How Addiction Happens
Think back to the first time you realized that your control over your use of alcohol or drugs was slipping away from you. Maybe someone said something about it and you felt defensive (though you probably know by now, you felt defensive because it was true!). Perhaps you recognized it yourself and tried harder to moderate your use, but you kept on coming to the same conclusion: one drink, one hit, one pill was no longer enough. One always led to more, and more led you to problems in your life. Yet even the problems weren’t enough to give you the strength to stop. The urge to continue, even if it made no sense, was too strong. This is what it is to have an addiction. You lose control over your use of drugs or alcohol, wreaking havoc on your life, and you find yourself continuing to drink or use anyway.
In this chapter, we’ll go into greater depth about the signs and symptoms of addiction, and you will learn about some of the things that might have made you vulnerable to addiction. After completing the exercises that help you identify your personal addiction risk factors and symptoms, should you decide that you need a professional to evaluate you, this chapter provides guidance to help you identify a qualified professional who can help.
Though you can easily look in a textbook or on the Internet to find the criteria that are used to determine whether someone has an addiction, you can probably define it just as well by reflecting on your own experience. What led you to believe that you were in need of help to manage your use of alcohol or drugs, and what were the consequences of your use in your life? As you are learning, addiction usually has to do with a loss of control over drinking or using drugs. Let’s think about how that might unfold. Consider what it was like when you started drinking or using. If you are like most people, you started drinking for one of three reasons:
If you were seeking the good, pleasurable feelings, or the performance enhancement, then your motivation was for what is known as positive reinforcement. If you were trying to alleviate physical or emotional pain, then you were “self-medicating” with alcohol or drugs. (This is also called negative reinforcement because you are drinking or using to “take away” something unpleasant, like pain.)
Regardless of the reason you were drawn to alcohol or drugs, in the beginning, it worked. You came to expect certain physical and emotional sensations when you were drinking or using, and just like we come to expect pleasure from a tasty dessert when we eat it (and the pleasure always comes!), you knew that you could count on feeling the sensations you were expecting each time you drank alcohol or used drugs. And this is what kept the pattern going: the more these expectations of elation, relaxation, happiness, confidence, relief, or any other sensation you were seeking were fulfilled, the more you wanted to drink or use drugs.
At some point, a transition occurred. The usual sequence of drink or use, and feel good or better did not work in the same way that it did initially. Maybe you developed tolerance. This happens when the amount of alcohol or drug that first gave you the feeling you were seeking no longer works in the same way; you begin to need more. Maybe you started to experience withdrawal symptoms, which are the unpleasant effects of alcohol or drugs leaving your body. These symptoms can lead you to want to drink or use more so that you will feel better. Though these effects are different depending on which drug you use, they usually involve a combination of unpleasant physical sensations (such as nausea or vomiting, headaches, shaking, and sweating) and emotions (such as depression and anxiety). When the symptoms of tolerance or withdrawal begin, this often marks the progression of what started as social or recreational alcohol or drug use to problematic use. As this transition occurs, you start to feel that you need to drink or use just to feel normal.
So, how do you know when you’re addicted? It’s when that need—to drink or use to feel normal—starts to override most of the other things you value in life. During that process, people and things that are important in your life become affected by what has now turned into compulsive drug or alcohol use. This happens because, when you are so preoccupied with drinking or using to feel “okay,” other things you used to do with the time that you spend using, recovering from using, and planning to use again start to fall by the wayside. What’s more, despite its negative impact on one or more aspects of your life (such as your ability to be productive, your physical and emotional well-being, and your important relationships), you find yourself continuing to drink or use anyway. In the 12-step philosophy this is often referred to as the “insanity” of addiction; you keep on doing the same thing over and over again (drinking or using), yet you are expecting different results. You think, It’s not going to get out of hand this time! when, in reality, your days of drinking or using in moderation are far behind you.
Let’s take a look at how this pattern developed in Charlie’s life.
