There are several resources to help determine if you, a friend, or a loved one is hooked on alcohol or drugs, but professionals, therapists, and drug and alcohol rehab programs can offer so many approaches and philosophies to understanding this issue that it can be overwhelming and confusing to navigate and arrive at practical answers. Add to this conundrum the multiplicity of opinions about and definitions for the terms “addiction,” “alcoholism,” “dependence,” “abuse,” and “misuse” and the prospect of seeking help for yourself or others can seem daunting.
To make things even more complicated, not everyone who uses becomes addicted, and some people just seem to phase out. There are social users, recreational users, people who seem to use just out of habit, and then there are people for whom addiction appears to be their predetermined destiny due to being dealt the bad cards of heredity. Still others have alcoholism checkered throughout their families yet somehow can take it or leave it and show no signs of addiction. Many don’t see the issue manifest until their forties or fifties, while others develop alcoholism or drug addiction shortly after their first drink, Xanax, or hit of heroin.
Early in my career, a young man came to me after being admitted to the hospital with acute and life-threatening alcohol intoxication. He said he never drank alcohol until a recent horrible weekend but now he knows he is an “alcoholic.” I was confused until he explained further. He said his mother was addicted to alcohol, his father had died of alcoholism, and all his grandparents were addicted to alcohol, so he knew he had the genetic loading and he avoided alcohol entirely until the weekend in question. It was his 21st birthday, so he decided to have just one shot of liquor. He liked how it made him feel, so he decided to have another … and then another. He finished most of the bottle, passed out, and needed to be rushed to the hospital, where his stomach was pumped.
When he came to me at the university where I worked, he walked in and said, “I’m an alcoholic. I never drank before because everyone in my family is alcoholic, in recovery, or dead. I drank once, I couldn’t stop, and now I’m going to be sober and I need to be for the rest of my life.”
As far as I know, to this day he drank only that once.
The Issues Beneath Addiction
In his book Breaking Addiction: A 7-Step Handbook for Ending Any Addiction, Lance Dodes emphasizes how addiction is designed to reverse a deep sense of helplessness. It’s not just an impulse issue. It’s more about managing profound feelings such as anger, loss of control, and an inability to feel that one can get what one wants in his or her life.
I liken addiction to the tip of an iceberg. What you are addicted to is the 10% of the iceberg that floats above the water. This is the part we see, and it’s affected by access to certain drugs or alcohol, culture, and society. For one person it might be drinking alcohol; for another, it might be smoking crack, shooting heroin, or taking prescription drugs such as adderall, oxycontin, percocet, or valium.
The 90% of the iceberg that you don’t see is made up of the things that fuel or drive one’s addiction. These are usually intense and pervasive feelings or psychological struggles such as poor self-esteem, helplessness, or anger, or psychiatric and psychological issues such as anxiety, depression, bipolar, or attention-deficit hyperactivity (ADHD). This aspect of addiction is harder to detect and may be the main reason someone self-medicates. The weight of the unexplored iceberg under the water must be excavated and examined in order to help the individual become more aware of himself or herself and to aid in beginning to identify the ways in which the person is not getting what is needed or wanted from life.
The field of addiction psychology includes generally agreed-upon best practices and evidence-based sources to consult, primarily The National Council on Alcoholism and Drug Dependence, National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism. While these are the country’s leading organizations in providing the public with information on addiction and alcoholism, they can be unwieldy because addiction is a broad and varied issue with very different manifestations from person to person and from drug to drug. Addiction to alcohol can look very different from addiction to heroin or oxycodone, and addiction to marijuana appears very different from addiction to cocaine or methamphetamines.
Inside the CAGE
Certainly the most well-known, easiest assessment measure of alcoholism was published in The Journal of the American Medical Association, Detecting Alcoholism: The CAGE Questionnaire by John A. Ewing, MD, in 1984. CAGE is an acronym for cut, angered or annoyed, guilty, and eye-opener in the context of the following four questions:
- Have you ever felt you should cut down on your drinking?
