THEORIES OF

ADDICTION
MODERATOR: DR. NAVKIRAN S. MAHAJAN
 INTRODUCTION
◦ Addiction is a behavioral pattern of drug abuse characterized by overwhelming
involvement with the use of a drug (compulsive use), the securing of its
supply, and a high tendency to relapse after discontinuation.
◦  characterized by a pathological and compulsive pattern of drug-seeking and
drug-taking behaviors.
◦ Persistent use of psychoactive drugs may lead to long-term changes in the
brain, leading to the multiple symptoms and features of addictions, including
craving, withdrawal, and tolerance
 MODELS OF ADDICTION
In our scheme for classifying theories, we are going to work with 3 general
theory domains that comprise a biopsychosocial framework:
◦ BIOLOGICAL
◦ PSYCHOLOGICAL
◦ SOCIAL CONTEXT THEORIES
◦ The biopsychosocial model of the causes of addictive behaviours forms the
basis of most treatment responses to addictions (Marlatt & VandenBos, 1997).
◦ The biopsychosocial model sees “addiction” as a complex behaviour pattern
having biological, psychological, sociological, and behavioural components.
◦ These include the subjective experience of craving, short-term gratification at
the risk of longer-term harm, and rapid change in physical and psychological
states.
◦ Addictive behaviour is distinguished from other problem behaviours by the
individual’s overwhelming, pathological involvement in drug use, intense
desire to continue using the drugs, and lack of control over his or her drug use.
 BIOLOGICAL MODEL OF
ADDICTION
◦ Early reward-centric models focused on pleasurable aspects of taking drugs
and proposed that drugs may “hijack” brain circuits involved in responses to
“natural” rewards like sex or food
◦ A central component in this circuitry is the nucleus accumbens located in the
ventral striatum and receiving dopaminergic innervation from the ventral
tegmental area (termed the mesolimbic dopamine system).
◦ This nucleus accumbens has at times been termed the brain’s “reward center”
given that all known drugs with abuse potential, as well as natural rewards,
lead to dopamine release in this structure
◦ There are multiple theories of the neurobiology of addiction, and two prominent
theories include the Opponent Process theory and the Incentive-Sensitization
theory.
◦ Other non-mutually exclusive theories, such as those relating to
 self-medication reward deficiency
allostatis
neurodevelopment
novelty/impulsivity and habit/compulsivity
genetics
 Incentive-Sensitization Theory
◦ ‘Neuroadaptationist’ model.
◦ Persistent use of psychoactive substances leads to a process of brain
sensitization toward substance-related cues or incentives.
◦ This sensitization manifests behaviorally through increased attentional bias
towards these substance-related cues or incentives
◦ Consistent with a role for rewarding effects of drugs in addictive processes and
a role for dopamine in this process, an incentive salience model of drug
addiction proposes that “liking” a drug may be separated from “wanting” .
◦ Incentive sensitization compels persistence in substance use irrespective of
whether the individual dislikes the substance and its negative consequences, if
they are attempting to abstain, or even in the absence of withdrawal symptoms
 OPPONENT PROCESS THEORY
◦ The Opponent-Process theory (Solomon & Corbit, 1974) suggests that once a
pleasurable state (a-process) is initiated in the brain, a series of opposing
mechanisms (b-process) down-regulate or reduce the intensity of that hedonic
or aroused state to bring the body back to homeostasis. 

◦  The remaining discomfort or distressing affective states are associated with

memories of the original rewarding experience from the a-process, thus
motivating the individual to crave or keep procuring the substance
NEUROCIRCUITARY AND IMPULSIVE
COMPULSIVE DISORDERS
Impulsivity is defined as acting without forethought; the lack of reflection on the
consequences of one’s behavior; the inability to postpone reward with preference for
immediate reward over more beneficial but delayed reward; a failure of motor inhibition,
often choosing risky behavior; or (less scientifically) lacking the willpower not to give in
to temptations.

