Episode 10
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What stages of addiction and use are there?
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How do I know which level of use my client is in?
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Do people bounce around in use stages or move in a linear fashion?
Stages of use are helpful in assessing your client’s use and determining when you should be concerned about someone’s use. It also helps direct our interventions so that we can tailor them more effectively.
In this Podcast
- The stages of use are no use, experimentation, misuse, abuse and dependence
- When assessing, you are looking for the age at which a person entered into each phase and also looking at what stage they are in currently
- As with mental health disorders we are looking for patterns and events that caused changes or increase in substance use
- Current stage of use helps you know whether you are looking at prevention or intervention
- The stages of use pulls from episode 7 where we talked about changes in the brain and how it impacts behavior.
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
Transcript:
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.
We’ve been working on laying down a basic foundation about addiction. We talked about whether or not addiction is a choice. We’ve talked about the brain science and the neuroadaptations that occur during addiction. We’ve talked about heritability and other genetic and biological risk factors, and then talked about environmental risk factors. And last week we talked about protective factors.
This week we’re going to talk about stages of use. When you’re starting to evaluate your client’s substance use, you’ll want to figure out where they are in their use process. One thing we can count on is that progression is a guarantee. And this is a key factor. Many people feel like they’ll be able to stop their use and continue at the same place moving forward. If that addiction switch has gotten flipped, they’re going to keep progressing. It’s not something that’s just a possibility. It is a guarantee. What I mean by progression is that addiction is a progressive illness, unless arrested, it gets worse over time.
I’m going to talk about five stages, which are: no use, experimentation, misuse, abuse and dependence. The first stage “no use” is referring to an age at which a person has no use at all.
At first, it might seem like this could be irrelevant in a stage of use. However, I believe it has some clinical significance for us. As a therapist when I’m looking at causes for things, I want to know what changed to move a person from one spot to another. So if somebody’s no use is at 12 years old and their experimentation is at 13 years old, I’m wanting to know what happened around 12 and 13 and how they got started with experimenting with drugs and alcohol to begin with.
So when we’re talking about no use, this is when the person has not done any drinking or using of drugs for themselves. This is not the same as having had a sip of alcohol from a relative’s beer. That’s not considered experimentation , in this context.
The second stage, experimentation, is just what it sounds like; they’ve started to experiment. Experimentation is a stage that can last a short period to a long period. It’s where the person is using different chemicals for the sole purpose of seeing what it’s like. So they might drink a couple times, smoke weed a couple of times, take a few pills, whatever the case may be. The purpose of this use is strictly to figure out what it feels like to be on the substances.
From here on out, the transition between stages can be a little murky. And so you’re going to take your best guess, but I’ll do my best to explain it. And we’ll use some case examples later to talk about the transition and what it looks like.
The third stage is misuse. Misuse is a little bit different than when someone is experimenting. This is going to be just a few times here and there. There really isn’t a drive. In misuse. we’ve moved to a place a person knows what the high is like, and are specifically seeking that high. They’re not at a place where they’re really using regularly on a consistent basis, but it’s not just once in a blue moon either.
So let’s take smoking weed for instance. A person knows what getting high feels like. They’ve tried it enough times that they know how to do it. They know what it’s going to be like when they get high. And they’re going to know what coming down is like, And what they’re choosing to do is search out marijuana in whatever form so that they can use to get that particular feeling and they know what they’re going to be getting.
In misuse there’s typically not a lot of tolerance built up. Even though they know what they’re getting and they might push the envelope in terms of how much they’re using. There isn’t a ton of tolerance. And so they’re still able to use small amounts to get the effect they need. In abuse, that’s where things start to pick up
The abuse stage tends to be the longest stage of the three: experimentation, misuse and abuse. In abuse. someone definitely knows this is what they want from this particular substance. This is where tolerance starts to grow and they start increasing what they need to get the high. And because tolerance is increasing, they need to use more of the substance to get the same effect.
So, let me take a side step here and say tolerance doesn’t necessarily mean that someone is abusing a substance. If someone is drinking on a semi regular basis, say a couple times a week, this doesn’t necessarily mean that they’re abusing alcohol. It depends on what happens while they’re using. It depends on their motivations while they’re using. And it depends on how they feel when they can’t use it all. I don’t want to pathologize people’s normal drinking habits. What defines normal can sometimes be difficult though.
For our conversation, you wouldn’t have abuse unless there’s tolerance as well. Because in order to build tolerance you have to be using on a semi consistent basis. Otherwise tolerance doesn’t build steadily.
