There are any number of reasons why people use and end up becoming addicted to alcohol and other drugs: to change the way they feel—for euphoria, sedation, and anesthesia; to self-medicate depression, anxiety, insomnia, boredom, and lack of pleasure. To treat addiction, you have to understand what it is, how people become addicted, and work to eliminate the underlying causes. If you don’t, you’re just addressing the symptoms and your treatment process won’t work. First of all, addiction doesn’t just happen—it takes time. There appears to be a “continuum” of people who use alcohol and other drugs. Let’s start by stating that many people at the beginning of this imaginary continuum never get involved with substances. In fact, there really are many people who never use or even try alcohol or other drugs. It may be against their religion, like Seventh-Day Adventists, or for some other reason they are fearful, or simply uninterested. In other words, a lot of people never touch the stuff. Having said that, let’s let the medical community weigh in with a definition. The American Society of Addiction Medicine defines addiction as “a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.” But please recognize that not everyone who uses alcohol and other drugs becomes addicted. Going back to the imaginary drug use continuum, we note there are many people who experiment with alcohol and other drugs but never become dependent or addicted to them. Who experiments with these substances? The answer is most people in our society. People experiment, even kids on a playground. You’ll sometimes observe them spinning in circles and going, Woo, I’m getting dizzy! This happens because people seem to have a desire to periodically alter their consciousness and it seems at the time like fun. I’m not saying that experimentation is always harmless because it isn’t. A kid can experiment with LSD and jump off a roof or experiment with cocaine and get arrested. But I am saying that many people do it and don’t run into any problems with it. As we move on along the continuum we observe people who use drugs recreationally. Recreational drug use means you go to a party and you smoke a little pot or snort a little cocaine. Or you go to a baseball game and have a few beers. Now, again, I’m not saying that recreational drug use is harmless or for that matter, legal. Because you could use cocaine recreationally and have a heart attack or you could be observed smoking marijuana and wind up getting arrested. Or you could get stopped for DUI on the way back from the baseball game. For these reasons and others, recreational drug use is a big problem in our society. Unfortunately, however, the media always manage to confuse addiction with drug use. Sometimes you’ll see an article in the paper reporting that the police busted a “rave” party, where kids were on ecstasy, and the media talk about what a big problem addiction is. The problem is that the two don’t have much to do with each other, at least not in that context. Kids do drugs, teenagers do drugs, adults do drugs. However, this phenomenon is not necessarily chemical dependency or addiction, but instead should be characterized as recreational drug use. For that matter, when you see articles in the papers or the news media about some kid falling down and hitting his head or “overdosing” because he did ecstasy at a rave, how do you know it was really ecstasy that he was using? Remember, these drugs don’t come from a pharmacy. They come from street drug dealers who often cut them with all kinds of potentially toxic chemicals. You should be aware of an organization called Dance Safe (www.dancesafe.org). They’ll test the kids’ drugs before they enter the raves or parties. The kid gives them the drug for immediate onsite testing and they give it back to the kid with useful information like “I don’t know what you thought you bought, but this is really crystal meth,” or “You may have thought this was ecstasy, but it’s really DxM (dextromethorphan) and it’s cut with all kinds of bad stuff!” Moving forward on our continuum, we see the next level of use: habit. Suppose a person has a glass of wine with dinner every night. Through repetitive experience, any action or reaction can become an acquired mode of behavior, also known as a habit. It is through ongoing repetitive experience, people become so accustomed to using alcohol and other drugs that this use becomes habituated. By the way, according to the United States Public Health Service, one glass of wine or one drink a day for a female, and two for a male, is considered normative or non-injurious drinking. Risky or hazardous drinking is defined as more than seven drinks per week or greater than three drinks per occasion for women and greater than fourteen drinks per week or greater than four drinks per occasion for men. The reason there is a male/female difference, in addition to gender-based differences in body size/weight, has to do with alcohol metabolism. Because males have higher muscle to body fat ratio and most women have less of the alcohol-degrading enzymes alcohol dehydrogenase and aldehyde dehydrogenase, women