Charlie’s Story
Charlie is a twenty-three-year-old man who is attending a local university as a Computer Science major. He experimented with drugs and alcohol throughout his teens, with phases of smoking pot daily alternating with phases of heavy drinking. But pot and alcohol were easy for him to give up and he never considered himself to be a person with “addictive tendencies.”
When he was in his second year of college, a friend of his offered to share some pills he was taking to enhance his ability to pay attention and stay up for long hours during final exams. The pills, called Adderall, were prescribed to his friend for attention deficit disorder, but his friend took a little more than he was prescribed and found that it helped him when he needed to cram for exams or big assignments. Charlie thought, Why not? and after trying the Adderall a few times, he found that it really enhanced his performance in school during finals. So he started asking around and found someone to supply him, just in case he wanted to get it in a crunch.
After a few months of using Adderall on and off, Charlie found himself using the pills not only for finals or major assignments, but habitually for studying or homework. Adderall became somewhat of a crutch for focusing his attention. Despite the benefits, Charlie, who was normally a very upbeat and sociable person, found himself feeling irritable, preferring to be alone much of the time. When he wanted to sleep after studying for long hours on Adderall, he just couldn’t bring his energy level down and he found himself struggling with terrible insomnia. Though he tried to cut back on the Adderall several times, each time he found that his concentration was poor, and he felt stressed about the impact this could have on his grades.
In an attempt to resolve his insomnia problem, Charlie acquired a prescription for some sleeping pills, but they didn’t work. He found himself doubling and sometimes tripling the dose to get to sleep. After only a few weeks of alternating between the sleeping pills and the Adderall, Charlie felt overtired and unable to think clearly. As a consequence, he was less productive at school. Charlie was becoming more and more isolated from his friends, and his grades started to slip. His life suddenly seemed to be dominated by pills: thinking about them, coming down from them, feeling the urge to take them, and planning how he was going to manage the balance between the uppers (Adderall) and the downers (sleeping pills) so that he could get everything done. Though he was trying his best to keep it all together, his life was slowly coming apart.
Though Charlie was working a part-time job at the campus bookstore, the cost of taking Adderall regularly began to add up and he started running out of money. As his supply of Adderall ran out, he felt depressed, irritable, unmotivated, and unable to concentrate. His parents came to visit him at school just prior to spring break, and without a thought, he took his mother’s checkbook out of her purse and wrote himself several checks of a few hundred dollars each to cash. Maybe, he thought, if the amounts were not so large and he cashed them gradually, she wouldn’t notice.
Like Charlie, you have probably found yourself acting in ways that are completely out of character for you when drugs or alcohol have taken hold of you and your life. What started out as using to feel good or to alleviate some negative feelings (or if you’re like Charlie, to enhance your performance in some way) somehow got very out of hand. Much of this has to do with the effects of substances on the brain, which are explained in the next chapter. But first, let’s spend a few minutes looking over the signs and symptoms of addiction.
Exercise 1.1: Addiction Signs and Symptoms
Below is a list of signs and symptoms of addiction. Place a check next to those that you have experienced in the past twelve months.
Tolerance
You need to use more alcohol or drugs to feel the desired effect.
The same amount of alcohol or drugs doesn’t do what it used to.
Withdrawal
When you don’t have alcohol or drugs, you are uncomfortable physically or emotionally.
You’ve used alcohol or another substance to help make yourself feel better when you were coming down from alcohol or drugs.
Craving
You think about drugs or alcohol frequently.
Until you’ve acted on an urge by drinking or using, it is very hard to get it out of your head.
Loss of Control
You’ve made rules for yourself concerning how much you will drink or use but you were unable to stick to them.
You’ve tried to quit or cut back your use of alcohol or drugs but were not able to.
You’ve found yourself drinking or using more than you had planned to or for a longer period of time than you meant to.
You’ve felt at times that you couldn’t fit in or feel good without alcohol or drugs.
You have used alcohol or drugs when you were feeling upset or angry with someone.
