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sailboat When Enough is Enough!

  • Addiction
  • Self-Assessment
  • A Struggling Loved-One
  • Family Participation
  • Is a Disease
  • Q & A


Addiction Definition

Addiction is a persistent, compulsive dependence on a behavior or substance. The term has been partially replaced by the word dependence for substance abuse. Addiction has been extended, however, to include mood-altering behaviors or activities.

Rainbow over oceanSome researchers speak of two types of addictions: substance addictions (for example, alcoholism, drug abuse, and smoking); and process addictions (for example, gambling, spending, shopping, eating, and sexual activity). There is a growing recognition that many addicts are addicted to more than one substance or process.

Addiction is one of the most costly public health problems in the United States. It is a progressive syndrome, which means that it increases in severity over time unless it is treated. Substance abuse is characterized by frequent relapse, or return to the abused substance. Substance abusers often make repeated attempts to quit before they are successful.

The economic cost of substance abuse in the United States exceeds $1.45 trillion, with health care costs attributed to substance abuse estimated at more than $874 billion.

By eighth grade, 52% of adolescents have consumed alcohol, 41% have smoked tobacco, and 20% have smoked marijuana. Compared to females, males are almost four times as likely to be heavy drinkers, nearly one and a half more likely to smoke a pack or more of cigarettes daily, and twice as likely to smoke marijuana weekly. However, among adolescents these gender differences are not as pronounced and girls are almost as likely to abuse substances such as alcohol and cigarettes. Although frequent use of tobacco, cocaine and heavy drinking appears to remain stable in the 2000s, marijuana use has increased.

An estimated four million Americans over the age of 12 used prescription pain relievers, sedatives, and stimulants for "nonmedical" reasons during one month.

In the United States, 15% of the population regularly uses tobacco. Tobacco use reportedly kills 2.5 times as many people each year as alcohol and drug abuse combined. According to data from the World Health Organization, there were 1.1 billion smokers worldwide and 10,000 tobacco-related deaths per day. Furthermore, in the United States, 43% of children aged 2-11 years are exposed to environmental tobacco smoke, which has been implicated in sudden infant death syndrome, low birth weight, asthma, middle ear disease, pneumonia, cough, and upper respiratory infection.

Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating, affect more than five million American women and men. Fifteen percent of young women have substantially disordered attitudes toward eating and eating behaviors. More than 1,000 women die each year from anorexia nervosa.

A Harvard study found that an estimated 15.4 million Americans suffered from a gambling addiction. More than one-half (7.9 million) were adolescents.

Causes and symptoms
Addiction to substances results from the interaction of several factors:

  • Drug chemistry
    Some substances are more addictive than others, either because they produce a rapid and intense change in mood; or because they produce painful withdrawal symptoms when stopped suddenly.

  • Genetic factor
    Some people appear to be more vulnerable to addiction because their body chemistry increases their sensitivity to drugs. Some forms of substance abuse and dependence seem to run in families; and this may be the result of a genetic predisposition, environmental influences, or a combination of both.

Key terms
Addictive personality - A concept that was formerly used to explain addiction as the result of pre-existing character defects in individuals.
Process addiction - Addiction to certain mood-altering behaviors, such as eating disorders, gambling, sexual activity, overwork, and shopping.
Tolerance - A condition in which an addict needs higher doses of a substance to achieve the same effect previously achieved with a lower dose.
Withdrawal - The unpleasant, sometimes life-threatening physiological changes that occur, due to the discontinuation of use of some drugs after prolonged, regular use.

Brain structure and function
Using drugs repeatedly over time changes brain structure and function in fundamental and long-lasting ways. Addiction comes about through an array of changes in the brain and the strengthening of new memory connections. Evidence suggests that those long-lasting brain changes are responsible for the distortions of cognitive and emotional functioning that characterize addicts, particularly the compulsion to use drugs. Although the causes of addiction remain the subject of ongoing debate and research, many experts now consider addiction to be a brain disease: a condition caused by persistent changes in brain structure and function. However, having this brain disease does not absolve the addict of responsibility for his or her behavior, but it does explain why many addicts cannot stop using drugs by sheer force of will alone.

