[Rudybega]

I think it's probably still useful to distinguish addictions with hardcore substance related barriers to quitting (think withdrawals) from addictions where the barrier is a lack of dopamine or serotonin or simple habituation.

For people with normal executive function, the second category of problems should be fairly tractable to overcome, whereas the first is still quite difficult.

The second only really becomes an issue when you have a bit of executive dysfunction.

Maybe that distinction is important and one merits the term addiction while the other doesn't? Though both categories seem to be relatively treatable with drugs that massively improve executive function, so the parallels are pretty glaring.

[vintermann]

Most of the addiction literature I've read says that physical addiction is overestimated: even heroin addicts regularly go through physical addiction, either involuntarily because they can't get it, or voluntarily (through treatment efforts, or simply deciding to sober up for e.g. a wedding or other important event). What makes them addicts isn't that they can't stop, it's that they start up again.

Conversely, people hospitalized for something acutely painful often get addicting (or, withdrawal causing) painkillers in amounts and at purities street users can only dream of. And once it's over, they go through withdrawal, and it's deeply unpleasant, and they never want to do it again. People going through something like that aren't more likely to become opioid addicts than anyone else, according to old study results (I may be able to dig them up if you're interested).

It's of course different for chronic pain. But then, the reason for people wanting to start up again is pretty obvious.

[Aurornis]

> painkillers in amounts and at purities street users can only dream of.

It’s true that pharmaceutical purity is higher, but it’s very much incorrect to say that hospital patients routinely receive higher amounts or doses than street users.

The doses used by chronic opioid, benzo, and stimulant addicts can be absolutely insane compared to even high doses given in medical practice. Even more so after tolerance builds.

This can be a real problem for severe addicts who become hospitalized or end up in the ER because their tolerance is so high that even the high end of doses used in normal patients may do next to nothing in patients with severe addictions.

Addicts also have several factors contributing to the increased severity of their condition: Their route of administration is designed to maximize the ramp up of the dose, which leads to stronger effects, habituation, tolerance, and withdrawal dynamics.

Undergoing many cycles of habituation and withdrawal (missing doses, running out, or just abusing on weekends and trying to stay sober during the week) can actually sensitize addiction problems and exacerbate the problem, even if the doses are not extreme. This is not a problem in a hospital where doses are scheduled and regular.

Finally, the duration of exposure and area under the curve is dramatically different. An addict may be exposed to 100X or 1000X as much of a drug over years due to higher dosing and long term addiction relative to someone in the hospital who undergoes a procedure and then is tapered off.

It’s really misleading to compare opioids or benzos prescribed in a controlled hospital setting to the use by addicts. They are so dramatically different that you can’t compare the addiction and withdrawal dynamics at all.

[vintermann]

It's the same compounds, though. And we're only comparing them on one dimension - simple physical addiction. How misleading can it be?

As I said, the studies are old. With the rise of superpotent synthetic opioids in the illegal market, and probably more caution in hospital use - one of the reasons these studies were made, was probably that someone noticed "wow, they sure used a lot of opioids during the Vietnam War, I wonder if that led to a rise in street addicts?" It's possible that it's no longer true that patients get much higher doses than the typical street addict. But it used to be the case, at least, and we can still learn from what we observed back then.

I think there's still plenty of support for the conclusions, that addicts can beat physical addiction, but that they start again, and that the fear of withdrawal pains is not a big factor in what's keeping them as addicts.

[knotimpressed]

Pretty misleading, to be honest. As the parent comment to yours said, the ROA + dose schedule + AUC + peak plasma concentration differ so vastly that "its the same compounds" almost doesn't matter.

The differences between street/illicit use and hospital use are so extreme even just from a physical point of view that it is unreasonable to compare the physical addiction/withdrawal they both cause.

That being said, physical addiction/withdrawal is definitely only one piece of the puzzle of why addiction happens and addicts don't stop their use. I think that using the data of hospitalized patients being able to push through it isn't as strong as an argument for that as you've made it out to be, but that doesn't mean it isn't true.

Addiction is a very hard problem, and I'm hopeful that we'll continue developing new treatments and support methods as a society, even if its semi by accident like with GLP-1s.

