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 noninjurious 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 abuse, which means suffering adverse consequences related to the use of alcohol and/or other drugs. Actually, the term “abuse” has two meanings in the context of addiction medicine. In the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), substance abuse is defined by adverse consequences, such as relationship, job, or legal problems, but abuse 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 abuse.
Addiction includes abuse, 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 abuse 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:
1 Physical dependence (which may be normal with certain prescription medications), plus
2 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.
I’ve heard people say things like: “I abused alcohol when I was in college and now I’m fine; I am able to drink normally now.” I would argue that this person was never really an addict; that he went through a period of life during which he abused 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.
There have always been addicts. Depictions of intoxication and addiction occur throughout history, from the Greco-Roman period, through the Middle Ages, during the Industrial Revolution, and so forth. There have always been people who couldn’t control their use of mind- and/or mood-altering substances.
In 1914, the United States government passed the Harrison Narcotic Tax Act, which essentially criminalized opiate/narcotic drug use. The government position was that alcohol and other drug problems were not medical problems, but rather issues for the police and law enforcement. Then came the Drug Enforcement Administration and the ever-expanding criminalization of addiction—to the point where doctors were actually arrested for the “crime” of treating addicts. This was true right up until the late sixties when the American Medical Association finally got involved.
Some very brave people who started the Haight Ashbury Free Clinic were at the forefront of the sea change that took place when the “flower children” were going up to San Francisco, zoning out, taking LSD, and having bad trips. The police kept trying to bust the medical practitioners at the Haight Ashbury Free Clinic, saying, in effect, “This is not a job for doctors or nurses; it’s a job for the police to handle.” Finally a lot of bigwigs got involved and went to the American Medical Association, there was a big protest, and the pendulum has now swung in the opposite direction.
Now addiction is considered a medical problem, but there is still “personal choice/failure of character vs. disease” tension in America. I remember when a well-known conservative radio host used to say that we should arrest all the addicts and “send them up the river.” That was, until he became an addict himself. If you’re in recovery you may well relate to the examples that I give here. For those of you who don’t have any background in addiction, please be aware that when somebody goes down that dark road of addiction and experiences powerlessness and loss of control, it becomes a very humbling and oftentimes, a