On the other hand, compulsivity is defined as actions inappropriate to the situation but
which nevertheless persist, and which often result in undesirable consequences. In fact,
compulsions are characterized by the inability to adapt behavior after negative feedback.
Habits are a type of compulsion, and can be seen as responses triggered by environmental
stimuli regardless of the current desirability of the consequences of that response
◦ Habits can be seen as conditioned responses (such as drug seeking, food
seeking, gambling) to a conditioning stimulus (such as being around people or
places or items associated with drugs, food, or gambling in the past) that have
been reinforced and strengthened either by past experience with reward
(positive reinforcement) or with the omission of an aversive event (loss of the
negative reinforcement that comes from withdrawal or craving).
◦ Whereas goal-directed behavior is mediated by knowledge of and desire for
the consequences,
◦ In contrast, habits are controlled by external stimuli through stimulus–
response associations that are stamped into brain circuits through behavioral
repetition and formed after considerable training, can be automatically
triggered by stimuli, and are defined by their insensitivity to their outcomes.
◦ Given that goal-directed actions are relatively cognitively demanding, for
daily routines it can be adaptive to rely on habits that can be performed with
minimal conscious awareness. However, habits can also represent severely
maladaptive perseveration of behaviors.
STAHLS PSYCHOPHARMACOLOY
 Circuitry of impulsivity and reward.
◦ The “bottom-up” circuit that drives impulsivity
(shown in pink) is a loop with projections from the
ventral striatum to the thalamus, from the thalamus to
the ventromedial prefrontal cortex (VMPFC), and
from the VMPFC back to the ventral striatum.
◦ This circuit is usually modulated “top-down” from
the prefrontal cortex (PFC).
◦ If this top-down response inhibition system is
inadequate or is overcome by activity from the
bottom-up ventral striatum, impulsive behaviors may
result.
 Circuitry of compulsivity and motor
response inhibition
◦ The “bottom-up” circuit that drives compulsivity
(shown in pink) is a loop with projections from
the dorsal striatum to the thalamus, from the
thalamus to the orbitofrontal cortex (OFC), and
from the OFC back to the dorsal striatum.
◦ This habit circuit can be modulated “top-down”
from the OFC, but if this top-down response
inhibition system is inadequate or is overcome
by activity from the bottom-up dorsal striatum,
compulsive behaviors may result.
 Shifting from impulsivity to
compulsivity
◦ Drug addiction provides a good example of the shift from impulsivity to
compulsivity that comes with migration from ventral to dorsal circuits.
◦ The impulse to take a drug initially leads to great pleasure and satisfaction (a
“high”).
◦ If this happens infrequently, the behavior may be a bit “naughty” but will not
necessarily progress to compulsivity.
◦ With chronic substance use, compulsivity may develop as an individual’s drive
turns from seeking pleasure to seeking relief from distressing symptoms of
withdrawal and anticipation of obtaining the drug.
 PSYCHOLOGICAL MODEL OF
ADDICTION
• Learning theory (operant and classical conditioning)
• Social learning theory (observational learning)
• Expectancies theory (a person’s expected outcomes associated with using a
substance)
• Information processing (effects of different types of substances on learning,
thinking, behaving)
• Psychodynamic & attachment theory (including self-medication theory)
◦ The classical conditioning process helps explain why stimuli in the environment or
sensations originating from inside the body often trigger a person’s craving for a substance.
◦ Certain areas of the brain may be triggered just by seeing the paraphernalia used to
administer a drug, inducing an intense craving for the drug.
◦ This is no different, really, from Pavlov’s dogs learning to associate food with the ringing of
a bell through classical conditioning, and drooling over the previously irrelevant sound.
◦ The craving trigger stimulus from the environment might involve any of the five senses:
hearing, seeing, touching, smelling, or tasting. Or, craving may be triggered by familiar
internal states (like anxiety, depression, loneliness) that were previously alleviated by taking
drugs.
◦ Operant conditioning is all about rewards and punishments. A person might
use a drug for the first time and enjoy the feelings it creates, which is a 
positive reinforcement for the behavior.
