Tahar AbdAlaziz MD, PhD
The terms drug dependence & drug addiction are often
used interchangeably, but this leads to confusion
regarding the diagnostic effects of these terms.
The definitions of 1957 & 1964 regarding addiction,
dependence and abuse persist to the present day in
In 1957 WHO defined addiction and habituation as
components of drug abuse.
In 1964 WHO found these definitions to be inadequate,
and suggested using the term "drug dependence”.
In 2000, the Diagnostic Statistical Manual of Mental
Disorders (DSM-IV-TR) introduced specific criteria for
defining abuse and dependence.
(DSM-IV-TR) uses the term substance dependence instead of
addiction, and defined it as
A maladaptive pattern of substance abuse, leading
to clinically significant impairment or distress, as
manifested by three (or more) specified criteria,
occurring at any time in the same 12-month period.
Criteria of Dependence & Abuse according to DSM-IV-TR
(3 or more in a 12-month period)
1) Tolerance (marked increase in
amount; marked decrease in
2) Characteristic withdrawal
symptoms; substance taken to
3) Substance taken in larger amount
and for longer period than
4) Persistent desire or repeated
unsuccessful attempt to quit
5) Much time/activity to obtain,
6) Important social, occupational,
or recreational activities given
up or reduced
7) Use continues despite knowledge
of adverse consequences (e.g.,
failure to fulfill role obligation,
use when physically hazardous)
(1 or more in a 12-month period)
Symptoms must never have met criteria for
substance dependence for this class of substance.
1) Recurrent use resulting
in failure to fulfill major
role obligation at work,
home or school
2) Recurrent use in
3) Recurrent substance
related legal problems
4) Continued use despite
persistent or recurrent
social or interpersonal
problems caused or
• DSM-5 consolidates substance abuse and
dependence into one disorder:
substance use disorder
• Criteria are nearly identical to DSM-IV with
-Recurrent substance-related legal problems
criterion has been deleted from DSM-5.
-And new criterion: craving, or a strong desire or
urge to use a substance added.
• The threshold is set at 2 or more criteria vs. 1
or more for abuse and 3 or more for dependence
in the DSM-IV.
Severity of the problem (NEW)
In DSM-5 severity for substance use
disorders is based on the number of
– MILD= 2-3 criteria
– MODERATE= 4-5 criteria
– SEVERE= 6 or more criteria
• American Academy of Pain Medicine
• America Pain Society
• American Society of Addiction Medicine
jointly issued "Definitions Related to the
Use of Opioids for the treatment of pain”.
The substance is used in a manner
that does not conform to social
norms; the motivation to use the
substance may or may not be
particularly strong compared with
• A behavioral syndrome
characterized by behaviors that
include one or more of the
– Impaired control of drug use
– compulsive drug use
– continued use despite harm
A state where the individual is
dependent upon the drug for
normal physiological functioning.
Abstinence from the drug produces
withdrawal reactions which
constitute the only evidence for
Some substances may produce
physical dependence without
producing an addiction
• The therapeutic uses of
certain steroids and some
syndromes when abruptly
motivation to continue
the use of these
substances for most
Some substances may produce
without producing an addiction
• substances can
produce a notable
motivation to avoid
abstinence such as
caffeine or nicotine.
Drug abuse can lead to drug dependence or
addiction. People who use drugs for pain relief
may become dependent.
The exact cause of drug abuse and
dependence is not known. However, a person's
genes, the action of the drug, peer pressure,
emotional distress, anxiety, depression, and
environmental stress all can be factors.
Peer pressure can lead to drug use or abuse,
but at least half of those who become
addicted have depression, attention deficit
disorder, PTSD, or another mental health
Children who grow up in an environment of
illicit drug use may first see their parents
using drugs. This may put them at a higher
risk for developing an addiction later in life
for both environmental and genetic reasons.
People who are more likely to abuse or
become dependent on drugs include
• Have depression, bipolar disorder, anxiety
disorders, and schizophrenia
• Have easy access to drugs
• Have low self-esteem, or problems with
• Live a stressful lifestyle, economic or emotional
• Live in a culture where there is a high social
acceptance of drug use
Theories of Addiction
1) MEDICAL MODEL
2) PSYCHODYNAMIC MODEL
3) SOCIAL MODEL
4) MORAL MODEL
5) BIO‐PSYCHO‐SOCIAL MODEL
Medical TheoryThis theory describes
addiction as a disease.
