Who is an "Addict"?
One of the main questions people have when they come to therapy for substance use concerns (be it their own use or a loved one’s) is – “Am I an ‘addict’ or ‘alcoholic?’” Whether or not the person qualifies for this label takes up a great deal of headspace; so much seems to be at stake in the answer. If they are, it means one thing; if they aren’t, it means quite another. Our beliefs about what it means to have an addiction color our perception of this question, from assumptions about personality characteristics and morals to treatment options and hopes for change. In my experience, this black-and-white, either/or way of looking at substance use is not helpful at all. People generally resist being reduced to a label, and the label really doesn’t do much to help us figure out what to do about the problem. The good news is that we don’t have to see substance use problems this way.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) contains lists of symptoms and categories for hundreds of different disorders, including substance use disorders (SUD). Nowhere in this book will you find “addict” or “alcoholic” as classifications. Instead, the DSM conceptualizes substance use disorders along a continuum from mild to moderate to severe. This is determined by how many of the 11 different SUD symptoms a person has experienced over the past 12 months. This applies to different substances, like alcohol, opioids, and cocaine, which means that a person can have more than one substance use disorder. Below, I’ll review the symptoms and describe examples of how they might look in daily life.
Disclaimer: Reading a blog post (mine or anyone else’s) is not a substitute for an actual clinical assessment with a licensed mental health professional. This post is intended to be purely informational and should not be taken as formal therapy services or used to diagnose anyone.
The DSM-5 (the fifth edition of the book, published in 2013) defines a substance use disorder as “a cluster of cognitive (thinking), behavioral (doing), and physiological (brain and body) symptoms indicating that the individual continues using the substance despite significant substance-related problems.” The manual also tells us that SUDs can involve long lasting changes in the way people’s brains work, and that relapse or recurrence of use is common. These descriptions and the diagnostic criteria outlined below are shaped by groups of experts who look to research and clinical experience to define what it means to have a substance use disorder. The 11 symptoms that make up SUDs are organized into four categories: Impaired control; social impairment; risky use; and pharmacological changes.
Here, the DSM describes problems people begin to have managing their substance use behaviors. One of the hallmarks of addiction is the inability to stop despite significant consequences. Does the person initially plan to have two drinks, but ends up having the whole bottle? Does he try to have a few lines of cocaine at a party, but spends the whole weekend bingeing? These point to the first symptom, which is that the substance is taken in larger amounts or for a longer period of time than the person initially wanted. Related to this, the person might begin to recognize that there is a problem and try to control their use, but find that they are unable to do so. People with SUDs often have many of these failed attempts to cut down or stop over the years. Another component of impaired control is that the person’s life becomes dominated by the substance, whether it’s time spent getting it, using it, or recovering from its effects. If we imagine our daily life as a pie chart, more and more of the space is taken up by something having to do with substances. Finally, because of changes in the brain’s neutral pathways, people who have used a substance over time begin to experience strong cravings, particularly when they see something associated with that substance. This could be an advertisement, paraphernalia, or even a person or place. While all of the other SUD symptoms disappear as a person enters recovery, cravings can last for many more years – or even a lifetime – because substances produce such a strong reaction in the brain.
The next set of symptoms fall into how the substance use impacts a person’s life. When we think of what constitutes a “normal” or “healthy” life, it is often based on the person’s ability to be flexible and capable in managing different demands at work, in school, and in our personal lives at home. According to the DSM-5 diagnostic criteria, a substance use disorder frequently means the person is failing to fulfill their obligations in these areas. As substance use becomes predominant in life, people drop the ball and sacrifice their other roles. This might look like chronic absenteeism at work, forgetting to pick the kids up from school, or failing a class – all because of something related to substance use. Another symptom in this category is continuing to use despite these social problems. Like impaired control, the person knows that he or she is having problems in these areas due to use, but continues to use anyway. Finally, as life becomes more centered around using, the person gives up or reduces time spent in important social, occupational, or recreational activities. Did he used to like playing guitar but hasn’t picked it up in months? Is she always cancelling lunches with friends?
Substance use often involves some element of risk. This might be because of the nature of the substance itself, such as an opioid with high overdose potential. Or it might be because many substances are illegal and therefore lead people to use in unsafe areas and situations. As outlined earlier, substance use impairs a person’s ability to make sound decisions and exert self-control; behaviors like driving under the influence is a common example of this. Another type of risky use pertains to using despite known psychological or health problems. For example, a person with depression knows that alcohol makes her feel worse in the long-term, yet she drinks anyway; or someone with a heart problem continues to use cocaine even though he knows it could lead to a heart attack. In risky use, we see that the person is losing control.
The final two symptoms of substance use disorder in the DSM are categorized according to changes in how the brain and body respond to the presence or absence of the substance. Our bodies are sensitive systems that adapt to changes, especially the extreme highs and lows caused by various substances. As a person exposes his or her brain and body to a substance repeatedly over time, the body tries to achieve balance by over-adjusting and negating the effect. This is the phenomenon of tolerance: the person needs to use more of the substance to achieve the same effect they experienced before. For example, he now needs a whole six-pack to feel buzzed when it used to take only two beers, or she needs heroin just to feel normal when it used to make her feel high. The last SUD symptom, withdrawal, is the opposite side of this coin: the body has grown accustomed to the presence of the substance, so it goes haywire when the substance is taken away. This pendulum effect produces the opposite of whatever the substance did; withdrawing from downers leads to anxiety and agitation, while withdrawing from uppers leads to lethargy and depression.
Is There Such a Thing as an “Addict”?
So this is how clinicians determine whether or not a person has a substance use disorder. By carefully reviewing the details of their relationship with substances, the problem (or absence of one) comes into view. This includes how severe (or mild) the problem is right now. As stated earlier, people can have more than one substance use disorder at different points along the severity continuum. This might mean that John has a severe cocaine use disorder with 8 out of the 11 symptoms, but has a moderate alcohol use disorder with only 4 symptoms. The problem with the black-and-white, either/or choice between “addict” or “normal” is that we lose the subtle nuances that make each individual unique. Effective treatment for substance problems needs to be individualized and specific to the person, without any predetermined course of action. By opening our understanding of substance use problems to this continuum model, treatment, including therapy or counseling, can better help a person understand his or her substance use as well as ways to change it.