Episode #126
Stages of addiction can help us understand how severe someone’s use is. This is key to understanding if someone’s use needs a specialist or not. The number of stages vary from model to model depending on who is talking. Previously, I’ve talked about a 5 stage model. However, lots of those models don’t account for a stage for normal use. The majority of people who are using substances, do so in a regular/normal way. We’ll talk about the different stages of addiction and what differentiates one stage from another.
Transcript
You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use 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 competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back to the All Things Substance Podcast. This is episode 126. Last week we talked about triggers and cravings. Cravings are a big part of the addiction process. According to the American Society of Addiction Medicine, it’s actually one of the main five components of addiction. If you didn’t have the chance to listen to that episode, head on over to betsy byler.com/podcast or wherever you get your podcasts to check out episode 120.
Today we’re gonna be talking about the phases or stages of addiction. At the outset, I wanna point out that there aren’t official stages of addiction. No one has said these are the stages. In fact, if you Google it, you’re gonna find some places that have four stages, some that have nine, some that have. What I’m presenting to you is my opinion based on my experience and based on the general consensus about how addiction develops.
Even if the stages that you might find are a little different, the important part is progression. I think the reason that nobody has said these are the stages is because it’s hard to know where someone is, have they moved through this stage?
Are they going into that stage? We have the DSM criteria. It’s not telling us that you have to have six out of this many in order to meet criteria, and that that is stage X. We know that they’ve chosen mild, moderate, and severe, but we have mild, moderate, and severe for a ton of things that isn’t necessarily the best descript.
The only two things that are the main points of a substance use disorder in the DSM are the withdrawal and intolerance. Those are the things that are really necessary when we’re talking about certain levels of substance use disorder. What I wanna get into today is a little more anecdotal.
The different stages or phases of addiction are very similar. Part of the struggle with it though, is that it can make it seem like there isn’t any normal use. That’s the criticism that I tend to have about most models. Even the one that I have used before didn’t really seem to account for what’s normal. The thing that I have tried to make really clear is that I do believe that there is a normal amount of substance use.
Substance use in and of itself is not problematic for the majority of people. My opinion on that changes depending on what the substance is and how often someone is using it. But in general, it’s pretty normal for us to be using substances. This is not the same as saying that it’s morally right or wrong, because that is certainly a subjective thing, at least in my opinion.
Lately, I’ve been using a little bit of a different model because I want to account for a normal stage of use. In the five stage model. We could say that that only applies to the stages of addiction and how we map out somebody’s path. Rather than, this is how use progresses, because in that model, there really isn’t a middle ground stage. It goes straight from experimentation to misuse and that isn’t accurate.
So when I found a model where it was using these six stages I really felt a little more comfortable with that. We start with the stage that is called initiation. This is the stage where somebody’s trying a substance for the very first time. This happens at any place in someone’s life, but typically for folks who have a substance use disorder, they started before they hit 18. Not always, of course, as there will be exceptions, but typically that’s the case.
Initiation in this case is different for each substance that a person tries. When was the first time they ever drank alcohol? And by that I mean not having a sip from somebody’s beer or wine, but instead having a drink to themselves with the purpose of having that drink.
If they try another substance later the age of initiation is whatever that age was. When was the first time they ever smoked marijuana or took acid or whatever the case may be. So initiation is simply that. It is, when the person first used the substance.
Many people will try a drug or a substance out of curiosity, and then once the curiosity has been satisfied, they don’t use it again. Sometimes the decision to use it again depends on the availability of a substance or their friends and whether they’re using it. Sometimes it’s family history and the environment they’re in, and sometimes it can do with having a really bad experience.
I’ve had experiences with lots of people who tried a psychedelic at one point in their life, like acid or shrooms, had a really bad experience and decided to never touch it again. The initiation for everyone is a little different.
The next stage is experimentation. This is when the person has moved past simply trying the drug on its own. They know what it was like. They want to experience it. Again, that’s what experimentation is, exactly what it sounds like. A person is using the substance in order to get a better feel for it and to see what its limits are.
If they drink this kind of alcohol, if they do it in this context, if they mix it with this or that, what if they eat? What if they don’t eat and they’re experimenting with the substance and kind of testing its boundaries all around. Experimentation is a conscious decision.
It can be done impulsively, or in a controlled manner, or both. It totally depends on the person’s personality and why they’re using it. There isn’t a dependency problem here. The person can easily walk away from the substance.