◦ Similarly, the person might find that the drug decreases a negative feeling like
pain, low mood, or anxiety. This, too, would be reinforcing—what we call 
negative reinforcement.
 NEGATIVE REINFORCEMENT
◦ Negative reinforcement provided one of the earliest theoretical explanations of
addictive behavior.
◦  The basic premise is that drug use reduces withdrawal dysphoria.
◦ A more recent and sophisticated example of this model highlights the
cumulative negative effects produced by repeated cycles of intoxication and
withdrawal, and falls under the rubric of the opponent process theory of
emotional regulation.
CLASSICAL ADDICTION MODEL
 Negative reinforcement views of
addiction (escape from distress)
◦ Negative reinforcers sustain behavior (drug seeking and drug taking in this case) not because of the
state they produce, but because of the state they alleviate.
◦ According to this negative reinforcement view of addiction drug use is maintained because the
aversive symptoms associated with withdrawal are alleviated by the drug.
◦ Addictive drugs that do not result in overt physical withdrawal symptoms, such as cocaine and the
amphetamines, are thought to act as negative reinforcers by alleviating a ‘psychological distress
syndrome’ produced by the discontinuation of drug use.
◦ In addition, previously neutral environmental stimuli associated with withdrawal can themselves
come to elicit withdrawal like symptoms, by secondary conditioning
◦ Thus, drugs may not only alleviate ‘primary’ withdrawal symptoms, but also the conditioned
withdrawal symptoms induced by exposure to drug-related stimuli.
◦ A second negative reinforcement view is that drugs are sometimes used to ‘self-medicate’, relieving
NEURAL BASIS
preexistent symptoms such as pain, anxiety or depression that occur in life independent of drugOF
useDRUG
CRAVING
 LIMITATIONS
◦ Both people and animals will self-administer opioids in the absence of withdrawal
symptoms or physical dependence.
◦ Maximal periods of drug self-administration often do not coincide in time with
periods of maximal withdrawal distress.
◦ There are many drugs used medically that produce withdrawal syndromes but “are not
typically self-administered for non-medical purposes”, including “certain tricyclic
antidepressants (imipramine, amitriptyline), anticholinergics and K-opioid agonists”
◦ There are numerous reports that the “relief of withdrawal is minimally effective in
treating addiction”
◦ There is a high tendency to relapse even after an extended period of abstinence from
drugs, long after overt withdrawal symptoms have subsided.
 A positive reinforcement view of
addiction (PLEASURE SEEKING)
◦ a positive reinforcement view of addiction posits that drug self-administration is
maintained because of the state drugs induce, not because they alleviate an
unpleasant state.
◦ In this view drugs are addicting (establish compulsive habits) because they
produce euphoria or positive affect.
◦ LIMITATIONS:
◦ there is no clear relationship between the ability of individual drugs to produce
euphoria and their addictive potential. For example, nicotine is considered highly
addictive, but nicotine does not produce marked euphoria or other strong hedonic
states.
◦ Second, it could be argued that in addicts the magnitude of the negative
consequences of continued drug use often far outweigh the magnitude of drug
pleasure or the memory of drug pleasure.
◦ does not adequately explain drug craving or relapse elicited by environmental
stimuli associated with drug taking.
 PSYCHOLOGICAL THEORIES
◦ These basic learning theories are taken a step further with an understanding of 
social learning theory.
◦ A person does not necessarily have to experience the rewards and punishments
themselves; learning also happens by watching others engage in the behavior
and seeing what happens to them.
◦ Through observational learning, we learn to imitate both the precise behaviors
and general classes of behavior modeled by others in our social environment.
◦ In other words, a person might not imitate a parent who uses alcohol for
relaxation from stress (the specific or precise behavior) but imitates the general
class of behavior being modeled by using marijuana this way.
◦  INFORMATION PROCESSING.