can tolerate alcohol less well. There are a number of studies that show that alcohol consumption in moderation is actually healthy. However, you can’t suggest that to your clients who are addicted because they have demonstrated through experience that they can’t just have one glass of wine with dinner. An often heard statement in AA is “one drink is too many, and a thousand’s not enough!” After habit on our continuum is use, which means suffering adverse consequences related to the use of alcohol and/or other drugs. Actually, the term “use” has two meanings in the context of addiction medicine. In the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), substance use is defined by adverse consequences, such as relationship, job, or legal problems, but use also refers to the use of a drug by a person for a purpose for which it was not prescribed or intended—for example, when a kid goes to his or her parents’ medicine cabinet and steals Vicodin to “party” with it. Adverse consequences of substance use can occur in different dimensions of a person’s life. Arrests for DUI or drug possession are examples of adverse legal consequences. Somebody who drinks so much that they sustain liver damage and continue drinking anyway is experiencing an adverse medical consequence. There are also adverse psychological and psychiatric consequences. Suppose someone uses cocaine or other stimulants like crystal meth, and he or she is depressed all the time but continues to use anyway. These substances wipe out the brain’s supply of dopamine (a neurotransmitter important to mood) so, of course the user is going to be depressed, an adverse psychiatric consequence. “Use despite adverse consequences” is a hallmark of use. Addiction includes use, but it also includes other components. There are a number of different definitions of addiction, including the American Society of Addiction Medicine’s definition, but they all generally include use and some of these other elements. As of the time of this writing, the American Psychiatric Association is currently working on a new edition of the DSM (DSM-5), scheduled for publication in May of 2013. what seems to be evolving in the definition of addiction is a phenomenon of two overlapping neuroplastic (altering brain anatomy and chemistry) states produced by repeated drug use:
- Physical dependence (which may be normal with certain prescription medications)
- Compulsive out-of-control drug-seeking (which may be moderate or severe). Drug dependence, which as we will see is different from addiction, means that neuroadaptation has occurred so that the brain doesn’t feel normal when not on it (whatever the “it” is). Ask someone who’s been on opiates for a long time how she feels when she stops taking them. She feels terrible, literally sick, because the long-term use of opiates changes the thermostat” in the brain. With addiction there is physical dependency coupled with compulsive out-of-control drug-craving and drug-seeking. But remember, dependence isn’t necessarily addiction. You are not an addict if you are dependent on insulin, because if you are a diabetic you require insulin to function normally, and if you suddenly stop it, you will experience serious adverse consequences! To use an example that’s more to the point, you can be dependent on opiate pain pills because you have a legitimate pain problem and you can’t function without them due to the pain. Let’s say you have metastatic cancer and you need to be on morphine to control your cancer pain. If you stop that morphine, you’re going to go into withdrawal. So you have developed an opioid dependency, but you’re not necessarily an addict—especially if you don’t exhibit compulsive out-of-control drug craving and drug-seeking. Compulsive out-of-control drug craving and drug-seeking, coupled with dependence, is the hallmark of addiction.
We can use the process of making a pickle as an analogy for how this process works. You start with a cucumber, put it in vinegar or some kind of juice, and then let it sit there. After a certain period of time the cucumber turns into a pickle. However, you can’t make it return to a cucumber again, because the composition has been chemically changed. A chemical reaction has occurred and it’s no longer a cucumber; it’s now a different vegetable, a different substance—a pickle. Similarly, when someone has the disease of addiction, as much as he or she might wish to, returning to “controlled” drug use is not an option. People say things like: “I used alcohol when I was in college and now I’m fine; I am able to drink normally now.” It’s possible that this person was never really an addict; that he went through a period of life during which he used alcohol, maybe was going through a divorce, perhaps had a stressful job, and self-medicated, i.e., “drank too much.” But he never turned from a cucumber into a pickle and didn’t meet all of the criteria for addiction. This blog post is an excerpt from The therapist’s Guide to Addiction Medicine – A Handbook for Addiction Counselors and Therapists – by Barry Solof, MD, FASAM; Published by Central Recovery Press (CRP).