Episode 11

  • What are effects of substance abuse?

  • What does progression mean when talking about addiction?

  • How does progression relate to the DSM criteria?

  • What addiction criteria shows up most often?

Progression is the key to addiction. It’s not about choice or willpower. It’s a biologically based occurrence that is a guarantee in addiction. Progression moves people along the stages of use into addiction, unless they are able to stop using before things move too far. 

In this Podcast: 

  • Progression is the key factor in developing an addiction
  • Progression happens because of the changes in the brain that we covered in episode 7
  • For some people the consequences they face because of substance abuse is enough to stop them and progression can be halted
  • People don’t tend to call for their substance use issues. Instead they tend to start with mental health and may or may not bring up their use to their therapist.
  • The DSM criteria use the designation of mild, moderate and severe to categorize use disorders
  • Tolerance is the most common criteria people present with
  • Cravings tend to be one of the harder criteria for people to meet
  • Withdrawal is almost always related to a severe use disorder, except where the substance is marijuana. Then withdrawal could appear in a moderate use disorder.
  • Our goals change depending on what the client wants to work on and where they are in the progression of their use. 

Helpful Links:

Chapter 2 The Neurobiology of Substance Use, Misuse, and Addiction, The Surgeon General’s Report on Alcohol, Drugs, and Health  https://addiction.surgeongeneral.gov/sites/default/files/chapter-2-neurobiology.pdf

Drug addiction (substance use disorder) – Symptoms and causes – Mayo Clinic https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112

Disease Stages https://www.asam.org/docs/default-document-library/nccbh-infographic.pdf?sfvrsn=dfe787ab_0

Chapter 3 Prevention Programs and Policies, The Surgeon General’s Report on Alcohol, Drugs, and Health https://addiction.surgeongeneral.gov/sites/default/files/chapter-3-prevention.pdf

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. 

I take topics that are typically aimed at substance abuse counselors and share them with mental health therapists in a way that is relevant and tailored to meet our needs. By adding substance abuse to your scope, you can expand your ability to treat the whole person and better meet your client’s needs. Bringing more hope, healing and freedom to the people you serve.

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.

Welcome back.  Last week, we talked about stages of use. We talked about how people progress through the stages.  Some people move through them quickly and some people spend more time in each stage.  If you haven’t had a chance to listen to that one, go ahead to betsybyler.com/podcast and listen to episode 10. 

The five stages of use were no use, experimentation, misuse, abuse and dependence. Today, we’re going to talk about progression. If you listened to any of these podcasts, you’ve heard me say the phrase progression is a guarantee and it is the key of addiction.  The reason I say that progression is a guarantee is because without progression, there would be no addiction.

Effects of Substance Abuse: Progression

The word progression can mean good things or bad things, depending on the context., You could be making progress on something, moving towards a goal, or you could be progressing towards something that isn’t desirable  In the stages of use we’re less concerned about experimentation and misuse;  we’re concerned about where things move from abuse to dependence. In my experience with clients, most people never think that they’re going to wind up in the dependence category.

Sometimes they can recognize when they’re in the abuse category, but I find it really rare that people can judge their use really accurately the first time they come into treatment. The reason this matters is that most people are able to identify depression, anxiety, and they end up showing up in therapy.

People find it so much easier to talk about their mental health rather than their substance use. The chances that you’re going to find someone in your office, who’s never been to treatment before, but has a pretty significant substance use problem that’s pretty high. And we as therapists need to be assessing and then be able to address substance use. There are lots of ways that people come to terms with their substance use and one of those ways is when they’re in a therapist office. 

Throughout my career, working with the intake department at various agencies, I’ve gotten a chance to understand  what people say when they call for services. They’ll talk about depression, they’ll talk about anxiety, they might talk about grief .  It’s not very often that people call solely because of their substance use. If they do, it’s usually related to a court situation or because a spouse or a partner or somebody has given them an ultimatum. The majority of people who come through our offices are going to be calling first about their mental health

Over the last podcast episodes, we’ve been breaking down what addiction means, how it happens, what the risk factors are,  protective factors for avoiding addiction, how people move through the stages and now onto progression. 

