There are probably as many theories about the causes of addiction as there are people brave enough to tackle

this age-old question. People get passionate about pet theories, which are sometimes linked to what they want to believe, or have experienced themselves, or have seen in another person. For almost every hypothesis you can say: 'Yes, that's right ... but not for everyone and not always.' It's interesting to turn the question on its head and ask what stops people from becoming dependent. After all, we all have access to alcohol and tobacco, and many other drugs are not hard to get hold of. Many people have tried various drugs, or even use them frequently, but don't get addicted. Is it the power of beliefs or scruples? That we have other interests that can compete with drugs? That we don't get the same buzz that another person gets? Or that we've learnt other ways of coping with life's ups and downs? The only logical way to tackle the question of dependence is to consider a complex web of factors: factors in the drug itself, in the person who takes it and in the environment in which they find themselves (you can make an analogy with a seed, its soil and the prevailing climate). The technical jargon for this is the bio-psycho-social model in other words taking into account biological, psychological and social factors.

social factors
The main theories relating to social factors (or the environment) centre around the availability of a drug, its cost, its 'marketing' and the behaviour of those around you. Availability is what gets legislators and public-health specialists (and many parents) worked up. There are glaring inconsistencies in the way countries and governments handle the problem, promoting drugs like alcohol and nicotine while restricting others. The message from a lot of research is: the cheaper the drug and the easier it is to get hold of it, the wider and more slippery the slope into addiction.

psychological factors
The emotional make-up of the person taking the drug (the psychological dimension) is also important. There are various psychological theories of addiction. One is the 'selfmedication hypothesis'. People who have a profound experience of relief or happiness, or just think they function much better when they take a drug, may want more, particularly if they can't find other ways of tapping into those experiences. So people who are shy or depressed or anxious or traumatised may slip into repeatedly taking a drug and risk addiction. But the catch with this theory is that research also shows that some people who use drugs a lot develop a range of psychological problems which they didn't have before. In other words, it's often hard to know whether the psychological problems led to the drug dependence or vice versa. Other psychological theories and there are many focus, for example, on how we learn to use drugs (for example how we observed our parents using alcohol), and on the

powerful associations and rewards that go with taking a drug. There are also psychoanalytical theories, which suggest that drugs and drug-taking are symbolic or symptomatic of conflicts at an unconscious level. Drug-taking might be a defence against unconscious aggression or sexual impulses, some believe, or might help to repress memories of traumatic events such as childhood sexual abuse.

biological factors
There is evidence that both nurture and nature are risk factors for addiction, so family background and genetic make-up are both important. There is no one gene for addiction, but there may be gene types or combinations of genes that increase the chances. A family history of alcoholism, and some other drug addictions, is associated with an increased risk of developing an addiction even if you are brought up away from your biological parents. (The evidence comes from studies of identical and non-identical twins raised either together or apart.) Overall, however, research suggests that the genetic component of a person's susceptibility is probably not as great as we once thought. Taking a drug repeatedly seems to be the trigger to what goes on in a user's brain and how it adapts. Drugs of addiction are teaching us a lot about how the brain works. It is a fascinating but frustratingly incomplete story. One thing that has become clear is that addictive drugs all share certain properties. Experimentally, they are what psychologists term 'reinforcing': animals exposed to these drugs want to go on to try them again and again and may prefer them above food, sex and other stimuli. All addictive drugs grab the brain's attention by mimicking or 'turning up the volume' in the brain circuits linked to reward or pleasure. These circuits are some of the oldest in terms of the brain's evolutionary development. They are deep in the brain (in the limbic area) and have very close links to those fundamental drives that keep us alive, such as sex and appetite. What drugs of addiction seem to do is to 'hijack' some of these systems by influencing transmitters or receptors in certain regions of the brain. If this goes on repeatedly, we now know, the brain changes to adapt (neuro-adaptation). The well-known examples of this are the way a user develops a tolerance for greater amounts of a drug and also starts to notice unpleasant things when the drug is taken away (withdrawal states). But it is subtler than that. Neuro-adaptation also goes on in learning and memory circuits, heightening responses to drug-related cues and situations. An example of this is the powerful craving or full-blown withdrawal experiences that can be triggered simply by the idea of a drug, or by something that represents it, for example tin foil for a crack smoker. The idea of the drug as a sort of 'evil tutor' in the brain is starting to gain currency, and the 'hard-wiring' that results actual structural and functional changes may explain some concepts that have been around for a long time. One example is the idea of alcoholism and other forms of drug dependency as a longterm or even permanent condition. Alcoholics Anonymous, for example, has always

