Identifying the exact point at which the use of a substance constitutes an addiction ought to be easy, but it is not.

Confu- sion arises because we are limited to observing and describing behaviors, when what we are really trying to define involves a change in the way the brain functions as a result of exposure to an addicting substance. It’s the same problem that appears in the story of the three blind men and the elephant.

One man feels the elephant’s ears and concludes that the creature is broad, thin, and waving like a leaf in the wind. Another feels the elephant’s trunk and believes that he is touching something long and sinuous, like a snake.

The third feels the elephant’s leg, and notes that it is chunky and sturdy, resembling the trunk of a tree. All three are correct, but none has discovered the true nature of the elephant. Addiction is a complicated condition, with biological, physiological, psychological, behavioral, and spiritual aspects. For this reason it is best to think of alcoholism and drug addiction as multifaceted disorders, only one of which is the compulsive use of the addicting substance.

In 1972 the National Council on Alcoholism and Drug Dependence convened a group of researchers and clinicians to propose a broad working definition of alcoholism. They came up with the following: “Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.

The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic” (Journal of the American Medical Association 268, no. 8 [1972]: 1012–13).

This statement encompasses several aspects of the disorder of alcoholism, and applies also to drug addiction. The two key elements that will constitute our working definition of addiction are (1) loss of control over the use of the substance, and (2) continued use despite negative consequences.

Defining addiction in the abstract is hard enough. Diagnosing addiction can be even more difficult. In extreme cases the diagnosis of addiction is obvious - the street addict who commits crimes in order to support the addiction, or the skidrow alcoholic. But what about the business executive who has two or three drinks - never more - every evening on the train home from work, but has withdrawal symptoms after elective surgery when his routine is disrupted? Or the church deacon who mostly shuns alcohol but several times a year goes on out-of-town benders for a week or so? Or the person who has one arrest for driving under the influence (DUI) and is sent by the court for alcohol and drug assessment?