◦ This area of cognitive psychology explains how substance use can affect the
way that a person takes in (perceives) information from the environment,
◦ stores the information as a short-term memory, moves information into long-
term memory, and later retrieves information in order to influence behavior.
◦ There are psychodynamic, attachment theory, and self-medication perspectives
about addiction to consider, as well.
◦ These psychological approaches suggest that a person uses drugs to fill a
terrific void in their emotional lives or as a means of quieting voices of inner
conflict. A person might be using the drugs to find relief from physical or
emotional pain.
◦ These are called self-medication theories. In this line of thinking, a person
uses substances to avoid or blunt their negative or disturbing feelings
 SOCIAL CONTEXT MODELS
◦ Evidence points to many relevant social and environmental factors that play a
role, such as:
• Family and family system dynamics
• Peer groups
• School and workplace
• Neighborhood and community
• Policy and enforcement
• National and global forces
 FAMILY SYSTEM THEORIES
◦ The family context holds information about how SUDs develop, are
maintained, and what can positively or negatively influence the treatment of
the disorder.
◦ Family systems theory and attachment theory are theoretical models that
provide a framework for understanding how SUDs affect the family.
◦ All the family therapy models share the basic principal of family systems
theory that is that the individual cannot be fully understood or successfully
treated without first understanding how that individual functions in his or her
family system.
◦ Individuals who present in our clinical settings can be seen as “symptomatic,”
and their pathology can be viewed as an attempt adapt to their family system
so as to maintain homeostasis.
 TERMS
◦ Codependence: The terms coaddiction and, more commonly, codependency or codependence are used to
designate the behavioral patterns of family members who have been significantly affected by another family
member’s substance use or addiction.
◦ Enabling: Enabling was one of the first, and more agreed on, characteristics of codependence or coaddiction.
 Sometimes, family members feel that they have little or no control over the enabling acts.
Either because of the social pressures for protecting and supporting family members or because of
pathological interdependencies, or both, enabling behavior often resists modification.
 Other characteristics of codependence include unwillingness to accept the notion of addiction as a disease.
The family members continue to behave as if the substance-using behavior were voluntary and willful , and
the user cares more for alcohol and drugs than for family members.
This results in feelings of anger, rejection, and failure. In addition to those feelings, family members may feel
guilty and depressed because addicts, in an effort to deny loss of control over drugs and to shift the focus of
concern away from their use, often try to place the responsibility for such use on other family members, who
often seem willing to accept some or all of it.
◦ Denial: Family members, as with the substance users themselves, often behave
as if the substance use that is causing obvious problems were not really a
problem; that is, they engage in denial.
The reasons for the unwillingness to accept the obvious vary. Sometimes
denial is self-protecting, in that the family members believe that if a drug or
alcohol problem exists, then they are responsible.
 Attachement Theory
◦ At the time of an infant's birth, the primary relationship, usually with the mother
but not always, serves as the template for all subsequent relationships throughout
the life cycle.
◦ Infants learn to communicate and relate to their environment.
◦ The way in which the primary caretaker responds to these cues will establish the
quality of the attachment.
◦ Generally, if the child experiences the primary caretaker as responsive and
nurturing, a secure attachment will form.
◦ If the child experiences the primary caretaker as unresponsive or inconsistently
responsive, an insecure attachment may form that can result in a variety of
problems including anxiety, depression, and failure to thrive.
 POLICIES
◦ Evidence indicates that higher prices on alcoholic beverages are associated
with reductions in alcohol consumption and alcohol-related problems,
including alcohol-impaired driving.
◦ Several systematic reviews have linked higher alcohol taxes and prices with
reduction in alcohol misuse, including both underage and binge drinking.
◦ Four longitudinal studies of communities that reduced the number of alcohol
outlets showed consistent and significant reductions in alcohol-related crimes,
relative to comparison communities that had not reduced alcohol outlet
density.
 POLICIES
◦ Commercial host (dram shop) liability allows alcohol retailers—such as the owner
or server(s) at a bar, restaurant, or other retail alcohol outlet—to be held legally
liable for harms resulting from illegal beverage service to intoxicated or underage
customers.