stressed that abstinent former drinkers must be ever watchful of their vulnerabilities. Relapsing into use of a drug is often due to persistent craving or vulnerability to stress. Addicts can find themselves back into heavy patterns of use alarmingly quickly and even have an exaggerated response to a dose of the drug that previously wouldn't have affected them (sensitisation). These vulnerabilities can last for a long time after someone has stopped taking a drug and may, in part, be explained by some of the brain changes that have gone on over the years of drug use.

adding it up
How does all this add up? For an individual with a drug or alcohol problem the best approach is usually to take an honest, hard look at all possible factors. They can then be listed in terms of relative importance. A route out of addiction, and any treatment, can then be aimed at specific problems. A better knowledge of what happens in addiction is helping us develop better treatments, both psychological and medical. A combination of treatment approaches often works best. Treatment often has to go hand in hand with radical changes in a person's environment where they live and with whom they mix. The amazing thing is that, despite all we still don't know, people still find the courage to work their way out of this most difficult and distressing human condition.

References Sweet, C, (1999) Overcoming Addiction: positive steps for breaking free of addiction and building self-esteem, Piatkus Books: London Robson, P, (1999) Forbidden Drugs: Understanding Drugs and Why People Take Them Second Edition, Oxford University Press: Oxford http://www.statistics.gov.uk/CCI/nscl.asp?id=6358 last visited on 28 September 2009

Office for National Statistics (http://www.statistics.gov.uk) Drug poisoning deaths Male deaths increased in 2008

Deaths related to drug poisoning, England and Wales, 19932008 The number of male drug poisoning related deaths in 2008, including those involving both legal and illegal drugs, was 2,075. This was an increase of 8 per cent compared with 2007 and the highest number since 2001. The number of female deaths rose to 853 in 2008, an increase of 17 per cent compared with 2007, after falling for the previous three years. There were 897 deaths involving heroin or morphine in 2008. This is an 8 per cent rise compared to 2007 and the highest number recorded since 2001. The number of deaths involving methadone also increased from 325 in 2007 to 378 in 2008, a rise of 16 per cent. This is the highest number of deaths involving methadone since 1998, when 398 deaths were recorded. Deaths involving cocaine rose to 235 in 2008, continuing a longterm upward trend since 1993. Deaths mentioning paracetamol and its compounds increased slightly in 2008 to 260 from the lowest recorded number in 2007 (242 deaths), following a long-term downward trend since 1997. The biggest impact on this decline was from deaths involving co-proxamol (paracetamol and dextropropoxyphene formulation) where the number decreased by one third between 2007 and 2008, from 72 to 48 deaths. The total number of deaths related to drug poisoning in England and Wales increased each year from 1993 to a peak in 1999, and then began to decline. The number fell to 2,570 in 2006, the lowest recorded number since 1995, but has since increased again.

This trend is mostly accounted for by the changes in drug-related deaths among males, which accounted for 71 per cent of drug poisoning deaths in 2008. From 1997 onwards there has been over twice as many deaths in males than in females. All drug-related deaths are assigned an underlying cause of death reflecting the verdict of the coroner and the wording on the coroners certificate. Among males across the period 1993-2008, broadly similar proportions of deaths were due to mental and behavioural disorders due to drug use (31 per cent), accidental poisoning by drugs (32 per cent) and intentional self-poisonings and poisonings of undetermined intent (37 per cent). Among females across the same period, the majority of drug-related deaths were intentional self-poisonings and poisonings of undetermined intent (62 per cent), with accidental poisoning by drugs accounting for 26 per cent of deaths and mental and behavioural disorders due to drug use for the remaining 12 per cent. Notes: More detailed information on deaths related to drug poisoning in England and Wales can be found in Health Statistics Quarterly 43, published 26 August 2009. The Office for National Statistics (ONS) database of deaths from drug related poisoning contains information on deaths from 1993. Provisional figures for 2008 death registrations were published on 21 May 2009. Deaths related to drug poisoning for 2008 have therefore been marked as provisional to allow further quality assurance before the release of final figures in the next annual report. The quality of the provisional figures is comparable with final death registration figures released in previous years.