It attributes addiction to
changes in dopaminergic
Addiction as a “brain
disease” due to
Child Teen Young Adult Adult
<12 12-17 18-25 >25
Addiction is a Developmental Disease:
It Starts Early
MRI Scans of Healthy Children and Teens Over Time
brain development through early adulthood, with blue indicating the mature state
Prefrontal cortex (white
circles), which governs
judgment and decision-
making functions, is the
last part of the brain to
•This may help explain:
• why teens are prone to
•vulnerable to drug abuse
•why exposure to drugs at
this critical time may affect
propensity for future
that starts in adolescence and childhood
National Epidemiologic Survey on Alcohol and Related Conditions, 2003.National Epidemiologic Survey on Alcohol and Related Conditions, 2003.
Age at tobacco, alcohol and cannabis dependence per DSM IV
55 1010 1515 2121 2525 3030 3535 4040 4545 5050 5555 6060 6565
Addiction Is A Developmental Disease
Circuits Involved In Drug Abuse and Addiction
PFC – prefrontal cortex; ACG – anterior cingulate gyrus; OFC – orbitofrontal cortex; SCC – subcallosal
cortex; NAc – nucleus accumbens; VP – ventral pallidum; Hipp – hippocampus; Amyg – amygdala
The developing strategies to treat addiction must put in
consideration these areas for better results
Psychodynamics is the theory and
systematic study of the
psychological forces that underlie
It is especially interested in the
dynamic relations between
conscious motivation & unconscious
• In Freudian thought,
psychodynamics is the study of
transformations and exchanges of
“psychic energy” in the personality
• The psychodynamic model explains
behaviors through the interactions
of Freud’s innate emotional forces,
the id, ego, and super-ego.
• This theory hypothesizes that substance
addiction is a learned behavior and it
develops as a result of social problems
such as poverty, violence, family
• These forces are believed to act as social
stressors and substance addiction is
considered to be an adaptation to the
resultant misery and unhappiness.
• The moral theory denotes substance
addiction as a vice الرذيلة or a sin الخطيئة .
• The theory implies that some
individuals, through their own free will,
make a conscious choice to become
• According to this theory drug abusers
choose to use drugs and they are
anti‐social and should be punished
• Substance addiction is the net result of a
complex interaction between a combination of
all of the factors:
• Each person’s drug use is a result of some
aspects of some or all the other models.
• Treatment and recovery require addressing the
body, mind, social environment, and spiritual
needs of an individual (including nutrition,
employment, family issues, psychological
The highest Risk Periods for Children
• The high risk periods for drug abuse among children
occur during major transitions in children’s lives.
• Transitions include:
– Significant changes in physical development (for
– Social situations (such as moving or parents divorcing)
– When they leave the security of the family and enter
– When they advance from elementary school to middle or
high school, they often experience new academic and
social situations, such as learning to get along with a
wider group of peers and having greater expectations for
Incidence of Addiction
Worldwide, 149-271 (million) people used an illicit drug at least once in
2009; which equals 1 in 20 people aged 15 to 64 who have used an illegal
In North America, nearly 11% of population aged 15 to 64 used cannabis in
Worldwide, 14-56 (million) people aged 15 to 64 used amphetamine-type
stimulants, such as speed and crystal meth.
Cocaine had 14 million to 21 million users worldwide.
Opioid use, including heroin, had an estimated 12 million to 21 million users
globally. The highest rates of use were in the Near and Middle East, where up
to 1.4% of the population aged 15 to 64 had tried the drug at least once in
Worldwide, 11 million to 21 million people inject drugs. The Lancet
Classification of Addictive Drugs
1) Narcotic Analgesics: drugs with opium like effects.
2) Stimulants: drugs which excite the central nervous system.
3) Depressants: drugs which depress the functions of the central nervous system.
4) Hallucinogens: drugs which affect perception, emotions and mental processes.
6) Volatile Solvents: volatile hydrocarbons, Petroleum derivatives
7) Other drugs of abuse: medically used drugs that do not fall into any of the above
categories, such as
• Muscle relaxants
• Anti-depressants / anti-psychotics
Commonly Used Psychoactive Substances
SOURCE: National Institute on Drug Abuse.