In the third stage, this is where regular use comes in. Once the experimentation is done and they’ve sort of figured out where the parameters are on this substance and how their body responds to it, then they move into regular use. This is a widely varied experience for.
Some people in this stage are using once a month, once a year, or it could be once a week or every weekend. Regular use is defined by the person. The attitude here is what we’re talking about. This isn’t about finding out the parameters or how this feels.
This is about the person knowing what they’re after and knowing how to get it. Let’s say a person wants to be able to drink but not get drunk. They already know what that limit is.
They’ve experimented. Now they know that they need to drink to this point and be done. I remember that when I was trying to control my drinking, I would drink until my teeth started to get numb. I knew that once my teeth started to get numb, that we were gonna head downhill into being very drunk pretty quickly. I would sometimes bite my teeth together to see, is it there yet? Can I have another?
I should have realized that actually that was a little too far for me because that was already moving past sober, past tipsy, heading down the hill. I just didn’t realize it at the time.
For some people, they are looking for that particular experience and they know how to get. They might be wanting to get to a drunk feeling and get there the fastest that they can, and they know that that comes by drinking this particular alcohol, and doing it in a certain way.
So this regular use pattern is going to be super varied. Some of the key features here is that there’s no addiction here. It is still a conscious decision. However, there can be some sort of mental reliance on the substance, even though we’re in regular use. An example of this is when somebody is looking to alcohol to help them relax after work, it isn’t necessarily an and they could walk away from it.
However, it is something that they know will work and something they’re looking forward to. Sometimes walking away from it might be a little harder than people expect, and it can still fall into this regular use category. There is something called gray area drinking that we’ve talked about a little bit in other podcast episodes.
In the regular use stage, there can be a negative consequence. Anybody who’s had too much to drink, is likely to have experienced a hangover. Sometimes a hangover can last more than one day, depending on the person and how they metabolize alcohol. So there can be negative effects, even in regular use.
It could be that somebody gets a panic attack when they were smoking marijuana, and normally they don’t. But for whatever reason, that particular strand of marijuana ended up inducing panic in them. That’s a negative.
Regular use can vary so much that for one person, regular use is having one drink one time a week. Where for someone else regular use is drinking each day of a weekend and drinking to excess. The difference here is what happens as a. .
Let’s imagine that somebody is drinking every weekend and getting drunk both nights of the weekend, and in some cases, three nights, depending on the weekend. What we’re looking at here is what is the outcome of it, and is a negative outcome happening often.
When it’s not. And for example, someone who’s drinking on the weekends, not driving, not making poor choices in other ways that go against their own internal value system, not suffering terrible hangovers, not spending more than they can afford to spend and being able to meet all of their obligations . I don’t see a problem with that. If that’s something that someone is able to do and they’re able to cut it off when they’re ready to cut it off, that still falls into regular use.
So this is a really wide spectrum, which is why it makes it so hard to determine where someone is in these stages. This brings us to stage four risky use. Risky use is what is called misuse In other stage models. I think that risky use is a better term because defining misuse can be a little more challenging.
In the risky use stage, there’s a negative impact on the person’s life more often. It’s becoming more frequent that there’s a bad thing coming out of whatever they were using. So it’s not just having an occasional hangover, it’s spending much of their downtime recovering from a hangover to the point that they’re not able to engage in other activities because they feel so badly.
It’s having other things pop up, like being too sick to be able to go to an event or to be able to show up at work. That happening once in a blue moon is one, having that happen more often though that’s not normal use and is likely to be risky to the person’s physical wellbeing or financial wellbeing or relational wellbeing. It all depends on the person, of course, but this is the area where we start moving away from what is regular slash normal into where it’s starting to bleed outside those lines.
Risky use could be a lot of different. It could be starting to miss too much work because you can’t make it because you’re feeling sick. It could be spending more than you can afford and needing to borrow money from others or pawning things so that you can afford stuff because you spent the money on whatever the substance was. It could be not following through on responsibilities with family or friends.
Oftentimes there may be something that’s really clear, like getting a DWI or a DUI. So for those who aren’t familiar, some of the states in the United States call it a DWI (driving while intoxicated). In some other states, it’s called a DUI or an OUI or an OWI. We call it all sorts of things operating under the influence. Driving under the influence, operating while intoxicated: all of those mean the same thing. It’s just that every state has a different way of saying it.
