What is the definition of addiction
Is addiction a choice or are addicted people victims of circumstance?
Episode 6 is the first part of a series about addiction. This episode looks at the definition of addiction and the components of addiction according to generally recognized authorities like the American Society of Addiction Medicine. It also begins to address the question of whether or not addiction is a choice or a disease with a medical basis.
In this Podcast:
- Three main sources of reputable information (links below)
- The five main components of addiction which are: inability to consistently abstain, impairment in behavioral control, cravings, decreased ability to recognize problems and dysfunctional emotional response.
- The above five features are qualities that will be present if there is an addiction
- Beginning assertion that addiction is not a choice. That a person says “yes” to feeling good and did not intend on saying yes to addiction.
- Addicted people are responsible for what they do while they are using. Addiction does not have to be a choice in order for people to be responsible for their actions.
- The brain science shows us that addiction is a biological problem
National Institute on Drug Abuse (NIDA) https://www.drugabuse.gov/
Substance Abuse Mental Health Services Administration (SAMHSA) https://www.samhsa.gov/
American Society of Addiction Medicine (ASAM) https://www.asam.org/
American Psychiatric Association https://www.psychiatry.org/
Alcoholics Anonymous https://www.aa.org/
Free Treatment Planning Tool www.betsybyler.com/treatmenttool
You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler, and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and confidence needed to add substance use to their scope of practice.
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Doing therapy is hard work. Made harder when addiction is thrown into the mix. Many of us didn’t get the training we needed to deal with substance use and finding the knowledge that you need to fill that gap can be difficult. Each episode, I’ll bring you information on substance abuse, topics that impact our work, helping you gain knowledge and confidence. In a relatable and practical way. So join me each week as we talk about All Things Substance.
Over the next few weeks, we’re going to be talking about addiction. It’s a really broad topic and so I’m going to break it down into a few components. First, the definitions of addiction. Next we’ll talk about the risk factors for addiction, the genetics, the brain science, environmental factors, and protective factors. Today, though, we’re going to start at the very beginning.
I want to let you know where to find really good, accurate information. When you do searches online, it can be really hard to find things and know “is this the right information?” “Are these people quoting things that are actually accurate?” There’s a lot of rhetoric on the internet, both prodrugs and anti-drugs. And for our purposes, we just want to know the facts. So the two best websites that I can recommend are the SAMHSA website and the NIDA website, which is the National Institute on Drug Abuse.
So SAMHSA stands for the Substance Abuse Mental Health Services Administration. It’s a branch of the US Department of Health and Human Services. Now this website is intense. It has so much information that it can be hard to move around sometimes. But it’s worth the look. There’s some really good information there. You want stats and figures, they have that. You want to find out about evidence based practices for treatment. You want to find out about training, want to find some treatment? You want literature? SAMHSA is sort of the gold standard. And if something says that it’s SAMHSA approved, you can pretty much guarantee that that’s about the most accurate information that we have.
So NIDA, the National Institute on Drug Abuse is a federal agency supporting scientific research on drug use and the consequences. They have some really good resources, too. They have clinical resources, drug topics, trainings, that kind of thing. So when it comes to addiction, the American Society of Addiction Medicine, or ASAM, is also another website and another source of information. It’s going to be more from a medical perspective, but it’s a pretty important organization because what they do is they’re going to say this works for addiction. This is what’s medically supported. And I do believe that medications can be helpful in helping someone overcome addiction.
Just a side note for each podcast, there will be show notes on the website at betsybyler.com/podcast. The show notes will have links that I’ve mentioned or links that I use to write this podcast, any downloads and a transcript of the podcast. So if you miss something or if you want to see something written out, that’s the place to go. Back to today’s topic.
So addiction is defined in a number of different places. The definition of addiction changes a little bit, depending on who you ask, but there’s some pretty standard words that are used when it’s coming to addiction. So for the American Psychiatric Association, it’s a complex condition, a brain disease, that is manifested by compulsive substance use, despite harmful consequences.
When people talk about addiction, they almost start talking about the reward pathways and yeah, that’s absolutely really important for addiction. But it’s not the only thing; it’s more than just the neurochemistry of reward. There are lots of things that we do that use the reward pathway that don’t end up becoming addictions. So the difference lies in that addiction literally changes the brain and the way it functions.
Addiction takes the natural structures of the brain and hijacks them, leaving them changed. The changed brain circuitry effects motivational hierarchies and supplants health-related behaviors with addictive behaviors. We see this in our clients who are using all the time. They don’t prioritize basic healthy behaviors. And the addiction related behaviors become more and more prevalent the further they go.
So ASAM, that’s the American Society of Addiction Medicine, and they talk about five main things that are characteristics of addiction. And I think they’re right on.