When people call for services, they contact the intake department and they typically know that this person is not a therapist. And so when they ask, “what would you like to be seen for” they’re going to be fairly vague. Now, once in a while, somebody is going to tell their life story to the intake person. This is usually pretty overwhelming. Thankfully, it’s not everyone.

One of the hardest things in addiction is saying the words “I’m an alcoholic” or “I’m an addict” or “I have a problem with drinking” or “I have a problem with drugs” and saying that to an intake person is probably not what’s going to happen. They’re going to find another reason to come in and then tell themselves that they’re going to tell the therapist when they get there.  Sometimes they do; a lot of times they don’t though, because the urgency is usually gone. 

When it comes to addiction one of the hard parts is getting people into the office really quickly because someone can decide of an evening that this is it, they need help. And they might call the next day and it could be two weeks, three, four before they get in.  By that time, perhaps they don’t think their use is that bad anymore. Over time though, because of progression, we’re going to see their use increase, and it’s something that we’re going to need to be able to address. 

Addiction is a progressive illness, meaning that it gets worse over time. Just like other diseases that are progressive, like cancer,  it will get worse unless it’s arrested somehow.  

As therapists, we’ve heard tons of stories of different people’s lives and one thing we know to be true is that people don’t tell us the whole story right away. There are always exceptions and people who want to share every little bit of their lives right away. In general, though, I have found that clients tend to hold back little pieces until they feel like they can trust us better. 

There’s a short questionnaire that was developed for use in primary care called the CAGE-AID. It consists of four questions.  The questions aren’t meant to diagnose, but to tell you whether or not there might be a  problem.  The acronym they use, CAGE is tied to a specific word in each question. It’s a little odd and I don’t totally get why they did it this way, but it’s a pretty standard measure used across the country. 

The first question:  have you ever felt the need to cut down on your drinking or drug use?  The second  : have people annoyed you by criticizing your drinking or drug use?  The third: have you ever felt guilty about drinking or drug use? And the last one:  have you ever felt you needed a drink or used drugs, first thing in the morning to steady your nerves or to get rid of a hangover.  And then in parentheses,  it says “eye opener”, the E for eye being the E in the word cage.  The patient then answers these questions ” yes” or “no”. 

Anytime someone answers a “yes”, it bears further assessment to see what they meant by that. 

I do think it can be useful as long as we’re following up on all the yeses and that even if all the questions are marked, no, we’re still going to be assessing a little bit to see if someone has some substance use that they’re not willing to talk about yet. 

The DSM IV talked about abuse or dependence such as alcohol abuse or alcohol dependence. In the DSM V we have substance use disorder, mild, moderate, and severe.   We’re going to talk about the criteria and how different criteria typically fall in terms of common, to least common and how that relates to abuse and dependence. 

Here’s the caveat. There are always going to be exceptions and your experience could vary. How I’m describing things is based on my experience, working in my programs and with clients over my career.

In order to diagnose a substance use disorder, there have to be at least two of the criteria met.  Meeting two to three criteria puts the person in the mild use category.  Four or five in the moderate use category and six and over in the severe use category.  

I have found that the most common criteria that’s met is tolerance.  Because tolerance doesn’t necessarily mean there’s an addiction. All addiction has tolerance, but not all tolerance indicates addiction. For instance,  for most people who drink alcohol they have some sort of tolerance built up from the first time they ever drank. 

Now, if you’re drinking once or twice a year, then you’re not going to have much of a tolerance.  These are the people we call lightweights, half a glass of wine, a beer or two, ,and they’re already giggly and tipsy.

For most adults though, they’re able to have a couple drinks before they feel any different. S o tolerance is going to be the most common criteria that people are going to admit to having.  We can develop tolerance to a lot of things. It’s just part of our body’s ability to adapt

The second criteria that comes up most often is: a great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects. This isn’t necessarily about something daily. This is about when they do use there’s planning and preparation that goes into it beforehand. Then there’s the actual using, and then there’s the coming down or recovering from the use. 

