How Do You Know If You Are Addicted to Something?

pouring more whiskey drinkThe road to recovery, however, begins with recognition.” —American Psychiatric Association

How do you know if you are addicted to something? Does “addiction” lie in how the body responds in the absence of a substance, the chronicity of its use, or does it have more to do with one’s behavior toward the substance? The concept has ignited a war on drugs by Nixon, been playfully mocked by the late Amy Winehouse, and glorified by such shows as Intervention. A nuanced examination of the medical and cultural language of addiction exposes broader implications.

For example, is there a difference between the increased irritability during smoking cessation, a caffeine withdrawal headache, and prescription medication “discontinuation syndrome”?

According to the American Psychiatric Association (APA), addiction is a “chronic brain disease that causes compulsive substance use despite harmful consequences. Health, finances, relationships, and careers can be ruined.” This implies one must be aware of his or her use causing negative outcomes in various domains.

The National Institute on Drug Abuse (NIDA) adds that addiction is a “relapsing” brain disease based in part on the fact “drugs change the brain; they change its structure and how it works.” We now know that virtually everything we do and how we think about what we are doing causes changes in the brain (i.e., neuroplasticity).

A medical definition for addiction includes the compulsive nature of the behavior around a “habit-forming substance.” There is a compulsive physiological need for and use of a habit-forming substance (e.g., heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physical compensations upon withdrawal. This leaves some ambiguity around which drugs are actually “habit-forming.” Does sugar fall into this category? It certainly lights up the brain’s reward center with blasts of dopamine in a similar way as cocaine.

In the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), you will not find an explanation for the specific term “addiction.” Substance “abuse” and “dependence” have been replaced by a combined term: “substance use disorder.” This encompasses substance use issues along a continuum rather than distinct entities (e.g., abuse, dependence). The criteria for “substance use disorder” has a broader scope that includes impaired control, social or relational disruptions, risky behaviors, and pharmaceutical use.

The DSM-5 now distinguishes mild, moderate, and severe as specifiers regarding substance use as well as the addition of “craving” as a symptom. This purportedly enables clinicians to more objectively document progress or regression during treatment as opposed to the static “dependence” and “abuse” criteria in previous manuals. There is even a behavioral diagnosis in this section: “gambling disorder.” One need not have a tolerance or withdrawal issue to be diagnosed with one of these so-called disorders.

In some regards, this section represents an evolution to the psychiatric canon. However, if the forest represents the process of addictive behavior, the trees are these detailed revisions. What about the exclusion of pharmaceutical dependence? For example, if you are prescribed a medication and you follow the instructions of your physician, you cannot develop a “substance use disorder.” What happens if you diligently follow the prescription of oxycodone (a pain-relieving opiate medication) by a doctor for multiple years and then discontinue the medication? It is likely that your tolerance has increased and your body will scream in agony via withdrawal symptoms. However, you would not meet criteria for a “substance use disorder.” Is this hypothetical person “addicted” to oxycodone as he or she goes into a severe fever, insomnia, and vomiting? From a conceptual standpoint, this is very confusing.

Let’s think about a more 2017 example. What if you are legally prescribed a daily dosage of vaporized cannabis that steadily increases over time? You notice dizziness, headache, and irritability before the morning wake-and-bake session. How does a person know if they are “craving” the ostensible medication or just following the guidelines for treatment? Does it matter? It might when it comes to other drugs.

By 2010, more than one in five Americans was taking a psychotropic medication. You would think it would be important to know the long-term effects of these medications. In Richard Whitaker’s 2010 book Anatomy of an Epidemic, he proposes not only a longitudinal addiction or dependency to psychotropic drugs, but a poorer outcome for those who stay on the medications. His provocative claims describe an iatrogenic process whereby the person’s mental health issues are made worse by the medication over many years (chronic courses with increased acute episodes). The author includes the fast-acting and shorter half-life drugs, such as benzodiazepines and neuroleptics, but also antidepressant medication in the argument.

When it comes to the seemingly more addictive drugs, our cultural ethos of “addiction” leaves the onus on the individual. We point at the self-destructing person who refuses to go to rehab and condone our own unskillful habits. The behaviors of the pharmaceutical user are at times less transparent.

Whitaker’s research hypothesizes a compensatory effect by the brain in response to the inorganic changes caused by psychotropic medication (imagine a tolerance built up over months to years). When describing the mechanism of selective serotonin reuptake inhibitors (SSRIs) such as Paxil or Prozac, a key and lock analogy is often used. SSRIs fit perfectly into the “locks” of our brain (i.e., receptors) similarly to the way nicotine fits into nicotinic receptors in the brain. If you plug a neurotransmitter key (e.g., SSRI) into the proper lock in the brain, it blocks reuptake of the serotonin (making more of it, which has been associated with increased mood).

