Addiction is a complex and multifaceted condition that affects individuals from all walks of life, regardless of age, gender, or socioeconomic status. For addiction counselors, understanding the causes and symptoms of common behavioral and substance use disorders is the first step in treating clients suffering from addiction.

• Genetics: Research suggests that individuals with a family history of addiction, particularly first-degree relatives like parents or siblings, may have an increased susceptibility to developing addictive behaviors.  
• Environmental factors: Children raised in unstable or abusive environments may be more prone to substance abuse as a coping mechanism. However, supportive family structures, positive relationships, and community engagement can mitigate the risk of addiction.  
• Trauma: Trauma often leads to emotional difficulties, including substance abuse, as individuals seek relief from distressing symptoms.  
• Underlying mental health disorders: Conditions like anxiety, depression, and bipolar disorder can exacerbate feelings of stress and anxiety. These can drive individuals to self-medicate with drugs or alcohol as a means of coping.  
• Brain changes: Prolonged substance abuse alters the brain's chemistry, particularly its reward circuitry, leading to diminished dopamine production and impaired pleasure response. Consequently, individuals may rely on drugs or alcohol to experience pleasure, perpetuating the cycle of addiction.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) defines opioid use disorder as a problematic pattern of opioid use. This leads to clinically significant impairment or distress. The diagnosis of OUD is made by meeting two or more criteria in a one-year period.  

Criteria includes:

•  Opioids taken in larger amounts or over a longer period than was intended
• A persistent desire or unsuccessful efforts to cut down or control use
• Excessive time spent to obtain, use, or recover from using the opioid
• Craving, or an intense urge to use
• Opioid use interferes with obligations
•  Continued use despite life disruption
• Reduction or elimination of important activities due to use
• Recurrent use in physically hazardous situations
• Continued use despite physical or psychologic problems
• Withdrawal
• Increased tolerance, which can include: a need for increased doses of the opioid for the desired effect or a markedly diminished effect with continued use of the same amount

The toxic side effects and addictive potential of opioids have been known for centuries. These undesired effects have prompted a search for a potent synthetic opioid analgesic free of addictive potential and other complications. However, all synthetic opioids introduced into medical use share the same liabilities of the classical opioids.  

The search for new opioid therapeutics has resulted in the synthesis of opioid antagonists and compounds with mixed agonist-antagonist properties. Drugs like buprenorphine have expanded therapeutic options and provided the basis of expanded knowledge of opioid mechanisms.

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All drugs of abuse affect the brain's reward pathways. The effects of alcohol appear to be related to complex multiple interactions with the dopamine, gamma-aminobutyric acid (GABA), serotonin, opioid, and N-methyl-D aspartate (NMDA) neurotransmitter systems.

Alcohol, food, and other drugs of abuse have similar effects on dopamine receptors. The development of addiction, including to alcohol, is affected by genetic predisposition and influenced by alterations in the rewarding chemicals released per dose.  

Studies suggest that the reinforcing effect of alcohol is partially mediated through nicotinic receptors in the ventral tegmental area. When combined with nicotine, these may be a factor in the high incidence of smoking among those with alcohol use disorder.

Substances of abuse are often put into categories based on their effects. Alcohol has effects similar to other depressants, which characteristics’ include: 

• Decreased cognitive function while intoxicated
• Decreased inhibition and increased impulsivity
• Risk of overdose
• Development of depressive symptoms in heavy users
• Withdrawal symptoms like other depressants
• Symptoms of anxiety during withdrawal
• Substance-induced psychoses in some heavy users

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The widespread use of methamphetamine stems largely from its potential to produce euphoria, reduce fatigue, enhance performance, suppress appetite, and induce weight loss. Coupled with multiple social, biologic, cultural, and psychological factors, this makes it a drug ripe for abuse.

Data from a large community survey of drug abuse conducted from 1995 to 1998 found the factors most robustly associated with progression from stimulant use to stimulant dependence were: 

• Early onset of stimulant use
• Multiple-substance abuse
• Daily cigarette smoking between 13 and 17 years of age 

Contributory and risk factors for methamphetamine abuse include:

• The presence of depression
• Childhood conduct disorder  
• A desire to enhance sexual pleasure
• The manic phase of bipolar disorder
• Adult antisocial personality disorder  
• Obesity
•  ADHD 

Methamphetamine use has increased particularly among people with an existing opioid use disorder. Among treatment-seeking people with opioid use disorder, reports of past-month methamphetamine use nearly doubled, from 18.8% to 34.2%, between 2011 and 2017.

Overall, methamphetamine use is one of the leading causes of drug overdose deaths in the United States, accounting for 10.6% of deaths in 2016. Of these deaths, 49.8% involved concomitant use of another drug (e.g., heroin, fentanyl, cocaine).

