HJNO Mar/Apr 2022

HEALTHCARE JOURNAL OF NEW ORLEANS I  MAR / APR 2022 29 compulsive drinking was characterized by a loss of self-control, and that the disease was primarily attributable to the drink itself and not the drinker. His remarks concerned only strong liquors; wine and beer, in his view, were salutary thirstquenchers. 17 In German- speaking countries, the most influential physician was Constantin von Brühl- Cramer, who is credited with coining the term “dipsomania” (“Über die Trunksucht und eine rationelle Heilmethode derselben” [1819]). Dedicated medical journals were created in the 19th century. The Journal of Inebriety appeared in the United States in 1876, while the British Journal of Addiction was first published in 1884. Emil Kraepelin, the physician who exerted the greatest influence on the shaping of modern psychiatry, fought alcohol with extreme dedication. 18 He published the first psychometric data on the influence of tea and alcohol in the early 1890s. As a result of his research, he came to the conclusion that chronic alcoholism provoked cortical brain lesions that led to a permanent cognitive decline. Drawing from personal consequences, Kraepelin became a teetotaler in 1895. Before that, he had been a moderate drinker, recognizing alcohol’s relaxing and mood-elevating effects, as in this letter to the psychiatrist August Forel in December 1891: “…I have often found that, after great exertion, and also after severe mood depression, alcohol has had a clearly beneficial effect on me….” 19 Kraepelin was particularly concerned about the social and genetic consequences of alcohol. Sigmund Freud, a contemporary of Kraepelin, laid the ground for the psychological approach to addiction. Freud wrote in a letter to Fliess in 1897: “…it has dawned on me that masturbation is the one major habit, the “primal” addiction and that it is only as a substitute and replacement for it that the other addictions—for alcohol, morphine, tobacco, etc—come into existence.”20 A consequence of the psychological approach is that the addiction to different substances (alcohol, opiates, etc) and even to certain types of behavior, such as gambling, have been gathered together under a common denominator, and regarded as different expressions of a single underlying syndrome. Interestingly, the Qur’an warns against both wine (khamr) and gambling (maisir) in the same sura (2, 219). In the 20th century, addiction medicine has been enriched by (i) diagnostic classifications and (ii) neurobiological and genetic research. Louis Lewin published his influential classification in 1924, distinguishing between stimulants (nicotine; caffeine- containing compounds such as coffee, tea, mate); inebriants (alcohol, ether); hallucinogens (lysergic acid diethylamide [LSD], peyote); euphoriants (cocaine; opium derivatives such as morphine, codeine, heroin); and hypnotics. Also, animal research and functional brain imaging studies in humans have led to the current influential hypothesis that all drugs of abuse share a common property in exerting their addictive and reinforcing effects by (i) acting on the brain’s reward system and (ii) conditioning the brain by causing it to interpret drug signals as biologically rewarding or potentially salient stimuli comparable to food or sex. Cues associated withmorphine, nicotine, or cocaine activate specific cortical and limbic brain regions. This conditioning involves the prefrontal cortex and glutamate systems. However, in rats, this pattern of activation displays similarities to that elicited by conditioning to a natural reward—highly palatable food such as chocolate. 21 Confronted by cues that serve as drug reminders, the individual experiences craving, and the degree of voluntary control that he or she is able to exert may be impaired. This hypothesis is partly derived from Pavlov’s conditioning paradigm, where food is equated to cocaine, the animal’s salivation to cocaine craving, and the bell to the drug cue. 22 Family, adoption, and twin studies have demonstrated the intervention of genetic factors in addiction, 23 notably in alcohol abuse and dependence. Genetic factors interact in a complex way with the environment. 24-26 Addiction - history of a word The definition of addiction has evolved over time. Today, addiction is defined by the characteristic fea- tures that are shared by a variety of substances: (i) the pattern of admin- istration can progress from use, to abuse, to dependence and (ii), as discussed in the previous paragraph, a common feature of several substances is that they induce pleasure by activating a mesolimbic dopaminergic reward system, and depen- dence by mechanisms involving adaptation of prefrontal glutamatergic innervation to the nucleus accumbens. The term “addiction,” in its current med- ical meaning, was used first in English- speaking countries, and then passed on to other languages that had used other terms previously. For instance, addiction has dis- placed the words toxicomanie or assuétude in French. Interestingly, the word assuétude (from the Latin assuetudo [habit]) had origi- nally been introduced into French in 1885