You have blacked out (or had periods of time for which you have no memory) when under the influence of alcohol or drugs.
You have overdosed on drugs.
You have used one or more drugs without knowing what it was or how it would affect you.
The thought of running out of drugs or alcohol makes you anxious.
Legal Problems
You have been arrested or had other legal problems as a result of drinking or using.
You have stolen things to pay for alcohol or drugs.
Problems in Social or Occupational Functioning
You have made mistakes at work or school because of your use of drugs or alcohol.
Your use of alcohol or drugs has hurt your relationships with others.
You have not been able to fulfill important role obligations (such as household chores, financial responsibilities, or caring for children or other loved ones) as a result of drinking or using.
You have lost interest in hobbies or things you used to enjoy (such as spending time with friends or family) while increasing the time you spend drinking or using.
Persistent Use Despite Negative Consequences
Despite your awareness of one or more negative effects of alcohol or drugs on some aspect of your life or ability to function, you find yourself continuing to drink or use drugs anyway.
Impairment or Distress Resulting from Use
You have not taken good care of yourself (for example, not eating well or not practicing good hygiene) because of your alcohol or drug use.
Drinking or using drugs has caused or worsened existing psychological or medical problems (such as depression, anxiety, or cardiovascular disease).
If you marked any of the signs and symptoms that go beyond tolerance and withdrawal, you have, at a minimum, experienced alcohol- or drug-related problems. Some people experience such problems without actually being addicted, and they decide to quit or cut back on drinking or using. These are very healthy choices, because having had the experiences described on the checklist suggests that you may be at risk for greater problems (including addiction) if you continue to drink or use. In the Resources section you will find resources for learning about controlled drinking or harm reduction approaches to the use of alcohol or drugs. The goal of harm reduction is to reduce, but not quit, drinking or using. It is important for you to know, however, that this workbook is written for those who suffer from addiction and are open to an abstinence-based program of recovery.
This exercise is not intended to substitute for a formal diagnosis of addiction. It will, however, help you to reflect on the way your use of alcohol and drugs has affected your life. If you have not been evaluated professionally, your responses may provide some indication of whether it would be a good idea to find out more about the seriousness of your problem and consider treatment that extends beyond self-help.
If you think that you may have an addiction, but you are not sure, then you should be evaluated by a professional right away. Ideally you should seek out a professional with expertise in addiction. Appropriate professionals may include medical doctors, psychologists, counselors or therapists (with a master’s degree in either psychology or social work), or admissions counselors at addiction treatment facilities.
How and Where to Seek Professional Help
Finding the appropriate professional to conduct a careful evaluation of your addiction symptoms is not always easy, especially if this is a new problem or if you have never seen a professional to help you with mental or emotional problems. If you have seen a mental or behavioral health professional in the past or are currently working with someone whom you trust, even if that person has not helped you previously with problems related to your alcohol or drug use, it is a good idea to share your concerns with that person, and ask them (1) if they have training and experience that will enable them to assess or treat you for this type of problem, and (2) if not, whether they can recommend an addiction expert whom you can see for an evaluation. If you don’t have a mental health professional to work with but you have a primary care doctor with whom you feel comfortable, you can request a referral to an addiction specialist from your doctor. It is always an advantage if you can get a referral from a trusted medical professional to someone else with whom they have worked. That way, the referring professional has a good sense of the quality of the person or program to which you’re being referred.
Sometimes people feel hesitant to talk with their doctor or counselor about alcohol or drug use because they are worried that the information will be shared with a family member or someone else. Remember that there are very strict privacy laws that prevent doctors and other professionals from sharing anything you tell them about your alcohol or drug use with anyone else without your explicit permission (unless you share information that indicates that you may seriously harm yourself or another person).