I usually say DUI or DWI. Getting a DWI in some places seems normal. I disagree. I don’t think it’s normal to be drinking and driving to the point that you get pulled over. The majority of people that I have ever known did not get pulled over and get charged with a DWI the first time they ever drove drunk.
That usually happens after you’ve done it a number of times, and for a lot of folks they’ve done it for years and never gotten. It’s so normal in certain places that if someone ends up rolling into the ditch because they’ve been drinking, sometimes the law enforcement there will end up taking the person home instead of taking them to jail because hey, everybody’s done that.
For some folks they’ve gotten picked up in a ditch a couple different times, and it wasn’t until the time they were so drunk they couldn’t stand or remember their name, that they ended up getting taken to jail. That is about culture and whether or not that feels normal in that area.
However, among normal drinkers, people who truly are in this regular use category who could pretty much take it or leave it, even if they have a mental reliance on it, they aren’t driving drunk. Most of us know that when we’re drinking, we’re. If we’re bumping into stuff, we’re dropping things. It’s not safe. I think that most rational folks believe that drinking and driving is risky.
The signs of risky use are oftentimes subtle at first, but later on tend to be a little more obvious. Here’s the thing about risky use, though. What we end up seeing on the outside is not the extent of it. It is always worse than we expect.
Here’s an example throughout my time as an administrator and supervisor, I had the occasion to have to let go of a couple staff. It was a terrible experience and the worst part about the job and something I absolutely don’t ever want to have to do again.
Being therapists, we want to see the why of why people act the way they do. We wanna understand their behavior. We want to encourage them to do better. So there may be times over the years where maybe I should have let someone go and let them get away with too much.
However, I always wanted to err on the side of caution so that if I had to let someone go, I was a hundred percent, 110% sure that I was correct about what the person had. And that I had given them chances if that was a possibility, and I had tried to work with them and exhausted every possibility before I had to make that call. In my experiences as well as in the other managers around me, I found something to be true.
What I found was that the problem was so much worse than I knew. So much worse. What I had seen was simply what was bleeding out, what was stretching over the lines. What I found was that the reason it was bleeding out was that everything underneath it was full. Like trying to shove too much into a container and then there’s overflow.
The overflow isn’t the only problem, the overflow is the sign of the problem. I always wanted to make sure that I was giving people the benefit of the and I had to remind myself that if I was seeing a thing, it was because the person could no longer hide it effectively.
Substance use is the same way. If someone’s substance use is being noticed, what we can guess is that whatever they’re using, it’s worse than we knew. It’s further down the line progression wise than we’re aware of. They’re using more often than we’re aware of and more at a time. I have never known that to be untrue.
In the risky use category, we’re not talking about somebody using because they have to, because they can’t live their life without it. We’re not even talking about them using daily. We’re talking about just using in a way that they’re risking problems with their health or their friends, or their family, or their job, or whatever the case may be that it isn’t in this range of regular use.
The longer that someone is in risky use and they’re continuing to use the substance, they are going to keep progressing. You will hear me say in many places that progression is a guarantee. It doesn’t necessarily happen in regular use, although tolerance does build. If someone’s using a substance more often, that’s just biological. Part of what our body does is get used to things and adjust. Its microevolution at its finest.
The mark of moving from risky use into dependence, and in this case, we’re having dependence and addiction Being separated is that dependence is when the person’s substance use is no longer recreational or medical, but instead, the person is becoming reliant on the substance in order to just do life.
This also can be a really broad stage because there’s tolerance, meaning that they need the substance and they are dependent on it. Typically, this has to do with withdrawal. There is a withdrawal syndrome for pretty much everything.
Dependence in this case can be physical or psychological or both. physical dependence is almost always the thing that is immediately felt. It’s the thing that causes agitation and vivid dreams and sometimes flu-like feelings depending on the substance.
For much of my career, I have heard this statement that marijuana isn’t physically addicting. It’s psychologically addicting. I have no idea where it came from. Probably a stoner said it. And being that I was a giant stoner, absolutely probably said that as well.
It absolutely is physically addicting and I think anyone who’s had marijuana for a long period of time knows that it’s physically addicting. Anyone who tells you that it’s not, it’s cuz they still smoke. But the withdrawal just isn’t that bad.
It doesn’t last forever, and you’re not gonna end up sicker than a dog and throwing up and all of that. It’s just unpleasant. Similarly, quitting smoking cigarettes, and for some people quitting caffeine is far more unpleasant and causes nausea and other issues more than marijuana.