◦  reducing days alcohol is sold was associated with decreases in alcohol-related
harms.
◦ 0.08 percent criminal per se legal blood alcohol content (BAC) limits, meaning
that no further evidence of intoxication beyond a BAC of 0.08 percent is needed
for a DUI case
◦ Sobriety checkpoints
 POLICIES
◦ Simulations done in India have demonstrated that implementing a nationwide
legal drinking age of 21 years in India, can achieve about 50-60 % of the
alcohol consumption reducing effects compared to prohibition.
◦ In India, the Narcotic Drugs and Psychotropic Substances Act (NDPS), 1985
provides the current framework for drug abuse control in country.
◦ The Government of India (GOI) created the Narcotics Control Bureau (NCB)
in March 1986 and empowered it to coordinate all activities for administration
and enforcement of the Act.
 PROGRAMS
◦ There have been reviews of the National Master Plan 1994, which envisaged
different responsibilities for the Ministries of Health and the Ministry of
Welfare (presently Social Justice and Empowerment) and the Drug
Dependence Program 1996.
◦ A proposal for adoption of a specialty section on addiction medicine includes
the development of a dedicated webpage, co-ordinated CMEs, commissioning
of position papers, promoting demand reduction strategies and developing a
national registry.
 NARCOTERRORISM
◦ The attempts of narcotics traffickers to influence the policies of a government
or a society through violence and intimidation, and to hinder the enforcement
of anti-drug laws by the systematic threat or use of such violence.
◦ Tramadol is reportedly used by terrorists and fighters in order to reduce pain,
to increase endurance strength, and to alter the senses.
◦ Fenethylline, sold under the brand names Captagon, Biocapton, and Fitton, is a
psychostimulant molecule, co-drug of amphetamine and theophylline.
Although illegal, fenethylline is a major substance of misuse in the Middle
East, and, due to its enhancing properties, it is also used by ISIS fighters and
other militant groups in Syria
 ENVIRONMENTAL MODEL
◦ Another potential causal factor underlying withdrawal manifestation is
environmental cues, which can elicit withdrawal symptoms (eg, negative
affect, craving) independent of deprivation.
◦ Such cravings may be relatively unaffected by smoking cessation
pharmacotherapy (nicotine replacement therapy, varenicline, or bupropion),
which do alleviate cravings related to drug deprivation.
◦ This is consistent with research that suggests different neurobiological
pathways for cue-induced versus deprivation-induced craving.
◦ Laboratory animals will self-administer drugs and learn the cues and actions
that predict drug access. Those cues drive subsequent drug seeking, even after
periods of abstinence. Thus, associative models of addiction in animals have
face and construct validity for human drug abuse.
◦ Stimuli related to the abused substance evoke neural activation in the striatum
of smokers, alcoholics, and cocaine users, exactly as one would predict from
the preclinical literature and from an aberrant learning and memory model of
addiction.
◦ PET scans with radiolabelled tracers sensitive to dopamine binding reveal
dopamine release in the dorsal striatum in cocaine users in response to cocaine
associated cues.
◦ Alcoholics too release dopamine in the striatum in response to alcohol cues,
particularly in situations when alcohol was expected but not delivered.
◦ Such expectancy violations or prediction errors may provide a strong impetus
to drug seeking and may drive new learning of Pavlovian cue-drug
associations and the instrumental actions involved in drug procurement.
 DEVELOPMENTAL MODEL OF
ADDICTION
◦ Flay and Petraitis have attempted to organize the array of theories focusing on
substance use etiology into one comprehensive micromodel.
◦ Their model of triadic influence assumes that health-related behaviors such as
substance use are most immediately controlled by decisions or intentions that
are a function of three streams of influence:
(i) cultural±environmental factors which influence attitudes,
(ii) social situation± contextual factors which influence social learning and
normative beliefs
(iii) intrapersonal factors which influence self-efficacy.
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