It could be in the abuse stage and be at the point where they need five or six alcoholic drinks in order to get drunk. And they could be at the place where they’re still at 14 alcoholic drinks in order to get drunk and still be in the abuse stage. That can feel a little confusing.
In the abuse stage the person is no longer relying on others to bring opportunities for them to use the particular substance. They are actively seeking out opportunities to do so. They’re the ones suggesting it, arranging it, providing, all of those things. If someone’s using drugs, it could mean that this is where they start buying their own stash, using their drug on their own. And taking it out of the realm of social use, into use that is completely self directed.
One of the things I’ll ask someone who’s using, and I’m not certain if they’re in misuse or abuse, is whether or not they’re buying their own stash and whether or not they’re the ones holding onto it. Those are two key areas in the beginning of using someone who’s in the misuse category. Typically isn’t the one taking the risk to hold onto the substance. Someone who has more experience holding onto something they aren’t supposed to have is going to be the one to take that risk. In abuse, however, in order to use consistently, the person needs to have access relatively readily available. And so they will often be the ones to hold their stash or to hold a stash for a group of friends. They also are making the connections in order to get what they need, rather than going through middle people all the time.
In the abuse stage they’re also starting to experiment with using outside of times when it’s stereotypically, and hear the quotes, appropriate. So instead of just using on a Friday or Saturday night, they’re starting to experiment other times when they might have to engage with other people or with other activities like school or work
At the beginning of the abuse stage, this could be something like using on a Sunday night, knowing that they have to get up in the morning and go to school or work. Later in the abuse stage could be using during lunch using before school or work where the use is starting to creep into other areas of their life and no longer being kept to times when they don’t have to interact or do anything that will constitute a responsibility
In the misuse stage people almost never are using in times when it’s going to impact other responsibilities they have, but in abuse that starts to change. And indeed by the end of the abuse stage, they have woven their use around multiple things in their lives and the use is typically crept into other areas.
They may even start experimenting with managing the withdrawal symptoms by using other drugs or more of the same drug that they’ve been using. A few episodes ago, we talked about the phrase, “a little hair of the dog that bit them”. What this is referring to is that sometimes people use a form of alcohol or the same form of alcohol to alleviate hangovers. This isn’t something that typically happens in a misuse stage. This is more of an abuse stage.
For instance, if someone’s been using meth, they might start smoking marijuana in order to help themselves come down from meth. Also in the stage of abuse somebody might replace one drug with another when something isn’t available. People tend to have a drug of choice. This is something that you’ll hear often, and it’s not that they don’t like or use other substances. Usually the way I phrase it is: imagine there’s a table, every drug is available, including alcohol, all of it’s free. What do you choose?
There is something that someone’s going to be drawn to if given the choice, that’s what we call their drug of choice. Typically, this is the drug that they use most often. There are some instances where somebody’s drug of choice isn’t readily available. And so they have a secondary drug that they use the most. Just sorta depends what their drug of choice is though. It’s going to tell you a bit about why they’re using and what it’s going to be like if they stop using.
Let’s say somebody whose drug of choice is marijuana and marijuana is not available. That person might choose to drink alcohol and get drunk because getting high wasn’t available Or somebody whose drug of choice is opiates in the form of pills might choose to use marijuana because they will get a high and it’s also a depressant so that it slows down their central nervous system.
If they’re further into their opiate use and marijuana isn’t enough, they might choose to mix marijuana with alcohol or muscle relaxers or something else. Looking for the additive effect from putting together multiple depressants. The choice here isn’t to not use and to not be high, but to find another way to achieve that purpose.
In the abuse stage there also tends to be consequences that are beginning to happen. This isn’t at the point where somebody’s life becomes a train wreck. This is where somebody starts experiencing consequences related to their use. It could be a DWI, it could be an underage drinking ticket. It could be a possession charge. That doesn’t necessarily mean they’re an addict or an alcoholic.
e’re not at that stage yet, but that happens to them and they typically don’t stop using. Now, there are people who get one DWI and that’s it for them. They never drink and drive again. And for people who do that, they typically aren’t going to progress into the dependence stage.
However, the person who continues to drink and drive after they’ve gotten a DWI, that is where we’re starting to move very close to the dependent stage. They’re definitely in the abuse stage and they’re getting more and more reckless with their use. This is where we start to see people ignoring consequences or not being able to recognize problems.