Physical dependence is the thing that people notice first. Later on though, psychological dependence is the more prevalent thing. So this is where it’s hard to get through a day, not because their body’s recovering from it, but because their brain is having a hard time managing without.
So let’s take nicotine for instance. It takes four to five days for nicotine to get out of the system. If that was it. People would quit smoking all the time. If smokers knew that they had to get through four or five days and then they would never wanna smoke ever again, they would quit. It’s the other part that brings people.
We can tolerate being sick. It’s not easy, it’s not pleasant, but the majority of us have been sick af at some point in our lives, and so we know that we’ve done it and we could do it again. It’s the other part that brings people back.
This stage of dependence is where somebody believes that they need the substance in order to do their daily life. Sometimes there’s this belief that if that person had to give up that substance forever, that life would no longer be fun, that it would feel gray, and they would never really have any joy.
This is an average feeling when it comes to substances. Even people who really like alcohol, if it disappeared from the world, or if somehow they developed an allergy, that alcohol would kill them. It might be a little sad at first, but the quality of life that they have isn’t gonna depend on whether or not alcohol exists or whatever substance.
For people in the dependence that is going to be their reality that not having it seems very bleak. I think sometimes people might judge others for feeling this way. I understand that it seems weird that how could someone need something like a substance in order to experience joy and happiness?
This isn’t a choice that they make. This is something that happens. Addiction develops slowly over time and nobody plans on becoming dependent or addicted. It is something that they believe they can overcome, that they aren’t going to be the ones who fall victim to it.
I’m not sure totally what it is in us that drives that. Why we believe that we won’t be the one to become an addict or an alcoholic or an addicted gambler or whatever the addiction. We always believe that we’re gonna beat the odds. It’s the most optimistic part of our human nature.
There’s something about us that we’re able to forget the pain of the past. The reason we have more than one child is that we are able to forget the severity of pain and anxiety and struggle. So we try again and we find out, oh yeah, shit, I remember this now. Yet, a couple years later, another child comes along. We are forever optimistic and it’s not silly or stupid, it’s just human nature.
The difference between dependence and addiction in this model is, the substance is still being used in a conscious way. The person knows that they need this and they are choosing to do it. There’s definitely risk involved as now they’re choosing to prioritize the substance over lots of things, and so the risky use is still there. It’s just that the dependence is going to outrank it.
They have a choice, even though it sometimes is a shadow of a choice. The reason I say that is that with some of the substances, the withdrawal is so bad that it is to be avoided at all costs. For instance, opiate withdrawal. So pain medications and heroin is so terrible and so painful and so unfathomably awful that there literally isn’t anything that compares to it.
And even the toughest, most hardened, strong people can’t withstand it. There’s a lot of reasons for that, and if you want to know more about that, you can again head over to the podcastPage@betsybyler.com slash podcast and go to substances and check out the ones on opiates that will go into great detail about why this happens to be the worst withdrawal.
While it’s the worst withdrawal to experience, it’s not the one with the worst outcome. I say this often, but it is like a public service announcement for me, alcohol withdrawal can be fatal and it isn’t even necessarily rare. I’m not saying that it’s common, but it’s also not rare.
Additionally, benzodiazepine withdrawal can also be fatal. While the experience of that withdrawal might not be quite as difficult to experience as opiate withdrawal, it certainly has the ability to cause p consequences.
In the addiction stage this is where the person basically is losing all ability to do life. Without it, it’s not really a choice. Their life becomes unmanageable out of control. They are doing things they would never have normally done. They are saying things they would normally not say. They are not the same person that they used to be. The addiction is now in control driving behavior, changing how they look at the world and becoming their sole focus.
A lot of times this is where loved ones are throwing up their hands and believing that their loved one has chosen the substance over them. It’s incredibly painful to watch someone you disappear because of an addiction. It’s hard to believe that love isn’t strong enough to overcome it. The truth is, it’s not strong enough that despite what songs and movies and poetry and literature says, Love is not enough.
Addiction is powerful, it is multifaceted. It causes changes deep in the brain that are permanent. We aren’t even sure that those changes can be reversed or even if they could. To what degree. The person literally is different. Their brain doesn’t function like a normal person because they’re not just an average person they are an addicted person.