According to Whitaker, eventually the perturbation of the brain chemistry prompts the serotonergic system to decrease production of serotonin. Other compensatory action includes less production of these receptors, which results in an imbalance: abnormally low levels of serotonin across the aggregate. What happens when one abruptly stops taking the antidepressant and thus removes all of those keys from the locks in the brain? According to the manufacturer of Paxil, you might experience dizziness, sleep disturbances including abnormal dreams, and sensory disturbances (including electric shock sensations, tinnitus) when stopping the medication.

When stopped more abruptly, Paxil and oxycodone have many of the same “discontinuation” symptoms: nausea, vomiting, agitation, anxiety, headache, and sweating. However, conventional wisdom does not view these symptoms as dependency issues or withdrawal from Paxil. Instead, the manufacturer’s warning on the label characterizes it as discontinuation syndrome. These issues reportedly resolve for most within two weeks, but can persist for two to three months or more.

When it comes to the seemingly more addictive drugs, our cultural ethos of “addiction” leaves the onus on the individual. We point at the self-destructing person who refuses to go to rehab and condone our own unskillful habits. The behaviors of the pharmaceutical user are at times less transparent. If someone doesn’t know the harmful consequences of taking a prescription drug, then he or she is misled. Ignorance and inexperience are now blurred concepts within the multiplicity of drugs. Insight cannot overcome a lack of knowledge about a drug’s effect on the body.

Recent warnings on psychotropic medication labels acknowledge the potential effects of discontinuation (e.g., thoughts of suicide). However, like the history of cigarette use, a scary warning on the package will do little to curb public demand.

References:

  1. American Psychiatric Association (APA). Addiction. Retrieved from http://www.psychiatry.org/addiction
  2. American Psychiatric Association (2013). Diagnostic & Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  3. America’s state of mind: Medco Health Solutions, Inc., 2001-2010. Retrieved from http://apps.who.int/medicinedocs/documents/s19032en/s19032en.pdf
  4. Center for Substance Abuse Research. “Oxycodone.” Retrieved from http://www.cesar.umd.edu/cesar/drugs/oxycodone.asp
  5. Merriam-Webster dictionary. “Addiction.” Retrieved from http://www.merriam-webster.com/medical/addiction
  6. National Institute on Drug Abuse. The Science of Drug Abuse and Addiction: The Basics. Retrieved from http://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction-basics
  7. Whitaker, R. (2010). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York: Crown Publishers.

© Copyright 2015 GoodTherapy.org. All rights reserved. Permission to publish granted by Andrew Archer, LICSW, therapist in Mankato, Minnesota

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.

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  • Sherman

    Sherman

    July 22nd, 2015 at 7:51 AM

    I guess that could be hard one to distinguish. I have never thought about it, but I guess that it could be tough to ascertain what is a craving or whether you are full blown addicted.

  • mary a

    mary a

    July 22nd, 2015 at 2:19 PM

    I have always thought that if you can’t make it through the day without constantly thinking about something or having to have it then that is what will make you an addict.

  • Alan

    Alan

    July 22nd, 2015 at 8:23 PM

    I feel that addiction can also be attributed to a co dependent relationship. The same cravings can be felt over the loss of a significant other or even a breakup. I think addiction and codependency on another individual are one in the same.

  • David c

    David c

    July 23rd, 2015 at 5:25 AM

    Any habit that leads to an inability to fulfill major role obligations in life is problematic. The focus on drugs as the problem simply distracts from the many, even socially supported behaviors that cause damage to individuals, families and communities. Workaholism, high risk stock trading and excessive religiosity cause far more damage than drugs but they are harder to look at and deal with. And, these behaviors are those of the upper classes and therefore are not examined. “Addicts” as typically conceived of ,are just scapegoats.

  • Tia

    Tia

    July 23rd, 2015 at 8:09 AM

    So if the warning labels are doing little to curb abusive behavior with so many of these drugs, then what is the answer to stopping the abuse? Or is there even an answer that is going to work? Aside from completely wiping these things out from society then is there even an answer?