In the abuse stage they’re not abstaining as much as they were planning to. Their brain is fully accustomed to having a certain level of dopamine getting released and on a consistent basis. And so when they’re not able to do that, and they’re forced to abstain, they tend to have cravings. Cravings are not the same as withdrawal. This is not someone who is addicted to alcohol, having the shakes or getting DT’s or whatever. That’s a different thing.
Cravings is a strong desire or urge. And when they’re kept from using that’s when they start to get irritable or try to find a way to use something so that as a friend of mine says they can “change the channel in their head”. They’re also not getting as much pleasure even when they are using.
They’re also having impairment in behavioral control. This is what I mean when I’m talking about getting DWI, underage tickets , having law enforcement involved because of fighting.
Some people will start to do things that they wouldn’t ordinarily do in order to get the substance such as stealing things or money or lying in an effort to be able to get their use and afford it. And if we’re talking about illegal drugs, they also might begin low level drug dealing, which they won’t think of it like that, but that’s what it is. Where they’re the one being the middle person for their friends in order to get the substance or they might be the one delivering drugs for their dealer in exchange for not having to pay as much or not having to pay at all.
They’re also having a dysfunctional emotional response. It’s not necessarily full blown in this case, but it is definitely there such as getting a DWI and continuing to drink and drive. They might be more careful about how drunk they think they are. But they continue to drink and drive thinking that they know that they’re not as drunk as they were last time or that they can handle it or whatever. This is a dysfunctional, emotional response. People who are drinking normally do not do this. A normal response is: a DWI is pretty serious and it stays with you a really long time.
In our field, we have to do credentialing and licensing all the time. And I’ve seen people have to put DWI on their credentialing packets for 20 years. So a normal drinker isn’t going to take that risk again. However, when we’re in this abuse stage and especially the longer someone’s in the abuse stage, they are going to start taking these risks.
So while the five things we talked about in the last few episodes are all included in the dependence stage. They begin in the abuse stage. They’re definitely not abstaining as often as they plan to, or as they think that they should; there’s impairment in behavioral control.
They’re having cravings. They’re getting irritable. or having some other kind of emotional dysregulation, because they’re not able to use, they’re having a diminished recognition of problems related to their use. And they’re having dysfunctional emotional responses to things that happen while they’re using.
The last feature of abuse is that this is typically not daily. Daily use is something that is found in a dependence stage. Someone could make an argument that someone in the abuse stage could use daily, but it sorta depends. So people talk about drinking wine with dinner.
I’m not really sure why we think that that’s the acceptable statement when we’re talking about drinking, but that’s what people say. That’s what people bring up when they want to talk with me about, well, what about wine with dinner?
Okay when we’re talking about wine with dinner. We’re talking about four to six ounces of wine and the purpose of that four to six ounces of wine is to accompany dinner, this is not to have one, some giant wine glass and then continue drinking into the evening. It’s truly about that one glass of wine. Certainly there are cultures where this is really normal and we’ll find that their drinking is also typically pretty normal.
They’re not drinking to get the effect of getting drunk. They’re drinking because this is the thing that’s paired with their meals that is normal drinking things that are culturally dictated and not stepping into a place of trying to change the channel in your head. That is a very different thing.
So if someone is drinking daily and then their drinking increases from one average glass of wine to a much larger glass of wine, to a couple of glasses of wine, two, three, four, five, whatever it is. And that’s happening every day, that is definitely getting into the abuse category.
Because typically by that point that person’s going to start having trouble sleeping unless they have that alcohol because there aren’t that many hours from dinner until bedtime. Just typically.
Now everybody’s, schedule’s a little different, but we’re talking four to five hours here. And if someone’s having four or five glasses of wine over four to five hours, it’s still going to be an effect when they go to sleep that night and it’s going to facilitate sleep because as a depressant and it’s slowing down their central nervous system.
So without it, they’re going to find that sleeping isn’t quite as easy and that they’re feeling agitated because they aren’t falling asleep and they weren’t able to have the alcohol that they’re used to having. Remember, this is not about morality or whether or not someone’s a good person. This has nothing to do with that.
This has to do with the changes that are happening in the brain. As we talked about a few episodes ago, the nucleus accumbens is busy wanting a specific dopamine level and it is pushing to get that dopamine level. Our reward pathways happen independently of what we want to have happen. And the dorsal striatum is ingraining this habit of having this alcohol before they go to sleep.
So we’re not talking about someone who has decided that in order to sleep, they have to drink. It’s an outcome. Needing to have alcohol in order to go to sleep is an outcome of that habit., not something that the person set out to do.