The third most common criteria:  Important social occupational or recreational activities given up or reduced because of substance use. I should note that this could also be that important social or recreational activities are built around the substance use as well.

When someone’s use becomes more important in their lives, they start to cut out things that don’t involve that use or people who aren’t using the same amount they are.  This process can be sort of slow. And so it isn’t quite as obvious to people, but it’s definitely one of the more common criteria that I see people meet.

Next, substance is often taken in larger amounts or over a longer period of time than the person intended. This one’s pretty common too. For instance “I’m going to go out, I’m only going to have two drinks and then I’m going to go home” and then they ended up having four or five, six, whichever.  Or they’re only going to use this much of something, or they’re only gonna spend this amount  and then it ends up being more. And that this happens on more than one occasion. This isn’t about trying to cut back. This is just about setting a limit on how much they’re going to use. We’ll talk about cutting back in a different criteria. 

Next, persistent attempts or one or more unsuccessful efforts made to cut down or control substance use. This is different than saying you’re going to have just two drinks and having more. This is trying to actively cut back, knowing that you’ve been drinking or using a little too much and the whole point is to cut back.

The distinction between these two criteria can seem kind of thin, but there is a difference. And it’s really the spirit of it. One is about intention and the other is about restriction.

I find that this next criteria is one that is typically kind of hard for people to admit to: craving or strong desire or urge to use the substance. Addiction. I’ve talked about craving in other podcasts and I believe it’s really important because it drives a lot of the progression.  This is due to the brain chemistry and the adaptations that are happening because of the substance use. This has to do with the way the brain changes that we talked about in episode seven.

A lot of times people will think about craving as being stereotypical junkie that is shaking and doing anything for a “fix:” and that’s not what I mean. It’s a feeling restless  this gnawing feeling that you want to do this thing or trying not to use.

There’s a trend that some people follow called dry January. The idea is to give up alcohol for the month. What I’ve read online as I’ve watched people go through this is that it’s the not drinking that gives them the information they need about cravings.

They weren’t aware they were having cravings because they had already planned on drinking or were actively drinking or using a substance often enough that the cravings weren’t really a big deal. Having to abstain and not have them, that’s when they start to notice the craving, 

Next is when people have continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effect of the substance. This could be letting someone down because they were too hung over to do the activity they said they were going to do. 

This could be a ditching, someone in order to stay at the bar . This could be making an embarrassing scene when you’re out with friends.  This could be getting drunk at the work Christmas party,  that kind of thing. 

This is where we’re moving more from moderate into severe; where people’s behavior becomes more outside of their usual norm and they don’t have as much ability to recognize that that’s happening.

The last four criteria I have found typically show up when someone is in a severe use disorder situation. 

Next recurrent substance use resulting in a failure to fulfill major role obligations at work school and home. When someone’s use is becoming severe,  other things tend to drop off that weren’t before .A lot of times you’ll hear someone say, “Oh, they’re a functional alcoholic” and what they mean is they’re still going to work or doing some other major role obligation.  The further addiction progresses that tends to fall off too. 

Next recurrent substance use in situations in which it is physically hazardous. This could be using while driving or being under the influence, operating machinery, going to work, taking care of children, those kinds of things.  the person at this point, because they have a severe use disorder, they’re losing the ability to see the consequences of their actions.

Next   substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem  that is likely to have been caused or exacerbated by the substance. This is typically seen in alcoholics in that they’re starting to have more liver problems, other kinds of issues, and that they’re continuing to drink anyway. In terms of psychological, this could be someone who’s developing psychosis because of their use and they keep using  even though it’s causing a deterioration in their mental health.

The last criteria is withdrawal. Withdrawal as evidenced by the characteristic withdrawal syndrome for the substance, or having to take the same or closely related substance in order to deal with the negative effects from not having the first substance.  

If someone is going into withdrawal from lack of alcohol, that is pretty far down the line and definitely not something that happens in a mild or moderate use disorder. It’s also really dangerous and can absolutely kill them. Alcohol is only one of two withdrawals that are deadly. The other being benzodiazepines.

