As with many illnesses, to understand the progressive nature of the disease of addiction, we have broken it down into stages. People who have addiction started in stage I and will inevitably end up in stage IV if not treated. The progression from stage I to IV may occur rapidly or may take years or decades. Stopping drug use might halt the disease process, but treatment is still necessary. Further, if use is restarted, the disease process will pick up where it left off. Like a passenger on a train traveling from New York to California, if you get off in Chicago (stage II), you will “reboard” in Chicago and continue west, heading inevitably toward stage IV, disability, and eventually death. Here are the stages in further detail: Stage I Stage I addiction begins with the first ingestion of a mood-altering drug. The feelings that occur are related to mood change. This is often a sense of “normalizing” the world, euphoria, or an energized sense of well-being. This sensation may be especially true of the first use of opiate painkillers. The pain goes away—both the physical and the emotional pain. Although there may be no outward behavioral changes yet, such drug use cannot be considered “safe” because in persons with the neurobiological risk for developing addiction, subsequent use may result in substance abuse and life changes beyond the person’s control. At this stage, family members generally have a greater awareness of the problematic use of substances than the addict. The developing addict may have an uneasy sense that there is something wrong, but denies it to him- or herself and others. The addict in stage I may cut down or even quit using for periods of time, but without recovery or treatment, typically he or she eventually resumes use and the problems recur and escalate. A person with chronic pain and addiction may be defensive about drug use and answer any criticism or questions about it by rationalizing, for example:

• Explaining why drug use is necessary: I have to take these medicines for the pain so I can function, or the doctor said I need to take this.
• Minimizing the consequences of drug use: It’s not that bad because I’m not taking that many, or I only take what’s prescribed and sometimes less (hoarding extras “just in case”), or I go to work every day, so I can’t have a problem.
• Denying: I don’t have a problem with drugs.

Other characteristics of stage I may include:

• Wanting the drug (craving).
• Counting pills.
• Worrying when the supply of pills is low.
• Focusing on the time until the next dose (preoccupation).
• Increasing the dose without a doctor’s order (tolerance).
• Taking a pill or two in the morning to “get going” (using for purposes other than those intended by the prescriber).
• Adding another substance to supplement the effects (commonly alcohol or other sedatives).
• Using stimulants because of fatigue caused by the opiates.
• This stage usually occurs in individuals who haven’t had chronic pain for very long but are beginning to develop problems with opiates.

Stage II In stage II, the addict begins to experience the negative consequences of drug use. This stage is characterized by problems in one of the following major functional areas: family or home life, job or school function, social function, legal status, or health. In stage II you experience problems in one of these areas, although several areas may be affected as time goes on. Examples of stage II problems include:

• Fighting at home, neglecting familial responsibilities, or separation.
• Being disciplined at work or decreased work performance.
• Calling in sick frequently or missing work without calling.
• Failing a major test at school or dropping classes.
• Using illegal methods to obtain drugs (consulting other doctors but not disclosing this to each doctor, acquiring pills from illegal sources, using multiple doctors or pharmacies, driving under the influence), but not yet having been caught or arrested.
• Experiencing a worsening of health problems, many of which are side effects of opiates, such as escalating pain, nausea, constipation, diarrhea, headaches, sleep disturbance, fatigue, or depression.

This stage usually occurs in individuals who have been dealing with chronic pain for some time, and though they may appear okay on the outside, they are beginning to experience deterioration of function. Stage III In this stage, there is intense preoccupation with the desire to experience mood-changing effects of the drug(s). Daily drug use, depression, and thoughts of suicide are common. Family troubles increase. Legal problems may ensue. Stage III is characterized by any one of the following major consequences in any one major functional area. If family function is the problem area, these consequences include:

• Being asked to move out for good, leading to the end of the relationship.
• Getting a divorce.
• Becoming estranged from close family members.

If the problem areas are outside the home, they could include any of the following:

• Getting fired.
• Failing out of school.
• Going to jail.

Stage III physical changes include:

• Being hospitalized.
• Being physically dependent on drugs; suffering withdrawal when trying to cut down or stop.
• Again, for it to be considered stage III, the addict must have only one of these problems, not multiple problems in all areas of his or her life, even though that may be the case. This stage usually occurs in individuals who have been dealing with chronic pain for years and the amount and variety of their medications has steadily increased, with progressive decrease in function, dependence on the drug(s), and general worsening of quality of life.

Stage IV Stage IV is considered late-stage addiction, where the effects of the disease have spread to all areas of the person’s life. Stage IV addiction, like stage IV cancer, is the period that precedes death from the disease. The length of time people can survive in this stage varies, but if the disease is treated, even at this point, the destructive process stops, life expectancy increases, and quality of life improves. Common causes of death from addiction include overdose, liver failure, accidents, suicide, and infections that would be preventable or treatable in nonaddicts. Those who have reached this stage need increasing quantities of drugs just to feel normal. Physical signs, such as damage to the heart, liver, and brain; malnutrition; lower resistance to pneumonia or tuberculosis; and overdoses are common. Stage IV addiction is characterized by multiple problems in more than one major life area. Generally it means the person has no meaningful family life or relationships left, has no job or school life, is cognitively impaired by drug use, and has severe long-term, often permanent health consequences, including brain dysfunction. In stage IV, pain and addiction are deeply entrenched in a person’s life and the person is alienated from loved ones and medical professionals alike. People with stage IV addiction fit the stereotype of those with addiction and are commonly homeless, in jail, or in an institution. Individuals with chronic pain often have histories of overdosing on drugs, either accidentally or on purpose. The acetaminophen in their opiate medications has caused liver damage. Their lives consist of unending pain, periods of sleeping and sleeplessness, staying in bed most of the time, and trips to the emergency room, either to try to get drugs or for treatment of complications of the advanced disease. This blog post is an excerpt from Pain Recovery – How to Find Balance and Reduce Suffering from Chronic Pain by Mel Pohl, MD, FASAM, Frank Szabo, LADC, Daniel Shiode, PhD, Robert Hunter, PhD; Published by Central Recovery Press (CRP).