When you talk with a doctor or other professional for the first time about your concern that you might have a drug- or alcohol-related problem, there are three key elements you can introduce to the conversation to help make it go smoothly and minimize your discomfort:
Finding the Words
Let’s take a look at how Charlie expressed the need for professional help, using the three key conversation elements described above. Even though Charlie felt that he couldn’t help himself when he stole the checks from his mother, he struggled with intense guilt and shame afterward, and he began to recognize that he was losing control over his behaviors surrounding his use of Adderall. Even though part of him didn’t want to give up Adderall, perhaps a greater part of him realized that he was acting in ways that were concerning and that he needed professional help.
Charlie had a pediatrician whom he really felt he could trust. His pediatrician treated him for general health issues all the way up until he went away to college, and even though he felt self-conscious about approaching him to talk about the problems he was having with Adderall, he didn’t feel ready to talk with his parents about it. He knew, however, that it was only a matter of time before his mom would notice the checks he had stolen from her and that, sooner or later, the truth would come out. Charlie realized that if he needed to tell his mom about his drug problems, he would be better off doing that with the advice of a professional. So he called his pediatrician, Dr. Amira.
Charlie: Hi, Dr. Amira. Thank you for taking the time to talk with me.
Dr. Amira: You’re welcome, Charlie. What’s going on?
Charlie: Well, this is very difficult for me to talk about because I feel worried for myself and, at the same time, very ashamed about this problem that I am having. So please bear with me.
Dr. Amira: Okay.
Charlie: Before I tell you about the problems I’ve been having, I need to ask you about the confidentiality of the things that I tell you. Are you able to talk with me about some issues I’m having without sharing what I say with my family?
Dr. Amira: Yes, Charlie. Everything you say to me is completely confidential, unless you tell me something concerning about your safety or the safety of someone else, such as expressing an intention to harm yourself or another person. Or if you tell me about someone who is being abused—under those circumstances I would need to report what you tell me to protect you or someone else who is in danger. But anything else that you say to me will stay between us.
Charlie: Thank you. It helps to know that. The reason I called is because you are the only person I trust to tell about what has been going on with me. I started using Adderall to stay up and study for finals, and I’m concerned that I may have become addicted to it.
Dr. Amira: Yes, Adderall can be highly addictive. Let me be sure I understand you, though. Did anyone prescribe it to you, or were you getting it some other way?
Charlie: (pausing, a little bit hesitant and embarrassed) Well, I feel bad admitting this, but I got it from a friend at first. Nobody is prescribing it to me. The reason I was calling is because I think I need a professional to evaluate me and help steer me in the right direction, and I was hoping that you might know of an addiction specialist in the New York City area whom you could recommend.
The three key elements in the sample dialogue—all of which emphasize directness and encourage empathy—can help you not only when you are asking a professional for a referral, but also when you’re communicating with friends and family about your participation in addiction treatment. We will come back to communication skills and rehearse them later, in chapter 4.
Returning to the issue of finding a competent professional to evaluate you, if you don’t have a doctor or other treatment provider whom you can ask for a referral, you have a few other options. First, if you’d like to speak with a doctor who has specialized training in addiction, there are a number of professional organizations you can go through. See the Resources chapter at the end of this workbook for some examples.
Apart from individual providers such as physicians or therapists, addiction treatment programs are staffed with various qualified professionals who can evaluate your symptoms. It may be reassuring to remind yourself that making an appointment for an evaluation doesn’t mean that you are committing to entering treatment. The Resources section at the end of this workbook contains some links to useful search engines for treatment programs.
Browsing the options on these websites, while very informative, can also be overwhelming if you don’t know what you’re looking for. There are certain questions that you will want to ask when you’re looking for a treatment program, to get a sense of the quality of the program and whether it can meet your individual needs. Some examples of key questions to ask, and the responses you’d look for in a quality program, are provided in the following table.
Questions to Ask When Seeking Treatment
Why me? you might find yourself asking. Why is it that some people can take or leave alcohol or drugs, experiment with them (even heavily), and then just turn the page as though it never happened? You can probably think of at least a handful of people like this whom you’ve known or even used to drink or use with. Now they just drink or smoke pot here and there, socially. Maybe they even get a little too drunk or high from time to time, but for the most part, they keep it under control.