The only difference here, in my opinion,  is a marijuana. Withdrawal from marijuana is somewhat controversial, which I find a little odd, but it is. Withdrawal from marijuana is actually pretty common and could be there even if someone’s not in a severe use category. They could start experiencing that in the moderate place. 

Withdrawal from marijuana is not severe. It lasts about four days for the first part where you’re having headaches or vivid dreams, kind of cranky, that kind of thing. It takes about a month to make your brain feel clear again.  I’ll tell you anyone who tells you that there’s no withdrawal, it’s because they still use. It’s just that the withdrawal isn’t that bad. Typically though, outside of marijuana,  withdrawal  is a really quick way to tell which end of the spectrum they’re on.

I want to use a case study to talk about progression because I think it will be the most helpful. This isn’t a severe progression story. I think most of us have seen that happen  where somebody goes really quickly through the stages of use and their life becomes a train wreck. The case study I’m going to use isn’t a person where their life is a train wreck yet, but definitely there are signs of progression. 

Marcy is a young 30 year old mother of two. She works, the kids go to school. She’s a good mom. She has some trauma history, which is why she showed up for me to begin with. In the beginning, she was smoking marijuana a few times a week, probably three to four, I would say.

As we moved through therapy and worked on some of her trauma stuff, her use of marijuana decreased to where she was only smoking maybe once or twice a week. It got to the point where she was feeling like she didn’t really need it anymore at all.

There was a time in her life when she was drinking more specifically before she had kids, but some after as well. During the time that she was seeing me, she wasn’t drinking at all; it didn’t really appeal to her.

She was feeling like it just wasn’t going to be a real part of her life anymore. There’s significant addiction in her family and she knew this and wanted to be cautious.  

So then the pandemic hit and lots of different things happened at once. All of a sudden, the kids are home, job is unsteady, money is a problem. Lots of different things popping up at once and it was really difficult. Her use of marijuana increased and her ability to attend therapy was almost non-existent.  At one point we checked in and she had been smoking marijuana probably six or seven times a week, which was a ton more than she had been the last time we had checked in on it.

She knew that her use of marijuana was causing issues for her because money was tight and she was spending money on marijuana and was having contact with a person that she didn’t want to have contact with because she was able to get it cheaper.  This was not a neutral thing in her life.  So she was really wanting to be able to quit.

Well, then tragedy struck. She had a family tragedy  that meant that she was in a deep and dark place emotionally for the first time in kind of a long time. and now her marijuana use is at three or four times a day.  Over this time as well, her use of alcohol started to increase because when you’re smoking marijuana and you’re smoking it often, it stops working. 

Part of the problem with progression is that if you’re using a substance, you can’t just get to a place where, “Oh, I’m good. I get this decent buzz or this decent high at this amount  and I’m going to stay here”. “I’m just going to, this is where I’m going to park it. I’m not going to go any further”. If progression  wasn’t a thing this would work. 

The problem is that moderation doesn’t work with addiction. We always are going to be increasing our tolerance. We’re always going to be ingraining habits.  As we talked about in episode seven, the brain wants a specific level of dopamine release and when it gets used to the amount of substance that you’re using and all of a sudden you’re not getting as much dopamine, as you used to your body is going to push for more.

So nobody gets to just hang out at one spot and just decide “I’m never going to use more than this. This is going to be enough for me”, because what happens is they’re going to get less and less high or less and less effect from the same amount of substance. This is not about willpower. This is not about thrill seeking. This is a biological function. .  There’s only so much dopamine that’s going to get released each time somebody uses and as the brain gets used to that, and as your body builds up a tolerance, you have to use more. That’s just how it is.

Everybody I have met who is an addict or an alcoholic, have a few things true. One, they literally never planned on becoming an addict or an alcoholic. Of course, there’s going to be somebody who is like, “I did it on purpose”. Okay. Fine. The rest of them though, they didn’t plan on it. I guarantee you, they thought ” I’ll pull the plug before it gets bad. I’ll know when to stop. I won’t let it get that bad. I watched my brother, sister, mother, uncle, nephew do this, and I’m not going to make the same mistakes”. And they really mean it. It doesn’t work that way. 

