I have noticed, often when meeting with family members of people with alcohol/drug problems (sometimes those who are considering an “Intervention”), that it is difficult for me to point to a book that does a great job of summarizing the features and realities of alcoholism/addiction that most clinical workers in the field generally share and take for granted.
One major source of addictions literature, Hazelden.com (the bookstore arm of the same corporation than offers one of the longest-running and best-known rehabs), has a plethora of books, pamphlets, videos, and whatnot, on many specific aspects of addiction and its treatment, but seems to come up a bit short on books providing an overview. Do an Amazon.com search for “alcoholism” and there is a similar paucity – loads of books on particular points of view (e.g., it’s not really a disease, or nutrition is the answer, or how to live with your alcoholic spouse), lots of memoirs (like Drinking: A Love Story or Dry, almost all worthy of reading other than the one that was faked by the guy who went on Oprah), but no grounded summary to help the layperson understand the landscape.
So I decided to begin putting down some of this, for now in blog form, largely in order to have something to which to direct those who come to me for consultation.
This "chapter" is for those who wonder how to determine whether they, or a person about whom they are concerned, may be alcoholic or addicted.
The terms “alcoholic” and “addict,” like most such labels in the larger field of mental/behavioral health, are attempts to meaningfully categorize conditions shared by subpopulations of people who have a lot in common. But there is no one litmus test, no blood or urine test, no genetic marker, and no precise list of symptoms that they all share. As is also the case for depression, anxiety, etc., no two alcoholics or addicts (and I regard the term alcoholic to mean “alcohol addict”) are exactly alike. The fact that it remains a struggle to define these terms is reflected in the fact that, with each new edition of the Diagnostic and Statistical Manual (DSM, the psychiatric “bible” of diagnoses), the criteria and terminology keep changing, evolving to keep step with current research and social/professional perspectives (and even politics).
But there are key concepts with regard to what most of us consider “addiction” that continue to apply. (By the way, the DSM does not use the words “addiction” or “alcoholism”, but rather the terms “abuse” and “dependence;” the latter is closest to reflecting what I believe most of us clinicians mean by addiction.)
As you read through the (non-exhaustive but key) list of features below, bear in mind that (a) one need not have all these characteristics to be considered alcohol or drug dependent – in fact, perhaps most people don’t; (b) most of these traits are probably more biological than psychological in nature.
· Tolerance: It takes more of the substance (whether it be alcohol, cocaine, Oxycontin, etc.) to achieve the same effect formerly achieved with smaller amounts. Most people develop some level of tolerance to alcohol, but alcoholics usually can “hold their liquor” to a much greater extent – they are often proud of that fact, but ironically it is indicative of a problem, or a potential problem.
· Loss of Control: Once the person begins drinking or drugging (often after reaching a certain point, say the 2nd or 3rd drink), s/he can no longer reliably limit or regulate how much will be consumed, and will in many cases continue to intoxication, or beyond that until reaching the point of passing out, running out, or being kicked out. Many people try to prove that they can control their drinking (or drugging), and quite often they can do so for a period of time – by paying a lot of attention to it, just as you might be able to hold in your stomach while walking along a crowded beach. But this is quite different from normal drinking, in which the person, without much thought or attention, reaches a point of satiety (i.e., had enough, no desire for more). Eventually, one relaxes and does what comes naturally – for the alcoholic or addict, that will generally mean reverting to loss of control. Loss of control is what’s behind the fact that most alcoholics have tried, repeatedly, to cut down; if it were simply a matter of choosing to change behavior, it wouldn’t be trying so much as just doing it. Note that this term does not refer to losing control of one’s life or behavior per se, just of one’s consumption of the substance.
· Withdrawal Symptoms: Although many alcoholics never get significant withdrawal symptoms, for those who do it becomes difficult to deny the addiction. At one time, withdrawal symptoms were seen as a key defining characteristic, but that is no longer the case. Some withdrawal symptoms (such as shakes or DTs for alcoholics, seizures for alcoholics or those addicted to tranquilizers, flu-like symptoms for opiate addicts) are readily observable and call for medical detoxification, while others are likely occurring at an unobservable, more cellular level. The essence of withdrawal symptoms is this: Your brain has become accustomed to regularly incoming chemicals that push it in one direction or another (e.g., stimulants up, alcohol down, marijuana maybe sideways), and has adapted by compensating, finding neuro-chemical ways to push back. Suddenly, the when the substance is removed (the person stops drinking or drugging, either out of a decision or because no supply is available), the push-back sends the nervous system out of kilter. Some withdrawal symptoms, such as seizures, can actually be fatal, which is why medical detox is the safest way to go. In detoxification, the individual is given either the same substance to which s/he is addicted or another substance that is similar enough to “fool” the brain (e.g., tranquilizers are used to substitute for alcohol, since they are actually quite similar in their mechanism of effect on the brain), and then the dosage is gradually tapered off, usually over a period of days (though some detoxifications can go on much longer).
· Centrality of Substance Use and Psychological Dependence: For the “normal” drinker or drug user, drinking or using is an optional activity, whether its purpose is to relax or make socializing easier, or even to provide a temporary escape or relief from stress. For the alcoholic/addict, thoughts of using (“I’ll be able to have some at 5 o’clock when I leave the office) and plans about using (“When we drive to Newport, I’ll keep a stash in the trunk, and then I know where I can get some once we’re there;” “My dealer is missing in action; where else can I get some?”), take up a lot of mental space. Alcohol and drug use (not to mention hangovers, fatigue, and other after-effects) become a central activity and concern, often pushing other interests, activities, and relationships out of the way. Some people get to the point of having no idea how they would cope with various situations if their substance were unavailable.
· Negative Consequences: Even with all the above, the diagnostic criteria are not fulfilled unless substance use results in recurrent, predictable negative consequences – and yet the individual continues to use. These consequences may be social (e.g., inappropriate/embarrassing behavior), legal (most commonly a drunk driving arrest), medical (e.g., signs of damage to the liver or esophagus from alcohol, holes in the nasal septum from cocaine snorting, contracting hepatitis from heroin needles), vocational (e.g., job loss or probation), psychological (e.g., increased depression from drinking, psychotic symptoms triggered by THC), relational (e.g., marriage on the rocks, friends alienated), etc. Quite often, the addict/alcoholic does not recognize that these developments are actually a result of drug/alcohol consumption, pointing the finger instead at others (“With my wife….,” “The cops need to fill a quota of DUI arrests,” “Of course I’m depressed with parents like these,” “My boss is a jerk who only likes people who kiss his ass.”
One additional note for those who wonder, “I’ve been taking a medication [such as a tranquilizer] for years, and my understanding is that it would be dangerous for me to abruptly stop taking it – am I not addicted?” This is where the terminology gets very confusing. You might consider yourself addicted to your medication in the sense that you would probably experience withdrawal symptoms (even dangerous ones) if you discontinued it without a gradual taper. But if you never developed much tolerance (i.e., it works for you at the same dosage it did years ago), experience no significant negative consequences or loss of control, you are probably not addicted in the behavioral sense. Obviously, if you have needed more and more of the medication and repeatedly exceeded the prescribed dosage, for example obtaining extra from friends or “doctor shopping,” you probably do have an addiction for which it would be wise to get help.
Ultimately, what matters most is not whether someone else thinks someone has developed alcoholism or addiction, but at what point the individual in question reaches that conclusion, because no one can implant a commitment to recovery in someone else. (That is not to say that one has no influence – much more on that another time.)