Scientists may have come closer to solving the brain's specific involvement in addiction in 2004. Psychiatrists say they have found the craving center of the brain that triggers relapse in addicts. The anterior cingulated cortex in the frontal lobe of the brain is the area responsible for long-term craving in addicts. Knowing the area of the brain from which long-term cravings come may help scientists pinpoint therapies.

Social learning
Social learning is considered the most important single factor in addiction. It includes patterns of use in the addict's family or subculture, peer pressure, and advertising or media influence.

Inexpensive or readily available tobacco, alcohol, or drugs produce marked increases in rates of addiction.

Individual development
Before the 1980s, the so-called addictive personality was used to explain the development of addiction. The addictive personality was described as escapist, impulsive, dependent, devious, manipulative, and self-centered. Many doctors now believe that these character traits develop in addicts as a result of the addiction, rather than the traits being a cause of the addiction.

In addition to a preoccupation with using and acquiring the abused substance, the diagnosis of addiction is based on five criteria:

  • loss of willpower
  • harmful consequences
  • unmanageable lifestyle
  • tolerance or escalation of use
  • withdrawal symptoms upon quitting

Treatment requires both medical and social approaches. Substance addicts may need hospital treatment to manage withdrawal symptoms. Individual or group psychotherapy is often helpful, but only after substance use has stopped. Anti-addiction medications, such as methadone and naltrexone/Vivitrol, are also commonly used. A new treatment option has been developed that allows family physicians to treat heroin addiction from their offices rather than sending patients to methadone clinics. The drug is called Suboxone (buprenorphine).

Researchers continue to work to identify workable pharmacological treatments for various addictions. In 2004, clinical trials were testing a number of drugs currently in use for other diseases and conditions to see if they could be used to treat addiction. This would speed up their approval by the U.S. Food and Drug Administration (FDA). For example, cocaine withdrawal is eased by boosting dopamine levels in the brain, so scientists are studying drugs that boost dopamine, such as Ritalin, which is used to treat attention-deficit hyperactivity disorder, and amantadine, a drug used for flu and Parkinson's disease.

The most frequently recommended social form of outpatient treatment is the twelve-step program. Such programs are also frequently combined with psychotherapy. According to a recent study reported by the American Psychological Association (APA), anyone, regardless of his or her religious beliefs or lack of religious beliefs, can benefit from participation in 12-step programs such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). The number of visits to 12-step self-help groups exceeds the number of visits to all mental health professionals combined. There are twelve-step groups for all major substance and process addictions.

The Twelve Steps are:

  • Admit powerlessness over the addiction.
  • Believe that a Power greater than oneself could restore sanity.
  • Make a decision to turn your will and your life over to the care of God, as you understand him.
  • Make a searching and fearless moral inventory of self.
  • Admit to God, yourself, and another human being the exact nature of your wrongs.
  • Become willing to have God remove all these defects from your character.
  • Humbly ask God to remove shortcomings.
  • Make a list of all persons harmed by your wrongs and become willing to make amends to them all.
  • Make direct amends to such people, whenever possible except when to do so would injure them or others.
  • Continue to take personal inventory and promptly admit any future wrongdoings.
  • Seek to improve contact with a God of the individual's understanding through meditation and prayer.
  • Carry the message of spiritual awakening to others and practice these principles in all your affairs.

The prognosis for recovery from any addiction depends on the substance or process, the individual's circumstances, and underlying personality structure. Addicts using multiple drugs have the worst prognosis for recovery.

The most effective form of prevention appears to be a stable family that models responsible attitudes toward mood-altering substances and behaviors. Prevention education programs are also widely used to inform the public of the harmfulness of substance abuse.


