Riverview Psychiatric Center

Psychology Articles by Dr. Arthur Dingley - Substance Abuse and Addition

Dr. Art Dingley

Humans have a long and complicated history of using substances to change the way they feel. Ethanol (alcohol) is probably the oldest and most widely used, though caffeine, cocoa, cannabis, and opiates have also been used since antiquity. The consequences of using mind-altering chemicals are determined, in large part, by the reasons for their use, as well as the amount consumed and the frequency of use. For example, cultures which have used hallucinogenic plants for religious ceremonies over many centuries do not develop problems with abuse and addiction. Even substances with great potential for addiction do not become problematic when used in a structured social context in moderate amounts. At the same time, it has always been clear that over-use of mind-altering substances creates serious problems. (Look no further than the Old Testament for examples of both.) So how can we reliably distinguish between the use and abuse of drugs and alcohol?

When a person takes a drug, or drinks alcohol, on a repeat basis, he is abusing that substance if any of the following things are taking place. First, recurrent substance use may result in failure to meet obligations, such as attending school, getting to work, doing housework, keeping appointments, caring for children, or paying the bills. Second, a person may put herself or others at risk by operating a vehicle (including snow machines and ATVs), swimming, climbing, diving, using power equipment, and so forth, while under the influence of a substance. Third, a person may have recurrent legal problems from drugging or drinking, including arrests for drug possession, for fighting, threatening, stealing, disturbing the peace, trespassing, violating probation, or damaging property. Fourth, a person may continue to use a drug, or drink alcohol, despite having personal problems which are made worse by intoxication. Personal problems may include things like arguments with family members and co-workers, emotional problems like irritability, depression, and anxiety, or serious mental illnesses like bipolar disorders and schizophrenia. Anyone whose use of a substance falls into any of these categories is a substance abuser.

In addition to use and abuse of substances, people may develop substance dependence. A person who has become dependent on a drug continues to use it despite significant problems. Since that is one criterion for substance abuse, we can say that every drug dependent person was first a user, then became an abuser, before progressing to dependence, or addiction. Beyond continued use in the face of mounting problems, drug or alcohol dependence requires at least three of the following difficulties: Tolerance often develops. The effect of the drug diminishes and the user must take more to achieve the same effect. Withdrawal symptoms occur when the drug is not taken soon enough, or the drug is taken expressly to prevent withdrawal symptoms. People who are dependent may set out to use a reasonable amount of a substance, or use it for a limited time. However, they end up using much more of it than they originally intended. When a person is substance-dependent, she spends a good deal of time finding and using the substance and a good deal of time recovering from its effects. Dependence on drugs or alcohol often results in giving up other activities. A person who has substance dependence will often continue using despite knowing that it is causing physical or psychological problems. Finally, people who are substance dependent are forever working on “cutting down” or controlling their use. In fact, making frequent unsuccessful attempts to cut down is one of the most reliable indicators of addiction.

How do people recover from substance abuse and dependence? The plain fact is that most people who recover from these disorders just say, “enough is enough”, and stop. A sizeable number of people, however, can’t do this. It may be that some people’s brain chemistry predisposes them to abuse or dependence. There does appear to be a genetic component to alcohol dependence, for example.

No one gets into recovery without first recognizing that he has a problem. The ways in which people avoid facing facts are endless. The less sophisticated end of the spectrum makes it onto tee shirts (“I don’t have a drinking problem. I drink. I get drunk. I fall down. No problem”) or into R&B songs (“If You Don’t Start Drinking, I’m Going to Leave”). Har har. The more sophisticated end of the excuse range includes the idea of “self-medicating my (insert random psychiatric diagnosis here)”, as though drinking or drugging were really just a well-intentioned, but homemade, method of treating mental illness. Please.

People who are dependent on a drug, or alcohol, may need to begin with medical treatment (often referred to as “detox”) in order to avoid seizures, delirium, or physical illness during the first few days without the substance. Detox is usually not necessary for substance abuse. After detox, someone who has been using heavily, or relapsing repeatedly, might want to consider enrolling in a residential recovery program. These provide intensive support, supervision, and treatment in a group home setting. These programs usually last from six months to one year. Another option after detox is an IOP, or Intensive Outpatient Program. These are typically run by hospitals and provide outpatient treatment 5 days per week.

One very popular form of treatment for substance abuse or dependence is Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). These are a network of supportive self-help groups organized around a set of guiding principles, most notably the 12 steps to recovery. Participants begin by attending meetings (sometimes daily), listening to the discussion, and admitting, first, that they are powerless over alcohol or drugs. 12-step recovery is abstinence-based. The goal is total sobriety. One drink wipes out years of sobriety. There is some controversy about whether total sobriety is the only reasonable treatment goal. Some other recovery programs aim to teach people how to drink in moderation. These “harm reduction” models, such as Motivational Interviewing, seek to prevent, or at least reduce, substance use by educating users to increase their willingness to quit. Many heavy drinkers, for example, believe that they are not drinking excessively because they have no idea how much other people drink. I have patients who drink a case of beer daily and tell me that their drinking isn’t bad compared to their friends! They are surprised to learn that their alcohol consumption puts them in a tiny fraction of one-percent of the total population. In addition to these forms of treatment, individual substance abuse counseling may be an important part of recovery for people who are engaged in treatments like AA or NA. There are also some medicines which reduce alcohol cravings and reduce the severity of relapse.

Methadone and, more recently, Suboxone treatment for narcotic addiction gained popularity over the past decade. These treatments, which substitute less abusable opiates for drugs like heroin, have proponents and detractors. So far as I can tell, both sides are correct to some extent. In the balance, however, it is fair to say that these treatments are hugely helpful to many people.

I’d like to thank the many people who have gone out of their way to tell me that they’ve enjoyed my column. This concludes my series of articles on mental health topics. I would like to invite readers to write me, however, with questions about mental health and psychiatry. You may have questions about certain medicines, diagnoses, or forms of treatment, for example, that weren’t covered in my series, or were covered too generally to be useful to you. I will use your letters, or emails, when I respond to them in the Franklin Journal, but won’t use your name unless you specifically tell me it’s OK. You can contact me through the Journal or at the email address below.

Dr. Dingley is a psychiatrist at Evergreen Behavioral Services in Farmington. He may be contacted at adingley@fchn.org.

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Psychology Articles by Dr. Arthur Dingley - Substance Abuse and Addition