The language of addiction treatment, explained

The World Health Organization describes dependence in ICD-11 through three central features. Two of them need to be present for the diagnosis. At the core is a strong internal drive to use that is not fully under conscious control. The same criteria apply whether the substance is alcohol, a medication or an illegal drug.

The older ICD-10 required three of six criteria within twelve months. ICD-11 simplified this and gave the craving itself more weight. For the person concerned little changes, but both systems still appear side by side in medical letters, so it helps to know which one a report is using.

The distinction at the lower end matters too. Use at risky or harmful levels is not yet dependence, though it can develop into it. Where someone actually sits cannot be read off a quantity alone, only worked out with a doctor or therapist.

Older diagnostic systems separated abuse from dependence. That line was hard to draw in practice and implied two different things were going on. DSM-5 merged them into a single diagnosis and introduced severity levels instead, based on how many criteria are met.

ICD-11 takes a different route and still distinguishes harmful use from dependence. Both systems are in use, DSM-5 mainly in research and ICD in day-to-day care and on medical letters.

The term also carries an advantage in wording, which both NIDA and the German DHS point to explicitly. It names a disorder rather than a person. Phrasings that equate someone with their condition are considered stigmatising because they reduce a person to a diagnosis, which is why person-first wording is preferred throughout this glossary.

In everyday conversation the term can sound clinical, and mutual-aid groups tend to use other language. For a diagnosis, an application or a conversation with a clinic, it is the precise expression.

The nervous system adjusts to a regular supply and pushes back against it. With depressant substances such as alcohol or benzodiazepines the brain compensates in the opposite direction. As long as the substance is in the system the two roughly balance out. When it is removed, the compensation persists for a while, and that is where withdrawal comes from.

Tolerance is often read as a sign of strength, in the sense of being able to handle a lot. Medically it points the other way. High tolerance indicates that the body has already adapted considerably.

Tolerance also falls again after a longer period without the substance. This is an underestimated risk, because an amount that once felt manageable can have a much stronger effect after a break. With opioids this loss of tolerance is the most common cause of fatal overdose after treatment or release from prison.

Craving feels physical to many people rather than like a thought that can simply be set aside. The most influential explanation comes from Robinson and Berridge. Repeated use sensitises the reward system to anything associated with the substance. Cues that were once neutral take on a kind of magnetic pull. The technical term is incentive sensitisation.

This explains an observation that many people find confusing. The urge can stay strong even when using has long stopped being enjoyable. Wanting and liking are separate processes in the brain, and dependence amplifies wanting in particular.

A meta-analysis in JAMA Psychiatry covering 237 studies and roughly 51,800 participants found that higher cue and craving measures were associated with about double the odds of later use or return to drinking. Measuring craving is therefore a core part of treatment rather than an optional extra.

One practical detail helps: craving comes in waves. A single wave usually subsides within minutes. Getting through that window rather than fighting it is the basis of most techniques taught in therapy.

Triggers form through learning. When a situation and using coincide often enough, the situation alone is later enough to produce the physical response. That is why the end of a working day, a particular song or the sound of glasses can produce a reaction well before any conscious thought about it.

The harder triggers are usually the internal ones. External cues can be avoided for a while, feelings cannot. Loneliness, conflict, exhaustion, boredom and also happiness are among the most common.

Knowing your own triggers is therefore a treatment goal in itself. Not in order to avoid every one of them, but to be prepared when one appears. This work is usually where an emergency plan comes from.

Typical symptoms are tremor, sweating, restlessness, nausea, a racing heart and disturbed sleep, along with anxiety and irritability. The course varies a great deal between individuals and depends on how much and how long someone has been drinking, on previous withdrawals and on other conditions.

The question of when the worst is over has two answers. The acute physical symptoms ease noticeably for most people after about four to seven days. Sleep, mood and the capacity to handle stress often take weeks to months to settle. Expecting only the first timeline makes the second phase feel like a setback when it is part of the normal course.

Withdrawal symptoms are the reason alcohol withdrawal belongs in medical hands. Untreated alcohol withdrawal can be life-threatening, through seizures and delirium tremens. The same applies to benzodiazepine withdrawal. Which treatment setting is appropriate is covered under alcohol withdrawal.

It typically appears 48 to 72 hours after the last drink, often following a withdrawal seizure, and affects a minority of people with established alcohol dependence. It usually peaks around the fourth day.

Delirium tremens can be life-threatening. Timely treatment in hospital is the decisive factor in reducing that risk substantially. That is why a withdrawal where delirium is possible belongs in inpatient care.