(liquor, beer, wine)
euphoria, stimulation, relaxation,
lower inhibitions, drowsiness
euphoria, relaxations, slowed
reaction time, distorted
(heroin, opium, many pain meds)
euphoria, drowsiness, sedation
hallucinations, tactile sensitivity,
(Ketamine, PCP, DXM)
feel separated from body,
delirium, impaired motor function
hallucinations, altered perception
Examples of Addictive Drugs
• alcohol abuse causes over 100,000 deaths in the
USA and Canada each year. It is the drug most
commonly abused by children ages 12 to 17.
Alcohol-related motor vehicle accidents are the
leading cause of death in teenagers. People who
drink alcohol are more likely to engage in deviated
sexual behaviors .
• It is a diacetylmorphine that functions as a
morphine prodrug. It can be used for medical
purposes as analgesic to treat severe pain with the
name diamorphine. The name "heroin" is only used
when being discussed in its illegal form.
Tramadol hydrochloride (Tramal) is a
centrally acting synthetic analgesic
used to treat moderate to moderately
severe pain. Tramadol is converted to
O-desmethyltramadol (potent μ-opioid
The opioid agonistic effect of tramadol
and its major metabolite(s) is almost
exclusively mediated by μ-opioid
• Hydrocodone or dihydrocodeinone is a
• It is an orally active narcotic analgesic &
• It acts at μ-opioid receprors.
• It is metabolized to hydromorphone
• About 53% of patients in rehabs across USA
were chemically dependent on Vicodin.
• an empathogenic (entactogenic) drug of the
phenethylamine & amphetamine class.
• MDMA has become widely known as "ecstasy"
(shortened to "E", "X", or "XTC), usually
referring to its street pill form.
• MDMA can induce euphoria, a sense of
• MDMA is criminalized.
• For 2008 the UN estimated between 10–25
million people globally used MDMA at least
once in the past year.
• Desomorphine is a synthetically derived
• Animal trials of desomorphine showed
that, by comparison with morphine:
– Stronger and more rapid analgesic effect
– Longer effect duration
– Quicker addiction
GHB (Gama Hydroxybutyric Acid)
• Asynthetic depressant available as a
prescription for sleep disorders
• In some countries was banned (in
the U.S.) by the FDA in 1990
because of the dangers associated
with its use.
• GHB and its analogs are considered
"date rape" drugs because they can
be mixed with liquids (even water)
and a victim wouldn't notice by
smelling or looking at it.
• GHB, by itself, has a soapy or salty
taste--but when mixed in a drink it
may be difficult to detect.
• DXM is a cough-suppressing ingredient
in a variety of over-the-counter cold
and cough medications.
• Dextromethorphan, a semisynthetic
narcotic, is an ingredient found in
more than 70 different products.
• DXM acts centrally to elevate the
threshold for coughing.
• At high doses dextromethorphan
produces dissociative effects similar to
those of PCP and ketamine.
• About 35 members of this group are presently marketed in different
• Shorter-acting benzodiazepines used to manage insomnia include estazolam
• Benzodiazepines with a longer duration of action are utilized to treat
insomnia in patients with daytime anxiety. These benzodiazepines include
alprazolam (Xanax®), chlordiazepoxide (librium®), clorazepate (Tranxene®),
• Rohypnol (flunitrazepam), most commonly known as a
• One of the significant effects of the drug is anterograde
amnesia, a factor that strongly contributed to be one of
the drugs used in rape.
• Anterograde amnesia is a condition in which events that
occurred while under the influence of the drug are
Ketamine (“Special K”)
Anesthetic developed to replace PCP, manufactured by
Used in human and veterinary medicine
Injected or dried and snorted
• Illicit use of pharmaceutical fentanyls first
appeared in the mid-1970s in the medical.
• The biological effects of the fentanyls are
indistinguishable from those of heroin, with
the exception that the fentanyls may be
hundreds of times more potent.
• Fentanyls are most commonly used by IV
administration, but like heroin, they may
also be smoked or snorted.
ABUSE OF ANABOLIC STEROIDS
• Anabolic Steroid abuse has become
an international concern.
• These drugs are used illicitly by
weight lifters, body builders, long
distant runners, cyclists, and others
who claim that the drugs give them a
competitive advantage and/or
improve their physical appearance.
• The American Controlled Substance
Act (CSA) defines anabolic steroids as
any drug or hormonal substance
chemically and pharmacologically
related to testosterone (other than
estrogen, progestins, and
corticosteroids), that promotes