So first the inability to consistently abstain. What we’re talking about here, isn’t that they have to use every day or that they’re unable to control any aspect of it, but that they’re unable to consistently do that. They’re unable to consistently abstain from using their substance. And so they’ll get a few days pulled together and then they’ll use again.
They might even, for some people, get a few months pulled together, but what happens is over time as addiction progresses, those periods of control using are fewer and farther between, and they keep trying to get back to how they used to be. And they used to be able to go to the bar, have a few drinks and go home. They used to be able to use this substance and keep it contained to weekends, that kind of thing. But the hallmark of addiction is that they don’t have the ability to consistently abstain.
The second thing is impairment in behavioral control. So when someone’s using in the beginning stages, they’re not addicted. And they can pretty much control their behavior and things aren’t getting out of control. That’s kind of the point. Most people who are using alcohol are not alcoholics. Most people who are smoking weed, they’re not addicts either. And so what we’re talking about is that by the time someone reaches addiction is that their behavioral control is not in a good place. They are having more and more trouble containing their use and keeping their behavior within societal norm. This starts bleeding over into other parts of their life, like at work or at home or at school or in relationships and they’re not able to contain it anymore.
The stage between being able to contain your use and not being able to contain your use isn’t really clear. It’s a transition and it happens over time. And so it can be harder to tell where that line is. Oftentimes later on when they’re in recovery, they are able to look back and see, this was the time period where things started going sideways. They can see that that’s when things really transitioned for them, but there is no moment where they feel the flip of the switch.
So the third characteristic are cravings. This is more than a desire. This is more than someone who loves chocolate being like, “Oh, I could really use some chocolate right now”. Or someone was drinking like, “Oh, I could really use a drink right now”. This is intense. This is the thing that’s gonna make you leave your house, at night in your pajamas, when you’re sick, doesn’t matter. That will push you to go and get whatever it is that you need. The craving is like a gnawing, ever present, growing noise that you feel all over. And it creates this restlessness and you feel like you’re going to crawl out of your skin. This is a craving.
Nobody wants to admit that they have cravings. And for addicts and alcoholics, this is something that’s hard for them even when they’re in recovery, they feel like it’s a failure to have cravings, even though it’s super normal. Addicts and alcoholics will even have using dreams. So when they’re trying to get sober, one of the things they don’t count on is that they’re going to have dreams where they’re using. You might be doing a great job staying away from your substance, but your brain wants to use. And in the background it’s processing that just like everything else we try to not think about. So while they’re sleeping, they’ll have these dreams and they’re incredibly real. And sometimes they wake up feeling like, “Oh my God, I just ruined everything”. Or it makes it so much worse because now they remember this visceral feeling that they used to get.
These cravings are part of addiction and they are the hardest part for people to accept a lot of times. Because they feel like it dooms them somehow, or it means that they somehow are animals or something; that they can’t control their base urges. When really the brain is incredibly powerful. And because of the changes that are made in the brain while someone’s using.
These cravings, they’re going to be there and they’re going to be intense. Thankfully they don’t last forever. And that in recovery, the promise is that if you remove the substance that causes craving that the cravings will disappear. And they do. There’s no timeframe for that though and so the interim can be really hard.
The fourth thing about addiction is the decreased ability to recognize problems. I remember working with a guy who had five DWI’s. He was convinced that he didn’t have a drinking problem. He had a driving problem. He went through all of treatment. This was like 12 weeks, three nights a week I think. And by the end of it, he still was adamant that there was nothing wrong with his drinking.
And that he would just not drive and that everything would be fine. And it was so dumbfounding. Normally what happens is that when someone’s in that place where they’re going to be in that level of denial, for lack of a better word, they usually drop out of treatment. They don’t usually stick around. Now, this guy had to stick around because he was on probation, but a lot of times that’s not even enough. And typically if they stay, they do change. They do start to get honest about what happens. and when things started to get out of control. Not this guy. And my hunch is that when he did start considering it, the reality of not being able to drink in his lifestyle with his family and friends was too much. And so it was not an option for him. He decided I don’t have a drinking problem. And the ability for people who are using to ignore problems is astounding.
They can ignore physical problems. They can ignore veins collapsing, they can ignore teeth falling out. They can ignore lost relationships and jobs that they’ve been fired from and debt all over. They can ignore those things and just say that they’ve had bad luck or they have bad genes or some other kind of thing. And it is really weird to listen to someone talk and hear the things that they’re able to explain away. This is a function of addiction.