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Cocaine addiction is best described as a chronic relapsing disease. It is characterized by the compulsive seeking and use of cocaine accompanied by functional and molecular changes to the brain. The single most defining aspect of cocaine use disorder is the salience of the relationship with the drug. The stronger the relationship, the more likely the patient is to continue problematic use despite internal and external consequences.

Psychologic dependence, whereby the patient believes the drug is necessary to complete daily activities, alleviate stress, and cope with problems, is a symptom of stimulant dependence. Physiologic adaptation, evidenced by tolerance and withdrawal, is often present but is not sufficient for a diagnosis of cocaine use disorder.  

Cocaine use disorder is diagnosed behaviorally. It is evidenced by at least two of the following within a 12-month period: 

•  Persistent desire or unsuccessful attempts to cut down or control use
• Great deal of time spent in activities necessary to obtain the drug
• Failure to fulfill obligations at work, home, or school as a result of cocaine use
• Continued use despite persistent or recurrent social or interpersonal problems caused by cocaine use
• Continued use despite knowledge of a problem likely to have been caused by or exacerbated by cocaine use
• Important activities abandoned or reduced
• Recurrent cocaine use in physically hazardous situations  
• Craving
• Tolerance
• Withdrawal

Cocaine abuse is a condition of frequent, binge-type use and continued use despite negative consequences, but with less severity and fewer behavioral symptoms than a use disorder.

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Although severe problems associated with abuse and dependence are less common among cannabis users than among other drug users, they do occur. In 2022, cannabis had the highest rate of past year use or dependence when compared with all other illicit drugs. As of 2024, the long-term societal and personal consequences of decriminalization of cannabis are unknown. The issue requires continued monitoring.

Cannabis use disorder is a chronic relapsing disease characterized by compulsive seeking and use of cannabis. Functional and molecular changes to the brain accompany this behavior. The defining aspect of cannabis use disorder is the salience of the relationship with the drug. The stronger the relationship, the more likely the patient will continue problematic use despite internal and external consequences.

Individuals who use cannabis often believe it is necessary to get through daily activities, alleviate stress, and cope with problems. Physiologic adaptation, evidenced by tolerance and withdrawal, is often present but may not be sufficient for diagnosis.  

Cannabis use disorder is diagnosed behaviorally. Evidence of a disorder includes: 

• Cravings for cannabis
• Preoccupation with use of the drug
• Sneaking and concealing ingestion
• Loss of the ability to control cannabis use
• Continued use despite significant physical, psychological, social, or occupational consequences

The DSM-5-TR uses 11 behavioral criteria to diagnose cannabis use disorder. Based on the number of diagnostic criteria fulfilled, a mental health expert may further qualify the disorder as mild, moderate, or severe.

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The drugs methylenedioxymethamphetamine (MDMA), ketamine, flunitrazepam, and gamma-hydroxybutyrate (GHB) have become widely used by college students while clubbing, and by a segment of the youth population that attends all-night dance parties known as raves. For this reason, this group of drugs has become known as club drugs.

Sporadic use of club drugs seldom produces acute or lasting adverse effects in most people. However, heavy use can lead to psychological and physical consequences of variable severity and duration, depending on the agent, the pattern of use, and individual factors. Individuals susceptible to addiction can become compulsive users of these drugs and develop psychological dependence.

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The term "addiction" is traditionally used to describe the pathologic behavioral patterns a subset of persons exhibit from exposure to substances with central nervous system (CNS) activity (e.g., heroin, cocaine, alcohol). However, addiction is not a unitary construct. It incorporates common features that include:  

• Repetitive engagement in rewarding (at least initially) behaviors
• Loss of control (spiraling engagement over time)
• Persistence despite consequences
• Aversive states when ingestion is halted or substantially cut back
• An appetitive urge or craving state prior to engaging in the behavior

Many of these pathologic behaviors have long been classified as impulse control disorders, including:

• Pathologic gambling
• Intermittent explosive disorder
• Kleptomania
• Pyromania
• Trichotillomania

Research suggests that several of these impulse control disorders more accurately represent behavioral addictions.

As a distinct area of study, behavioral addiction is recent, and extensive knowledge advances have been made since 2010. Growing evidence suggests that behavioral and substance addictions overlap in clinical expression (e.g., craving, tolerance, withdrawal symptoms), comorbidity, neurobiologic profile, heritability, and treatment.  

Behavioral and substance addictions also share similar features in natural history, phenomenology, and adverse consequences. Some of the most common non-substance behavioral addictions include pathologic gambling, compulsive sexual behavior, compulsive buying, and compulsive video gaming.

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