So we have this thing called optimism bias .  One of the landmark studies was done in 1984 and there hasn’t been a ton since, but the idea is that we have this bias, as humans, that makes us think that we’re going to have a more favorable outcome than someone else, without backup for it. So we’re going to be able to use without having the adverse effects of someone else.  We’re going to be able to walk around with a bunch of other people and not get the coronavirus, those kinds of things. It’s part of human nature. and in addiction, it’s a huge problem.

As we’ve talked about with the way the brain functions, how addiction develops, that people have an increased deficit in judging risk and consequence, and that their ability to deny what’s happening gets really powerful. This makes addiction progression the key.

So as we’re walking through this with Marcy,  Marcy is not in the severe category yet. She has definitely moved from a “no use disorder” when she was smoking maybe once or twice a week to a mild use disorder and now we’re in a moderate use disorder edging towards severe.

Now some might disagree with me about a “no use disorder” in marijuana  and if we change out marijuana for alcohol and someone’s drinking once or twice a week  we’re not going to call that a mild use disorder. I’m not going to pathologize smoking marijuana once or twice a week when there are people who can do that and not develop an addiction.

This is not to say that I think that marijuana is beneficial and not a big deal. And we’ll talk about that in a future podcast, I’ve got a lot of things to say about marijuana and I want to make sure that we’re not making it seem more dangerous than alcohol because it’s not

At this stage, Marcy is not having physical or psychological problems that are exacerbated by her use. She will get there because we’re going to be dealing with the inability for her to manage her anxiety without it. Probably dealing with some chronic respiratory issues.  She’s not missing work or failing to take care of her children.

She definitely has withdrawal. She definitely hasn’t been able to cut back. Definitely has cravings.  She spends a lot of time having to either find a way to smoke or find a way to buy it, obtain it, hide it, that kind of thing.  And she’s using more than she planned. 

As we walk through the criteria we’re watching her progression and this happened fairly quickly. So in less than a year, she’s gone from a no use disorder to a moderate towards severe use disorder.

So why does this matter?

Well, it matters because when you have a client in your office and they’re convinced that they don’t want to use any more, that they experienced enough consequences and that they’re going to cut back, or they’re going to make sure that they put limits on their use. You’re going to want to notice if they’re able to follow through with that, , because if they aren’t able to follow through on those commitments, then you have another problem. 

Someone who hasn’t hit that level, they typically are able to moderate. They might realize, Whoa, I’m drinking a lot. I’m going to stop 

Let’s say somebody has an experience where they have some sort of consequence. They passed out drunk at a cousin’s wedding and embarrassed their family. They drove home from the bar when they didn’t realize how drunk they were. A normal non-addict response to that is surprise, shock and not going to do that again. And they take steps to cut back and it works.  

For other people they might see it,  they might try to cut back, but there is a limit to how much they’re going to be able to.  What happens in addiction is that their moderator, their ability to moderate,  gets broken and they’re not able to do it anymore. And the problem gets worse over time.  

The reason progression matters for us is that it changes the goal when we’re talking about use.  This is something that we’re going to address next week.

In the addiction world, in terms of treatment, there are two schools of thought . And some people think that they are at odds, but I don’t actually think they are. So one is called abstinence and the other is harm reduction. Abstinence means that the goal is to abstain from all mood altering chemicals and harm reduction has to do with limiting the amount of harmful effects that someone’s getting from using.  So the goal there is not to quit use of all substances, but to moderate .

This has been the topic of a ton of debate in the addiction world and probably will continue; each side thinking that the other is missing a piece. When really, I think that we’re talking about similar things, we’re just focusing on a different part of the problem.

That’s what we’re going to cover next week on All Things Substance.  Hope to see you then.

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 podcast@betsybyler.com. I’ll see you on next week’s podcast and until then have a great week.

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