And it can be really hard as a therapist because we’re listening to them and we’re like, Oh, okay. Um, they’re missing this. And the thing is you gotta be really sly when you’re working with them. Because if you come at them, head on about this problem, it is not going to go well. Everything in them is going to resist and you won’t get anywhere. It’s this way that we have that we all practice all the time of walking beside someone and being like, huh? I wonder what it would be like if this wasn’t there. And we see this in a lot of clients and indeed in people who have issues in their lives that they’re just not willing to face yet, and it’s not addiction. And so it’s not just that they can’t recognize problems it’s that they can’t recognize problems in the context of all of these other five things.
So the last one is a dysfunctional, emotional response. So up until now, I think probably nothing has really stood out as being brand new information. Right. We know that people who are addicted can’t control their use. We know that their behavior gets out of hand. We know that they’re going to want to use and have cravings. We know that they don’t recognize their problems. So that’s all pretty standard. So this last one, I don’t love the phrase because I feel like it doesn’t really explain what it is. And sometimes I feel like when we’re using professional language, it’s just words and it doesn’t really mean much. And so I struggle with this and I spent a long time reading about it and trying to discern what people were saying and what they were suggesting here. And I got it, but I want to explain it in a different way that I think is more accessible.
So imagine that there is a bush and it’s got pretty flowers on it and it’s full of bees. So there’s bees flying around all over because the pretty flowers are drawing all the bees to the yard. And a person wants to smell the flowers. Each time they get close to the bush, they keep getting stung. Well, an average response would be stay away from that bush. For an addict or an alcoholic that doesn’t occur to them. What occurs to them is to try again, to try a different angle and to keep going back over and over and over, even though they’re getting hurt, even though they’re getting stung, it doesn’t matter. And this isn’t that they’re not intelligent or that they can’t see cause and effect. It is a function of addiction. That they just have this opposite response to what an average response would be.
So remember earlier, when I talked about the fact that the brain functions change and they supplant healthy behaviors with addictive behaviors. And so literally what’s happening in the brain is that self preservation goes way down. And they’re not thinking about how to take care of themselves. They’re not thinking about how to make sure that they’re staying safe. That is not what’s driving them. They have to get the substance, whatever it is. Now in the beginning stages and even in the middle stages, what they’re willing to do to get that isn’t as severe. They don’t cross lines from the beginning. It’s not like they’re right out the gate stealing and lying and wrecking lives and that kind of thing. This takes time. But it’s this continued dysfunction in their responses that drives the addiction forward.
So when you’ve had too much to drink you stop. When you’ve had too much to eat you stop. For an addict their stop meter is broken and they just keep going. I remember one of the first times I ever saw this in person. I went to Michigan state for my undergrad, and it’s a huge party school. There were these guys that we were friends with and they had a house off campus. And so they were having a party and we went over there. I wasn’t drinking and so I was just chilling and kind of watching everybody. One of the guys had a history of getting super drunk and I had heard that he was drinking during the week and that people were a little worried about him. And he ended up throwing up in the middle of the living room in front of everyone. And as soon as he was done he wiped his mouth and grabbed a bottle of Jack Daniels and I watched him proceed to chug it. That is not a normal response.
That’s an exaggerated example, although it’s a true example, of the dysfunctional emotional response, but that is what happens to addicts and alcoholics all the time. It’s not just that they don’t see the problems that things are causing. It’s that their reaction to those problems isn’t just to ignore them, but to push into the substance use.
So Alcoholics Anonymous, when it was first founded, they wrote something that we call the Big Book. And in the Big Book, it suggests that addiction is something they call the ‘allergy of the body and the obsession of the mind’. And the idea that there’s an allergy was something that was new, not scientifically proven yet, but really compelling. Because what they were noticing is that their response to alcohol was really different from people who weren’t alcoholics. In AA circles, they call those people “normies” or the “normal people”, people who don’t have alcoholism. And what they recognized is that when they drink they want more. That is the reaction that their body it’s like it found the thing it was looking for. And instead of being able to moderate, it becomes that one is too many and a thousand is never enough. And so I see that in this dysfunctional emotional response, and I think it is a huge part of what sets addiction apart from compulsions.
So there is the compulsive aspect to it. In the beginning of someone using it’s more impulsive, but by the end, it is definitely compulsive. But there are some changes in the brain that make it really different. So it’s different from a compulsion. Let’s talk about self-injurious behavior in the form of cutting. We know that when someone’s cutting that in the beginning, their cuts are usually pretty shallow. They are smaller. They’re not really as intentional, but as they get more used to cutting the cuts become more substantial and they will also start hiding them. If you’ve ever worked with someone who has significant cutting behaviors, it can be really severe. This isn’t just a small scratches on someone’s forearm. They cut under their clothing. They’ll do it on their legs, on their stomach, underneath underwear, that kind of thing. And the cuts can get really bad, needing stitches even, and this tends to be something that they have a really hard time stopping. They’re doing it not even when they’re necessarily dysregulated, but the act of refraining from cutting is what’s dysregulating them. Now, some people might see cutting as an addiction. And indeed there are some similarities. I don’t believe that we have the research to back that up though.