Warning signs that need immediate medical help are increasing confusion, hallucinations, fever, a severely racing heart or a seizure.

Alcohol reduces anxiety in the short term because it strengthens inhibitory signalling and dampens excitatory signalling. The brain compensates for that shift. Once the alcohol has been metabolised the compensation is still active, and the system is over-aroused for several hours.

This is what many people experience the next morning as anxiety without a cause, palpitations and inner restlessness. The effect is neither imagined nor a character flaw, it is a pharmacologically explicable process.

A loop can develop from it. Dampening the rebound with more alcohol brings short-term relief and increases the swing over time. With repeated withdrawals the over-arousal can become more pronounced each time.

In everyday use the word covers two quite different things, and the confusion regularly leads to disappointment. One is detoxification, which carries the body safely through the acute phase and usually takes five to ten days. The other is a fuller inpatient withdrawal treatment, which includes the same detoxification but embeds it in psychological and social support and runs for three to four weeks.

Detoxification alone usually takes five to ten days and addresses only the physical side. That is necessary, but it changes nothing about the patterns that led to the drinking. Inpatient withdrawal treatment uses the period straight after detoxification for motivational work, education about the condition, handling craving and planning what comes next.

The German S3 guideline recommends a treatment duration of at least around four weeks for the inpatient form including detoxification. In practice it is often the bridge into a subsequent rehabilitation.

This model is more established in German-speaking countries than in the UK or US, where the equivalent is usually described as medically managed withdrawal followed by residential or outpatient rehabilitation.

It takes place in a specialist clinic or on an outpatient basis and runs for weeks to months depending on the setting and the need. The content is individual and group therapy, work on craving and on setbacks, social and occupational stabilisation, and the question of what function drinking has served.

In Germany the responsible funder is usually the Deutsche Rentenversicherung, because the treatment is intended to preserve the ability to work. For people without a sufficient contribution record the health insurer often takes over. Applications generally go through an addiction counselling service or the clinic's social work team.

The move from a clinic back into ordinary life is one of the most demanding stretches of the whole treatment. In the clinic, structure, people to talk to and distance from familiar cues are all a given. At home both disappear at once, and a considerable share of returns to use falls into this period.

Acamprosate and naltrexone are the two most commonly used for relapse prevention in alcohol use disorder. Acamprosate acts on the balance between excitatory and inhibitory signalling and is directed at the craving that arises from inner tension. Naltrexone blocks opioid receptors and reduces the pleasurable, reinforcing effect of alcohol. Nalmefene is licensed for reducing consumption in particular circumstances.

The German S3 guideline rates the evidence for acamprosate and naltrexone highly and recommends their use as part of an overall treatment plan. The effect is real but moderate. These medicines do not do the work on their own, they make the therapeutic work easier.

Whether such treatment is appropriate, which preparation fits and what argues against it is always a decision for the treating doctor. This section is not medical advice and does not replace a consultation.

The word comes from the Latin abstinere, to hold back. In addiction medicine it is first of all a description of behaviour over a period of time. It says nothing about how someone is doing while they do it.

Mutual-aid communities also use the phrase dry drunk for a state in which someone has stopped drinking while the craving and the old patterns remain unchanged and life feels tense or joyless. The contrast drawn is with a contented sobriety, where a life without alcohol is genuinely experienced as better.

Neither is a medical diagnosis and neither appears in any guideline. As descriptions they are still useful, because they hold on to an important point. Stopping and recovering are two different processes, and the second takes considerably longer.

For families this is a helpful distinction. If no relief arrives after someone stops drinking, that is not ingratitude, it is a sign that the actual work is still ahead.

A note on wording: phrases that label a person by their condition, such as calling someone an alcoholic, are widely considered stigmatising because they reduce a person to a diagnosis. Both NIDA and the German DHS recommend person-first alternatives, for example a person with alcohol use disorder. Self-description within mutual-aid groups is a separate matter, and there it can strengthen belonging.

Clinically a distinction is drawn between a single episode of use, often called a lapse, and a return to the old pattern. The distinction is not academic. What happens in the hours after a single episode often decides whether it becomes the second thing. Shame and secrecy are the largest risk factors here, because both stop anyone finding out in time.

In addiction treatment resilience is what comes after abstinence. Abstinence takes the substance out of the picture. Resilience is what allows the pressures that used to be anaesthetised to be handled differently.

It is made of very concrete things. Enough sleep, regular meals, movement, a social network that holds, and the ability to ask for help early. That sounds unremarkable and works for exactly that reason, because it lowers the baseline load that craving builds on.