  • Andrew Archer, LCSW

    Andrew Archer, LCSW

    July 23rd, 2015 at 1:08 PM

    Thanks for sharing Sherman and Mary A. I think if we reduce our view to either “addicted vs. not addicted” we miss out on a lot of the actual process of being attached to something. It is hard to draw a line just based on behaviors. Alan, I agree that compulsion and perceived need aren’t limited to drugs. David, the concept of “addiction” does tend to focus on what the culture deems as unacceptable despite the components being the same (e.g., strains on relationships, health effects, etc.). Tia, as you are pointing out, the eradication of certain substances will not stop people from dependencies. Part of the answer (IMO), is increased transparency of psychotropic medications in terms of long-term effects, potential withdrawal, changes to the brain, etc., which would illuminate the similarities between all drugs. This is opposed to the dichotomy between “addictive” and seemingly “non-addictive” drugs. Thanks for the great feedback and discussion comments.

  • Jaymes

    Jaymes

    July 24th, 2015 at 7:47 AM

    It starts to consume your thoughts every single minute of the day

  • Andrew Archer, LCSW

    Andrew Archer, LCSW

    July 24th, 2015 at 2:56 PM

    Thanks Jaymes. You are defining “addiction” in terms of the psychological or mental omnipresence the object has over someone. This fits with the APA version of the addictive process which involves an ability to recognize the issue as it is happening.

  • Jaymes

    Jaymes

    July 25th, 2015 at 7:21 AM

    Just to add to the previous comment, don’t you also think that there are many of us who would deny in the beginning the control that this thing, whatever it may be, actually has over us? We think oh I can go a day or two without this, when in reality it does actually consume our every thought and makes it next to impossible to function, if that is the best term, without it.

  • Andrew Archer, LCSW

    Andrew Archer, LCSW

    July 25th, 2015 at 3:41 PM

    Jaymes, the old adage of “addiction treatment” was centered around this concept of denial toward an “illness.” In this article, I was trying to introduce the idea of being “addicted” without actually having a cognitive awareness of the dependency (e.g., neurochemical changes). More information is needed about all kinds of substances in order to recognize the effects of using them are on the body.

  • BillyS

    BillyS

    July 26th, 2015 at 4:33 PM

    There can be sincere physical or psychological pain when you try to eliminate that substance or action from your life

  • Andrew Archer, LCSW

    Andrew Archer, LCSW

    July 27th, 2015 at 9:15 AM

    I wholeheartedly agree BillyS. Thanks.

  • Dana

    Dana

    July 27th, 2015 at 10:42 AM

    I have been to a few AA meetings before, just to see what it is all about, and while I think that I do have a problem with drinking a little too much every now and then, there is some sort of disconnect when I am in those rooms and those meetings that I cannot at all relate to. I don’t know if it is my mind telling me that I don’t belong there or I don’t want to be there or if I have this feeling that this is not something that I need. I am very much struggling because while I know that there has to be a line drawn somewhere I am not sure that this is it for me.

  • chase

    chase

    July 28th, 2015 at 10:26 AM

    @Dana- you know that you have to acknowledge that there is a problem before the impact of the meetings can begin to settle in with you. So this may not be the treatment path for you, that’s fine it is not for everyone. But I think that there has to be a part of you that knows that there is something that you need to work on otherwise you would have never even gone to the AA meetings to check them out.

  • Andrew Archer, LCSW

    Andrew Archer, LCSW

    July 28th, 2015 at 1:34 PM

    Dana, thank you for sharing that. If one doesn’t feel like they fit the exact group consensus, it can be really challenging. Narrow criteria like “addict” can be intimidating. You are probably aware, but there are harm reduction groups like Smart Recovery that might interest you.

  • BZ

    BZ

    February 14th, 2016 at 1:47 PM

    Addictions extend way beyond the current categories people wish to label them nowdays. Years ago folks got addicted to their cars, in addition to a lot of other things in their lives. I went to see about getting help for my addictions to television, coffee and a few of other habits that I believe make me suffer, but I was dismissed. Unless you fall into a category considered a “treatable addiction” by current mainstream practitioners, they won’t even take sufferers seriously, or even acknowledge your concerns.
    I know a few kids & adults who are addicted to online gaming. Their problems are only recognized by those who want to send bills, but have little idea about how to seriously help many of them overcome their perceived or real problems of addiction to all kinds of things. Maybe it’s just a phase…. that they’ll outgrow on their own or in time

  • Andrew Archer, LCSW

    Andrew Archer, LCSW

    February 16th, 2016 at 1:55 PM

    @BZ, I’m sorry to hear that your experience has been less than beneficial regarding managing habitual patterns. I would agree that there is an over-emphasis on the sort of ‘objects of addiction’ rather than the individual experiencing distress around the pattern.

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