Addiction: A Self-Assessment Exercise
The following series of questions about the effects of alcohol and other drug use can help you or your loved-one to conduct a self-assessment regarding addiction.
Please respond to the following statements:

  1. Sometimes I or my loved-one have had to use about twice as much alcohol or other drugs to get the same effect as I/they used to. Yes or No (If yes, please think of examples.)
  2. There have been times when I or my loved-one experienced withdrawal symptoms after I/they stopped using alcohol or other drugs. Yes or No (If yes, please think of examples.)
  3. I or my loved-one have used more alcohol or other drugs than I/they intended or for longer periods of time than I/they intended. Yes or No (If yes, please think of examples.)
  4. I or my loved-one have tried (or wanted to try) to cut down or control the amount of my alcohol or other drug use. Yes or No (If yes, please think of examples.)
  5. I or my loved-one have spent a great amount of time using alcohol or other drugs, recovering from their effects, planning to obtain more, and thinking about the next time I/they will drink or use. Yes or No (If yes, please think of examples.)
  6. Because of my or my loved-one's alcohol or other drug use, I/they have given up or reduced my/their involvement in important social and occupational activities, either to spend time with other drug users or to use drugs in isolation. Yes or No (If yes, please think of examples.)
  7. Despite realizing that my or my loved-one's alcohol or other drug use was causing physical, psychological, or social problems (or making such problems worse), I/they continued to drink or use. Yes or No (If yes, please think of examples.)

The previous self-assessment questions are adapted from the diagnostic criteria developed by the American Psychiatric Association (APA). The APA says that agreement with three or more of these statements provides sufficient information to suggest that an individual meets the medical diagnosis of addiction.

Select yes or no for the following question:

Do you feel that you or your loved-one meet the criteria for a diagnosis of addiction? Yes or No

Most drug-addicted people spend large amounts of time trying to obtain the drug; smoking, snorting, or injecting it; and recovering from its effects. This can range from just a few hours per day to nearly the entire day.

In the self-assessment exercise below, one of the questions is related to tolerance. Tolerance describes the process in which the same amount of a substance no longer causes the same reaction. Once people develop tolerance, they will need to take more of the substance to get the same effect.

Please answer the following questions:

  1. Do you or your loved-one spend time obtaining, using, and recovering from the effects of alcohol or other drugs? Yes or No. How many hours per day would that total?
  2. Have you or your loved-one noticed that you/they need to use more drugs to get high? Yes or No (If yes, please think of examples.)

In the self-assessment exercise below, the questions relate to withdrawal symptoms.

Withdrawal symptoms are those feelings, experiences, and physical reactions that occur when people cut down or stop using their drug of choice. These withdrawal symptoms will be different depending on your primary drug of choice, such as alcohol, cocaine, heroin, and benzodiazepines.

Please answer the following questions:

  1. What kind of withdrawal symptoms have you or your loved-one experienced? What have you/they done to relieve these symptoms?
  2. Have you or your loved-one used alcohol or other drugs to avoid having withdrawal problems? Yes or No (If yes, please think of examples.)

In the self-assessment exercise below, the questions address whether normal obligations at work, school, and home are getting pushed to the side because of drug use. Examples of this may include calling in sick, working while intoxicated or high, working with a hangover, working while in withdrawal, or working while experiencing severe drug hunger.

As mentioned, addiction is progressive. Therefore, good, old friends are often replaced by new, substance-using friends. Some people tend to use drugs in isolation and spend increasing amounts of time alone, using drugs. In addition, using drugs soon replaces hobbies and activities that were once important.

Please answer the following questions:

  1. Have you or your loved-one ever worked or taken care of your/their kids while drunk or high? Yes or No (If yes, please think of examples.)
  2. Have your or their social and work activities begun to suffer because of alcohol or other drug use? Yes or No (If yes, please think of examples.)

A question in the self-assessment exercise below asks you or your loved-one about continued alcohol or other drug use despite negative consequences. Some of these consequences are physical, psychological, emotional, financial, spiritual, and family problems.