I believe that in order to treat addiction effectively, that this has to be answered in your own mind, whether or not it’s a choice that this person is an addict or an alcoholic. Because there is a lot that goes into working with someone and this will keep coming up over and over. My belief is that it is not a choice. I believe that it is a brain disease, a medical illness that this person did not choose to have. This is not to say that they are not responsible for their choices. Yes. The person chose to use. And they were choosing the high, the pleasure that they got from the substance, they weren’t saying yes to addiction.
So let’s talk about choice for a minute. For a long time, addiction was seen as a moral failing, being self centered and not caring about others or even themselves. There’s been some work done on breaking that stigma. But I think in many people’s hearts, they still feel like it is a choice. So when talking about an addict or an alcoholic in their life and the difficult things that they’re facing and how hard it is for them to stay sober, inevitably somebody says, but it was still their choice. And what I am arguing was it really wasn’t. Their choice was to use substances. And as humans we’ve used substances all along, ever since there were humans. In every tribe and every country, it doesn’t matter. We figure out a way to celebrate or escape by using some kind of mood altering substance. Could be chewing on Coca leaves, could be fermented drinks, whatever it is. This person was using substances like other people around them. What they didn’t know was that what they were going to end up with was addiction. They were saying yes to the experience of using a substance. They weren’t saying yes to the addiction.
And I know that this can be a really hard thing because when you’re faced with someone who is an addict or an alcoholic in your life, they wreak havoc everywhere. And it is super hard to continue to have compassion for them when they’re doing terrible things and hurting people. And I think that’s what keeps people from accepting that this isn’t a choice they made, because the people around them are so hurt that they have to be able to have the person have responsibility for their actions. The person is responsible for their behavior.
Any good recovery program has the addict or the alcoholic takingresponsiblity for the choices they made while they were using. They’re not taking responsibility for becoming addicted. They’re taking responsibility for the things they did while they were using that harmed themselves or others. In no way do I think that we should give addicts and alcohol a free pass when it comes to the things that they did while they were using, I don’t believe we need to heap shame on them either, but I believe that they should be able to accept responsibility and they have to, in order to stay sober. Part of getting sober is being able to be honest about the way that the substance affected you and what things it caused in your life, all around you. Whether it was you or whether it was someone else.
This is where our ability to hold two seemingly opposite things true at the same time. And we as therapists, we do a great job of that. And we talk about this a lot in therapy. For instance, you can love someone and not subject yourself to them if they’re going to be hurtful. You can be angry with someone; more angry than you’ve ever been and you can feel badly for them when they’re going through a hard time. We are capable of holding those two things true. It just takes a shift in our thinking and I think that’s something that we are able to help our clients do all the time.
As I thought about what to tell you about addiction, there are so many things that I was thinking about. It can be hard to narrow it down. And the thing that I came to was: addiction isn’t a choice. I think that’s part of why the stigma stays around so long. Is that the devastation that addicts and alcoholics have in their wake demands that somebody answer for it. I think we have to start with addiction and whether or not it’s a choice because it changes what we do as we move forward in treatment. If it is their choice, then we’re dealing with some pretty antisocial people who continually hurt the people they love and must not have the capacity to love people more than themselves. And that just isn’t true.
I’ve spent a lot of time leading treatment groups. And over and over the clients talk about the things that they did to their family, to their kids, to their friends, to their partners with great remorse. And they express the same kind of incredulity about their actions that someone on the outside. They don’t understand why they can’t just stop. And it grieves them in a way that I think people don’t see, unless they’re the ones involved in treatment with an addict or an alcoholic. Oftentimes these people have promised up and down sworn on everything that is holy, that they’re going to quit and they just can’t. So either we have really antisocial people or there’s something else going on. It’s this something else that I think is vital that we understand. And so we have to look for another solution. And for me, the answer lies in the science. The things that we know about the brain when it becomes addicted to a substance are pretty profound. I’m going to be going through that in another podcast, because it’s pretty in depth and I don’t know that any of us were science majors. And so I’m going to break it down in a way that I think will be helpful. And that I think we’ll answer a few questions about why people continually make the choices they make.
If you’re ready to take the next step in addressing your client’s substance use head on over to betsybyler.com/treatment tool. The treatment planning tool I created will help walk you through the process of evaluating your clients use and deciding how and when to intervene. The tool is completely free and will be delivered to your email so that you can use it right away.
Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist, friends, and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to firstname.lastname@example.org. I’ll see you on next week’s podcast and until then have a great week.
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