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present in most cases of addiction that is associated with the persistence of
engagement with addictive behaviors. The state of addiction is not the same as the
state of intoxication. When anyone experiences mild intoxication through the use of
alcohol or other drugs, or when one engages non-pathologically in potentially addictive
behaviors such as gambling or eating, one may experience a “high”, felt as a “positive”
emotional state associated with increased dopamine and opioid peptide activity in
reward circuits. After such an experience, there is a neurochemical rebound, in which
the reward function does not simply revert to baseline, but often drops below the original
levels. This is usually not consciously perceptible by the individual and is not
necessarily associated with functional impairments.
Over time, repeated experiences with substance use or addictive behaviors are not
associated with ever increasing reward circuit activity and are not as subjectively
rewarding. Once a person experiences withdrawal from drug use or comparable
behaviors, there is an anxious, agitated, dysphoric and labile emotional experience,
related to suboptimal reward and the recruitment of brain and hormonal stress systems,
which is associated with withdrawal from virtually all pharmacological classes of
addictive drugs. While tolerance develops to the “high,” tolerance does not develop to
the emotional “low” associated with the cycle of intoxication and withdrawal. Thus, in
addiction, persons repeatedly attempt to create a “high”--but what they mostly
experience is a deeper and deeper “low.” While anyone may “want” to get “high”, those
with addiction feel a “need” to use the addictive substance or engage in the addictive
behavior in order to try to resolve their dysphoric emotional state or their physiological
symptoms of withdrawal. Persons with addiction compulsively use even though it may
not make them feel good, in some cases long after the pursuit of “rewards” is not
actually pleasurable.
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Although people from any culture may choose to “get high” from
one or another activity, it is important to appreciate that addiction is not solely a function
of choice. Simply put, addiction is not a desired condition.
As addiction is a chronic disease, periods of relapse, which may interrupt spans of
remission, are a common feature of addiction. It is also important to recognize that
return to drug use or pathological pursuit of rewards is not inevitable.
Clinical interventions can be quite effective in altering the course of addiction. Close
monitoring of the behaviors of the individual and contingency management, sometimes
including behavioral consequences for relapse behaviors, can contribute to positive
clinical outcomes. Engagement in health promotion activities which promote personal
responsibility and accountability, connection with others, and personal growth also
contribute to recovery. It is important to recognize that addiction can cause disability
or premature death, especially when left untreated or treated inadequately.
The qualitative ways in which the brain and behavior respond to drug exposure and
engagement in addictive behaviors are different at later stages of addiction than in
earlier stages, indicating progression, which may not be overtly apparent. As is the case
with other chronic diseases, the condition must be monitored and managed over time
to:
a. Decrease the frequency and intensity of relapses;