Typically it’s not daily use yet from my experience, they are using multiple times a week. They’re using with people and without people, The presence of others isn’t necessary in order for them to use.
This is also where preoccupation picks up, where they’re starting to think about using fairly often. A lot of times people will start thinking about drinking that evening first thing in the morning when they wake up. And the further their use goes, progression is happening and they’re starting to think about it more and more.
And it becomes a preoccupation bordering on obsession at times. Sometimes people notice this and they recognize that they’re thinking about using all the time and that that’s probably not great. But remember , we also have a diminished recognition of problems and the dysfunctional, emotional response to take into account
Someone who’s not heading towards addiction, recognizing that they’ve been drinking a lot, that they’re thinking about it all the time. A normal response to that would be, “I need to cut back or I need to stop drinking altogether for awhile”. That’s a normal response. However, when someone’s further down this path, their brain has already begun changing. The idea of stopping or cutting back is pretty distant.
So let’s talk about the transition from abuse to dependence. Part of the reason that I use the phrase dependence is that some people have less of an intense reaction to the word dependence than they do addiction.
Dependence sounds like something that you aren’t necessarily responsible for and that you didn’t cause. Addiction sounds like depravity to a lot of people and so using the word addiction can feel pretty intense. I find that people are less defensive. If I’m talking about a more clinical word, like dependence.
So in the dependence stage we’re talking daily use or near daily just sort of depends if it’s not a drug that can be used daily consistently. We’re talking about big binges. For instance, meth, you can’t use meth every single day for years. It’s not possible. You have to crash.
In the beginning of using meth you can sleep, you can eat, you can do things you normally do as you progress. And as we know, progression is guaranteed, you’re going to be staying up and you can’t stay up for years at a time. Typically people will go on a two to three week binge, and they’ll crash really hard for a number of days and then they’ll start another binge.
So it’s near daily use or daily use. It’s pushing out other activities. They’re not involved in things they used to be involved in. They’ve given up relationships. They’ve given up hobbies. They’re using in situations where it’s hazardous. So this should sound like the DSM five criteria to you, which it is.
When you look at the DSM criteria we have mild, moderate, and severe in terms of substance use disorders. Two to three symptoms is mild. Four to five symptoms is moderate and six and over is severe. That’s what you’re going to be looking for when you’re talking about when evaluating someone’s substance use to see whether we’re in the dependence category or whether we’re in the abuse category.
I would generally put someone who’s moderate also into dependence because people under report the consequences and experiences of their use. However, this is going to be a judgment call for you. The diagnosis is a thing that we’re documenting. These stages of use are more for your clinical conceptualization than for diagnosing.
So let’s talk about some case examples, and these are going to be pretty brief. And so as you think about them, I want you to draw a table in your head, not a table you eat on, a table like from Excel.
You have a person on the left side and across the top, you have the five stages, no use experimentation, misuse, abuse, and dependence. And what we’re looking for here are ages at which this started to happen. I find it really useful to go through this with clients and ask them to rate themselves after I’ve explained it. It works even better in a group setting.
When you’re working with adult clients, this will be something that will be a little bit challenging for them at first to start thinking about when the transition happened, but you’re going to find that they’re able to do it. And it’s really interesting to look at. For our case examples I’m going to use teenagers because this is typically when addicts and alcoholics make these different transitions. So by the time we see them in their adulthood, they’re already into the dependence stage. Typically once in a while we find some people that are in the abuse or misuse stages, and they’re looking to help them with their use when it’s become a bit unmanageable.
Alright. First case, Mark is a 16 year old male. Many of his relatives use marijuana, and this was seen as pretty normal. Mark first tried marijuana at age 10. He didn’t really like it and didn’t try it again until he was 12. After that he used on occasion, but it wasn’t something he really tried until his 13th birthday came around and that’s when he got drunk for the first time. He decided then that he liked marijuana better than he liked drinking. And so he started using a few times a week. At 14 he started using a vape pen and THC oil and using that vape pen every day.
Alright. So let’s graph this out. Remember, so Mark is on the left hand side and across the top, we have no use, experimentation, misuse, abuse, and dependence. So for Mark, his experimentation started at age 10. He only used once and then not again until he was 12, but he still used with the intention of experimenting and seeing what it was like to be high. So no use, we put 9, experimentation we put 10, the next one is misuse. We’re going to put 13. So he was experimenting at age 12, on his 13th birthday we’re told that he drank for the first time, but that after that he started smoking marijuana a few times a week. This is in the misuse category.
