

The three models developed here - the cultural model, the subcultural
model, and the Critical Medical Anthropology Model - display how
addiction is not an experience to be considered only biomedically.
Through consideration of addiction alongside the biological,
psychological, social, cultural and spiritual
(biopsychosocial-spiritual) elements which influence its experience, a
holistic and comprehensive understanding can be built.


Social learning theory
========================
Albert Bandura's 1977 social learning theory posits that individuals
acquire addictive behaviors by observing and imitating models in their
social environment. The likelihood of engaging in and sustaining
similar addictive behaviors is influenced by the reinforcement and
punishment observed in others. The principle of reciprocal determinism
suggests that the functional relationships between personal,
environmental, and behavioral factors act as determinants of addictive
behavior. Thus, effective treatment targets each dynamic facet of the
biopsychosocial disorder.


Transtheoretical model (stages of change model)
=================================================
The transtheoretical model of change suggests that overcoming an
addiction is a stepwise process that occurs through several stages.

Precontemplation: This initial stage precedes individuals considering
a change in their behavior. They might be oblivious to or in denial of
their addiction, failing to recognize the need for change.

Contemplation is the stage in which individuals become aware of the
problems caused by their addiction and are considering change.
Although they may not fully commit, they weigh the costs and benefits
of making a shift.

Preparation: Individuals in this stage are getting ready to change.
They might have taken preliminary steps, like gathering information or
making small commitments, in preparation for behavioral change.

Action involves actively modifying behavior by making specific,
observable changes to address the addictive behavior. The action stage
requires significant effort and commitment.

Maintenance: After successfully implementing a change, individuals
enter the maintenance stage, where they work to sustain the new
behavior and prevent relapse. This stage is characterized by ongoing
effort and consolidation of gains.

Termination/relapse prevention: Recognizing that relapse is a common
part of the change process, this stage focuses on identifying and
addressing factors that may lead to a return to old behaviors. Relapse
is viewed as an opportunity for learning and strategy adjustment, with
the ultimate goal of eliminating or terminating the targeted behavior.

The transtheoretical model can be helpful in guiding development of
tailored behavioral interventions that can promote lasting change.
Progression through these stages may not always follow a linear path,
as individuals may move back and forth between stages. Resistance to
change is recognized as an expected part of the process.

Addiction causes an "astoundingly high financial and human toll" on
individuals and society as a whole. In the United States, the total
economic cost to society is greater than that of all types of diabetes
and all cancers combined. These costs arise from the direct adverse
effects of drugs and associated healthcare costs (e.g., emergency
medical services and outpatient and inpatient care), long-term
complications (e.g., lung cancer from smoking tobacco products, liver
cirrhosis and dementia from chronic alcohol consumption, and meth
mouth from methamphetamine use), the loss of productivity and
associated welfare costs, fatal and non-fatal accidents (e.g., traffic
collisions), suicides, homicides, and incarceration, among others. The
US National Institute on Drug Abuse has found that overdose deaths in
the US have almost tripled among males and females from 2002 to 2017,
with 72,306 overdose deaths reported in 2017 in the US. 2020 marked
the year with the highest number of overdose deaths over a 12-month
period, with 81,000 overdose deaths, exceeding the records set in
2017.


                               Notes
======================================================================
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                           External links
======================================================================
*
* [http://www.tedmed.com/talks/show?id=309096 Why do our brains get
addicted?] - a TEDMED 2014 talk by Nora Volkow, the director of the
National Institute on Drug Abuse at NIH.
Kyoto Encyclopedia of Genes and Genomes (KEGG) signal transduction
pathways:
* [http://www.genome.jp/kegg-bin/show_pathway?hsa05034+2354 KEGG -
human alcohol addiction]
* [http://www.genome.jp/kegg-bin/show_pathway?hsa05031+2354 KEGG -
human amphetamine addiction]
* [http://www.genome.jp/kegg-bin/show_pathway?hsa05030+2354 KEGG -
human cocaine addiction]


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