- Have people annoyed you by criticizing your drinking?
- Have you ever felt bad or guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?
Subsequent assessments and measures simply substituted “drinking or drug use” to also assess whether someone had a drinking or drug-abuse problem.
To score these items, responses on the CAGE questions are given a 0 for “no” and 1 for “yes” answers, with a higher score being indicative of alcohol or drug problems. A total score of 2 or greater is considered clinically significant, meaning someone has a problem and should seek help for alcoholism or drug addiction. Most clinicians believe that a score of 1 for any item of CAGE should be considered a red flag and could indicate the presence of an alcohol or substance-abuse issue.
CAGE is obviously a quick and dirty assessment of alcoholism and addiction. The more comprehensive and most widely used tool is the Diagnostic and Statistical Manual of Mental Disorders (DSM). Until very recently, the fields of addiction psychology and addiction psychiatry differentiated between substance abuse and substance dependence in the DSM; these terms bear mention because they are still so widely used.
Substance abuse: Substance abuse was defined as using alcohol or drugs in a way that causes continuing or growing problems in one’s life that affect major areas of functioning, such as work, school, legal troubles, and problems with friends and family, or use of substances to the degree that it causes or exacerbates a mental health issue. This category of substance abuse is considered less severe than the following category of substance dependence.
Substance dependence: Dependency was defined as a continual pattern of drug or alcohol use in spite of major problems in the above-mentioned significant areas of one’s life. Usually this is characterized additionally by tolerance and withdrawal, drug-seeking behavior, withdrawing from society and activities, unsuccessful attempts to quit, and continuing use in spite of negative consequences.
The View from the DSM
The most recent incarnation of the DSM, the DSM-5, has done away with distinctions of abuse and dependence, suggesting that these are artificial differentiations which really describe drug use, abuse, and dependence along a continuum. Furthermore, the change was made because the term “dependence” has been confused with a normal physiological dependence that occurs when people are prescribed treatment drugs which they should not be considered “addicted to” but, in fact, dependent on as part of a normal medical and psychological treatment regimen. Drugs such as suboxone and methadone have become invaluable and integral components of some individuals’ treatment plans despite the insistence of many members in 12-step fellowships such as Alcoholics Anonymous and Narcotics Anonymous who suggest that the users of such medications are not “abstinent” or “clean” by virtue of their dependence on them.
In the DSM-5, addiction is described as a pattern of activation of the brain’s reward system that can be so reinforcing of behavior that an individual may neglect normal activities in order to use drugs instead. Even though the underlying physiological mechanisms and the pharmacological processes for each drug of abuse are different, the brain reward system’s activation is similar, resulting in feelings of pleasure and euphoria. This may be the opposite side of the coin that Dodes describes in counteracting a powerful sense of helplessness, anger, and other associated negative feelings that the user seeks to escape. The DSM-5 also suggests that people are to varying degrees vulnerable to developing substance-related “disorders,” and some have higher or lower levels of self-control due to biology and heredity predisposing them to addiction given various levels of access to drugs and alcohol, exposure, and repeated use.
The DSM-5 highlights 11 separate areas of functioning along a continuum from mild to moderate to severe levels of a substance use issue. Two or three symptoms indicate a “mild substance-use disorder”, four or five symptoms indicate a “moderate substance-use disorder,” and six or more symptoms indicate a “severe substance-use disorder.” The following 11 areas should be discussed and explored in the context of working with a professional knowledgeable about addiction and other mental health issues.
- Using substances in larger amounts or for longer than intended in terms of frequency, duration, quantity, and intensity (stronger-proof alcohol, for example).
- Repeated and unsuccessful attempts to cut back or stop using substances.
- Spending inordinate time seeking, using, or recovering from substances and their use.
- Cravings and urges.
- Drug use affecting work, school, home, or legal issues.
- Drug use causing problems in relationships.
- Forgoing or loss of interest in important social, occupational, or recreational activities.
- Using substances despite dangerous circumstances.
- Drug or alcohol use with the knowledge of physical or psychological problems that may have arisen or been exacerbated by substances.