Why can’t I do that? you may wonder. Many people who seek out help for their alcohol or drug use find themselves, at some point in the process, wishing they could be that person who could take it or leave it. You might find yourself fantasizing about drinking or using socially at some point, and it is normal to want to be able to do that. The loss of control over drinking or using drugs that you’ve experienced is not normal, and addressing that effectively might mean giving up your “ideal” of drinking or using in moderation, at least for now. It doesn’t mean that for everybody, but clearly the least risky path to long-term recovery from addiction is to quit using altogether. Coming to terms with the reality of that can be very hard.
Although there is no single reason that can explain why you are more vulnerable than some of your friends or family members, studies have shown that there are common risk factors that increase the likelihood that a person will develop an addiction. The worksheet below will help you to identify some of your personal risk factors.
Exercise 1.2: Personal Risk Factors
Below you will find a list of biological, environmental, and other conditions that increase the risk for addiction. Place a check mark beside those conditions that you have experienced.
You have at least one family member who suffers from addiction.
You have had depression, anxiety, post-traumatic stress disorder, or other psychological problems.
Your parents or other role models used alcohol or drugs excessively around you when you were growing up.
Your parents or other role models engaged in criminal behavior consistently when you were growing up.
You had friends and acquaintances at school who were using drugs and alcohol when you were in your teens.
You had trouble in school as a child (for example, a learning disability or poor grades).
You had difficulty making or keeping friends or feeling like you “fit in” with your peers when you were growing up.
There was a lot of chaos and conflict at home when you were growing up (for example, lots of fighting between the adults in your home).
You were physically or sexually abused.
You started experimenting with alcohol or drugs as a child or in your early teen years.
You have smoked or injected drugs.
You had some traumatic experiences in your life prior to starting to use alcohol or drugs excessively.
The more risk factors you have, the more vulnerable you are, so if you have lots of check marks above, it will help you to make sense of why you’ve been affected by addiction. But even if you didn’t check off anything on the list, or if you checked off only one or two risk factors, you can still develop drug or alcohol addiction.
How could that be? you might wonder. For starters, it is important to remember that these risk factors do not each have an equal influence on whether or not you become addicted. For example, genetic factors (such as whether or not you have an immediate family member with addiction) explain between 40 and 60 percent of a person’s vulnerability to addiction (Kendler et al. 2000; Tsuang et al. 1998; Tsuang, Stone, & Faraone 2001). Although many people with family members who suffer from addiction do not themselves become addicted, among those who do develop an addiction, the genetic vulnerability is usually paired with conditions in the environment that “activate” problem drinking or drug use (Enoch 2012).
For example, when a person who is genetically vulnerable grows up in a chaotic home environment, where he or she is abused and witnesses a parent or role model abusing alcohol or drugs, these conditions can “activate” the genetic tendency to drink or use drugs excessively. Even with a perfectly healthy home environment, a person who suffers from depression or anxiety and is exposed to a peer group that is using drugs or alcohol would be more likely to develop an addiction than a person who experienced either one of these conditions alone.
In this chapter, you’ve learned some important things about yourself. You explored some of the unique aspects of your history, family, and life experiences that placed you at risk for addiction. You also identified your symptoms of addiction. You can reflect on this list any time you need to strengthen or remind yourself of your motivation to keep on actively working on your recovery.
If you aren’t in treatment already, you now have some guidance about how to ask health care professionals whom you know and trust to help you identify one or more treatment providers with specialty training in addiction. You can also access some helpful resources at the end of this workbook to enable you to do some research on treatment on your own, and you are armed with good questions that will help you to find the treatment program that is the best fit for you. In the next chapter, you will deepen your understanding of the way addiction has affected you biologically and how some of the effects of these substances on the brain can explain your loss of control over alcohol and drugs.