By 14, we know that he’s using daily, multiple times a day. His misuse and abuse are both at 13 years old. So that year between 13 and 14 was pretty intense. His use escalated pretty quickly. So now he’s 16 and you’re seeing him, he’s been smoking daily multiple times a day using THC oil, which has a very high concentration of THC. And in this case, high concentration is anything over 10%. THC oil is between 60 and 90% and we’re talking about a developing brain.
So we take those five things we’ve been talking about. And we add that to a compromised prefrontal cortex and one that’s not completely developed and this is where you start to see some significant problems happening. Alright so across the board, we have 9, 10, 13, 13, and 14, right? In each of those categories.
Second case. Adrianne is a 15 year old female. She tried her first sip of alcohol from a relative’s beer when she was eight. She didn’t have any alcohol until she turned 15. She first tried marijuana on the same day as her first drink of alcohol. For the first few weeks after, she drank and smoked a few times. Within the next two months, she was buying her own stash, smoking alone and using multiple times a week.
She doesn’t drink as often as she uses marijuana, but she does have a decent tolerance for alcohol. So Adrianne had that first sip and like we talked about, that’s not experimentation, that’s just someone giving her a sip. She did not have a drink to herself. So her first drink wasn’t until she was 15.
When we look at her in the table, her no use is at 14. Her experimentation is at 15. Her misuse is at 15. And her abuse is also at 15 because we’re talking about her smoking alone, buying her own stash. That kind of thing. We don’t know if she’s reached the dependence stage yet because we haven’t gotten that far in our assessment. The narrative doesn’t tell us that. So across the board, we have 14, 15, 15, and 15.
The odds here are not great for Adrianne. She didn’t use at all and within the first year of trying anything and she’s popping up in therapy. Something is happening in this girl’s life that is making her substance use increase dramatically in a very short period of time. So this was a pretty high risk kid even though she didn’t start using until she was 15 and age of first use across the country tends to be 11 or 12.
So what if we saw just someone’s use pattern? So I want you to think about this as I tell you about Ben. I’m just going to tell you the ages at which he moved into these stages. And I want you to think about what that says.
So for Ben, his no use is at 11. His experimentation is at 12. His misuse is at 15. Abuse is at 15 and dependence is at 19. Okay. For our purpose, the main things we need to know is that there are three years between experimentation and misuse, misuse and abuse happened within the same year. And then there’s another three years where he hangs out at abuse before he gets to dependence.
So for me as I look at this, knowing nothing else, I see that Ben experimented for a while, really wasn’t looking into drugs; really wasn’t trying it very often. Remember experimentation is just looking to see what the feeling is like. And that happening between 12 and 15, he wasn’t doing it very often at all. He moved into misuse at age 15, which as a therapist makes me wonder what happened at age 15, because also he moved from misuse straight into abuse. And so his use got really intense.
So by the time he’s 16, he’s using multiple times a week, developed a tolerance, starting to ignore problems, starting to miss out on different things that he used to do. And his use increased pretty heavily that year. I would bet money that there are things that either happened to him or around him that are impacting this increase.
Then we see that he doesn’t move to dependence until he’s 19. So what this tells me is that he was able to manage the abuse and not let it totally overtake his life until he was 19. One could make the assumption that something happened at 19, but I don’t know that it did. Remember that progression is a guarantee.
And three to four years of consistent drug and alcohol use, whichever substance it was, is going to change the brain. He’s also doing this during a time of significant development in his brain. And so by 19, this might not be about trauma or difficulty. This might be just the progression of use. And that’s the moment where he started using it daily and it was over. So the switch got flipped.
So as we talk about stages of use, this is what you’re looking for. When did someone start experimenting? How old were they? What was the circumstance?
So usually I’ll ask someone. It was the first time he tried alcohol and I’ll say, okay, did you get drunk? Did you get sick? All right. So after that first time, how long after that, did you drink again? It seems like they wouldn’t remember, but typically they do. They’ll be like, “Oh man, it wasn’t for a couple of years” or “ I don’t know, like a month or two”, that kind of thing.
And so we’re looking for what kind of experimentation process did they have. Then we’re going to ask them about when they moved into misuse, and we’ll explain what that is, into abuse and then we’re evaluating whether or not their independence by using our DSM criteria.
The stages of use tells you where they are and if they’re already into the dependence stage, it tells you when they got there and usually some pertinent information about what pushed them from transition to transition.
A few times during today’s podcast, I’ve talked about progression and the fact that I believe it’s a guarantee. So that’s what we’re going to talk about next week.
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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