- Requiring more of the substance to achieve the same high.
- Withdrawal symptoms.
Do You Have a Problem?
If you are attempting to determine whether a friend, loved one, or family member is addicted, learn as much as possible about the substance-use issue and familiarize yourself with educational resources, sources of support, and treatment options. Determining whether you are hooked, addicted, or dependent is a complicated matter. Practically speaking, only you can determine whether you have a problematic relationship with alcohol or drugs for which behavioral changes are worth considering or making. Because denial is a well-recognized symptom of addiction, it can be extremely hard to determine for yourself if you may have a problem. Alcoholism and addiction may be the only disease that exists wherein the disease itself tells you that you do not have a disease (I got that from an AA meeting).
There are several resources, tests, and measures as outlined above that can be valuable tools to help you evaluate whether you, a friend, or loved one has a problem. At the same time, it is important not to rely on personal research alone. Since the drug and alcohol treatment industry has a wide variety of professionals working with multiple approaches and philosophies, defining the terms for yourself and as a consumer of possible treatment is complicated. Furthermore, the addiction treatment industry may have revenues upward of $34 billion in the next year, according to an AOL Daily Finance article suggesting a lot of money is to be made and therefore honest, evidence-based treatment may be hard to come by. A Slate article stated that the U.S. government alone spent $94 billion per year dealing with the fallout from alcohol abuse. For some perspective, the federal government spends about $138 billion on education. Alcohol abuse and addiction affect so many people annually, and still finding help is a herculean task. So where is the best place to start?
Back to the iceberg for a moment. Since 90% of the iceberg is hidden below the water, when searching for a therapist it is important to find someone who is not only an expert in addiction but a professional who is well-trained in all aspects of mental health. This person should be able to understand and diagnose most forms of psychological problems and should have a firm grasp of, and expertise in, addiction psychology. A good start is identifying a mental health professional such as a psychologist, psychiatrist, social worker, or licensed professional counselor who is also a certified addiction counselor or certified alcohol and drug counselor.
If you wonder whether you, a friend, or loved one may be struggling with a drug or alcohol problem, talk to people honestly and openly about your concerns and attend a support group. Even if you decide you aren’t addicted, it can be a tremendous learning experience to attend a support group such as Alcoholics Anonymous, Rational Recovery, or Moderation Management. In fact, dollar for dollar, these meetings are the cheapest form of addiction education and support that anyone can afford. Whereas some of the top inpatient treatment rehabs can cost from $1,000 to $2,000 a day, AA only asks that, if you have a dollar, you put it in a basket (one of their 12 traditions). However, recognize that these groups are for support; they are not treatment. Treatment for drug and alcohol abuse includes the use of support groups, but the cornerstone of drug and alcohol treatment is comprehensive psychotherapy.
The Right Kind of Help
A good therapist can be the bedrock for recovery and can help you add components to your treatment as needed, including medical assessment, psychiatric evaluation, family or couples counseling, vocational and recreational support, and aspects of recovery individually tailored to you or your loved one’s needs. The goal of therapy is to eventually not need a therapist and to be able to accomplish what you were able to do with a therapist gradually on your own or with friends and family. An outpatient psychotherapy consultation is the best place to start. Have this evaluation at an inpatient facility and you may be whisked away into expensive, drastic, and unnecessary inpatient treatment.
To be sure, there are times when inpatient and especially medical detox are essential and critical first steps for anyone seeking addiction treatment. Only speaking to friends about your addiction issues risks that they’ll tell you what you want to hear and not what you need to hear. Sitting down with an addiction expert knowledgeable about the psychology of addiction and evidence-based best practices counseling approaches to individual, couples, and family therapy for alcohol or drug abuse will surely help you evaluate your choices and alternatives, enabling you to determine the best treatment approach for you or people about whom you care.
© Copyright 2014 GoodTherapy.org. All rights reserved. Permission to publish granted by Jeremy Frank, PhD, CAC, Drug and Alcohol Addiction Topic Expert Contributor
The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.