Yes, people can and do recover. They learn to live with the changes in their brain. They learn how to do life differently. It is a struggle though. It’s an uphill struggle. There are some beautiful moments, and thank God it’s not always a struggle. There are phases to how people recover.
It’s those phases that I wanna talk about next week. I wanna share with you what recovery is. recovery is becoming a word that more and more people are familiar with, and I am super grateful for that because recovery is more than just sobriety. Recovery is a way of life. Recovery is a process. It is not a destination.
When we’re thinking about our clients and we’re thinking about where they are, there are some things that mark the change from typical and regular use to hmm, that could be a problem. And that is really the risky use area.
If something’s a one-off and something bad happened when somebody was using substances, I’m not concerned about that. Everybody has a bad moment, a bad outcome, bad. , At one point In these experiences. It’s when that’s repeated, it’s when they fail to learn the lesson that they should have learned the time before or the time before that.
That’s when I start wondering about risky use, because remember, if I am seeing it, if I’m hearing about. It’s more prevalent than what I know.
When people come into session, they don’t think about the highlights the same way we do. Sometimes they’ll tell us the things that we need to know, but there are other times where they’ll say something and I’ll say, hang on, hang on, hang on. What? And they’ll say, oh yeah, didn’t I tell you about that? And I’m thinking, uh, no, I would remember that.
That’s because we just have a tendency when we go in to see a doctor or a therapist or whomever to talk about the things that stand out to us. And if those things don’t stand out, then we probably don’t mention them. And so we can’t count on the fact that if they had a negative experience with a substance that we would somehow know about it. That’s the thing that we need to ask.
So if you have. Suspicion that somebody’s use is a little more than what you would consider regular or normal. That’s something that I would be listening for, but you also might have to ask.
The stages of addiction are important because we want to know where things. The initiation and experimentation phases. The reason those are important to know where the ages are is that early use is highly correlated with dependence and addiction. The earlier someone is using substances, the risk goes up exponentially for them developing substance use disorders later in.
If someone has moved through regular use and is heading into risky use, that’s important for us to know. That’s usually a time when it’s a little easier to help them look at their choices and figure out whether or not this level of substance use is serving them or not.
This isn’t about morality or judgment or saying that they’re an addict or an alcoholic or what have you. It’s about holding up a mirror so that they can see it clearly. Knowing if they’re in dependence, knowing why they’re using on a regular basis, why they feel like they have to continue to use at the level they’re using, that’s all really useful information.
If the person is in the addiction stage, that’s the kind of thing that you may end up needing to refer to a specialist. If the person is acting in such a way where they are doing a lot of things impulsively and compulsively and don’t seem to be able to pull any clean time together, that may require a higher level of intervention than outpatient.
The kind of information that I’m sharing with you today is just a glimpse of the information that I cover in my main.
When I set out to do the podcast, I wanted to share good, solid research-based information for my fellow therapists. I wanted to tell you what I felt was important for a therapist rather than giving you all the information, because frankly, we don’t need all of that. What came out of it was that I developed Charting the Course.
Charting the Course is a comprehensive six week live taught program with 12 CEUs that will provide you with the information that you need to know in order to feel more competent and confident in addressing substance use with your clients. The goal is not to make you a substance use specialist. The goal is to simply provide you with the information that you might not have gotten in order for you to be able to work with substance use effectively.
I don’t believe that you need a bunch of new skills to work with substance use. I think you have them. We are excellent at skills and behavior modification and insight development. We have what we need. A lot of us just needed some more information and some clarification.
Some folks also have felt like they could use a little guidance, a little consultation. So as part of the program, what I did was put in consultation calls after the training is over, so that once a month you have the opportunity to bring real cases to me and talk through them.
I want people to feel like they have a good understanding of this information and know how it works in their day-to-day practice. I encourage you to go over to betsy byler.com/course and check out the program. You can sign up to be on the waitlist, which is simply that you will find out as soon as the registration door is open. Again, that’s betsy byler.com/course.
The reason I wanted to share this with you today is I feel strongly that understanding the stages of addiction are really important. When we work with our clients. We want to understand their experiences, knowing where they came from, where they are, and where they’re headed.
When we talk next week, I’m gonna be sharing with you the different parts of recovery and what those stages are. I hope you’ll join me for that podcast. And until then, have a great week.
This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.
Helpful Links
The 4 Stages of Alcohol and Drug Rehab Recovery
Why the pull of addictive cravings is so hard to resist | Aeon Essays