[galagawinkle489]

I think I have heard the same. People whose lives are hopeless are much more likely to get addicted. The addiction then makes their life worse which causes this downward spiral of despair.

People with physical addictions can choose not to use drugs etc. Smokers can take 12 hour flights and they don't involuntarily take out a lighter and cigarette and smoke half way through. It is about self control.

[falcor84]

With my limited second-hand experience, I tend to think it's less about self-control and more about the hopelessness you mentioned earlier - addicts seem to be exactly the people who for various reasons attach very little value to "being a healthy and productive member of society".

[Aurornis]

> addicts seem to be exactly the people who for various reasons attach very little value to "being a healthy and productive member of society".

These are just the people you notice and see because they don’t care that you see them that way.

My friend worked in the rehab industry. The people who attended rehab came from all different walks of life. Many of them had everything going for them and great lives. It was common for people doing well in work and their social life to think that they could abuse drugs because they could handle it better than “those people” and they wouldn’t allow their use to get out of control.

The idea that addiction is only ever a response to life circumstances is a myth. Lots of people get tangled up with drugs simply because they’re seeking some extra recreational value or euphoria and don’t think the addiction part will apply to them.

In fact, I think the idea that addiction only happens to people who aren’t good members of society is a contributor to many of these people dabbling with drug abuse: They’ve heard so much about addiction only happening to people of poor morale character or who are victims of their circumstances that they think they’re not at risk for addiction because they don’t fit that description.

[ToucanLoucan]

I agree broadly with everything you've said but I think that you're unnecessarily implying/attempting to isolate it to a single cause, and I think it makes more sense as a variety of causes, all of which can contribute to what creates an addict:

* A lot of people who have broadly good lives get into trouble because their particular blend of biology and mental health makes them vulnerable to addictive behaviors, but others use those same drugs without issues

* People with poor life circumstances (and certain mental health conditions like ADHD) are more susceptible to addiction because they have rough lives and anything that gives you dopamine, be it exercise, casual sex or drugs has the potential to cause addiction, and people in those circumstances utilize behaviors for dopamine release more frequently and readily, and also have a stronger lack of dopamine when they stop

It's a very complex subject that's still developing, but one thing I think we can say for certain is that stigmatizing addicts and addiction and treating the people struggling with it as criminals doesn't solve anything. The criminal penalties for drug use and sale have never once helped anyone. What does seem to reliably help people struggling with addiction, any addiction, is support and safe places/drugs to use. And if GLP-1s can enhance that, I'm all for it.

And, it wouldn't hurt to change our society somewhat so we have fewer people on the bottom rungs of it, barely getting by due to whatever circumstance, whom are then less likely to get in trouble with drugs broadly. And to legalize drugs, because making them illegal doesn't do anything apart from inflate police departments' budgets, and push people who want drugs into dangerous situations, addiction being among them but not the only one.

[hamdingers]

The distinction you're reaching for is addiction vs dependance.

[intrasight]

For clinician, this might be an important distinction. But for a layperson, the distinction is not very clear.

[hyghjiyhu]

Idk I think the importance given to withdrawals is overrated. Dealing with withdrawals is just matter of gradually lowering the dose.

The lifelong craving is the bigger issue.

[normie3000]

How is a lack of dopamine different from "withdrawals"?

[Aurornis]

“Lack of dopamine” isn’t an accurate description. It’s a reductionist pop culture metaphor that feels scientific but it’s not really accurate. Drugs of abuse involve multiple systems including opioid receptors, which modulate reward. There is much more going on than simple levels of a single neurotransmitter, which can actually be completely normal relative to non-addicts. Dopaminergic systems are actually involved in driving certain addictive and craving mechanisms, which should be a hint that it’s not as simple as “lack of dopamine”.

In fact, the side effects of certain drugs that directly increase dopamine levels (L-DOPA) or drugs that directly stimulate dopamine receptors (dopamine agonists like bromocriptine) include a risk of compulsive gambling, shopping, and risky behaviors.

Ironically it’s more accurate to simply say “withdrawals” than to try to inject reductionist neurotransmitter speak.