Please answer the following questions:

  1. Have you or your loved-one often told yourself/themselves that you/they drank or used drugs because of various family problems? Yes or No
  2. Do you now believe that those problems were actually caused by the alcohol or other drugs? Yes or No (If yes, please think of examples.)


No one likes to suspect that their child, parent, sibling, or spouse is struggling with addiction. Love is blind and we'd rather believe the best about our loved-one who we often look up to. Unfortunately, the shocking revelation that someone close to us has succumbed to addition can come by means of death due to overdose, arrest by the police for possession, sales, distribution of narcotics, or some other similarly catastrophic event which precipitates us into the nightmare of ingrained addiction - if only we'd spotted it sooner, we may have been able to have done something about it and prevented the outcome.  Well, maybe yes, maybe no. Being aware of the presence of addiction and knowledgeable about available resources for the treatment of addiction can greatly benefit the addict's chances for recovery. However, only the addict can commit to his/her own recovery, and a successful recovery can only happen if the addict makes the effort to recover.  It may be necessary for individuals suffering from addition to "hit bottom" in order to change, for example, a drug related arrest with other dire consequences. Therefore, knowing that your loved-one is struggling with addiction may not always help. Nevertheless, addiction is one situation in which ignorance is not bliss.

Addiction is a progressive disease, meaning that there are various stages of addiction. At first, the addict may use intermittently, say, at parties or social events. Eventually, this can graduate into full blown addiction where the addict's mind becomes focused solely on acquiring and consuming the drug. Critical thinking diminishes and any means of funding the addiction suddenly seem reasonable.

Over time, addicts become proficient at hiding their addiction; dodging questions and all out lying. The disease of addiction is said to be cunning, baffling, and powerful. You might think that if a loved-one had such a terrible problem as addiction, that they'd come forward to discuss their problem. But sadly, often no. If they can acquire and use their drug, telling you about the problem would disrupt and defeat their ability to maintain their lifestyle. And they believe "they will eventually be able to stop on their own when they're ready", "it's really not a problem yet, and they're just having fun", or "they only need to do it a couple more times and then they will be ready to stop using". So they live in a world of secrecy where people are divided into those that provide/use, and those who don't have a clue. To add insult to injury, they may also be putting you at risk by hiding their drugs somewhere in your house, using in your house, bringing questionable people into your home or conducting transactions on your premises.

So what to do? How do you find out if your loved-one is struggling with addiction? What are the signs? Well, there are many that should raise a red flag. I will list a few of them here:

  1. There are new blind spots in your awareness of your loved-one's schedule or activities. It's as if, suddenly, there are time slots in your loved-one's schedule that are dark or blanked out. And inquiry into these periods leads to dodgy, evasive answers.
  2. Your loved-ones activities/interests have changed and they suddenly no longer enjoy activities they used to like and seem to be away at times when they were previously in the household engaging in regular activities.
  3. You no longer see them as much as before and your encounters with them become more and more brief and to the point. For example, they come by to collect money that they need for a temporary setback and they leave soon after receiving the money and are then out of sight, out of mind.
  4. Their mood is different and they're suddenly relaxed, euphoric, agitated, anxious, or angry. Furthermore, specific drugs react with conditions such as bipolar disorder. The addict may experience what he/she believes is relief from the condition, but the disorder is only exacerbated by the drug.
  5. They can no longer respect appointments, and schedules; they arrive late if at all. They seem to have developed a casual attitude towards obligations in general, including work deadlines and requirements. In the past, they had exhibited responsible behavior toward goals and ambitions.
  6. Items of value start disappearing in your house, checks and credit purchases are drawn in your name without your consent.
  7. Their driving habits have changed where they're suddenly driving either too fast or too slowly.
  8. Their health seems to be diminishing; for example, they've lost weight but don't look especially healthy.
  9. Their household/living quarters are disorderly, perhaps overrun with clutter whereas they used to be tidy.
  10. They become intensely preoccupied with some activity. For example, a trip to the hardware store lasts hours.

What to do if you suspect that a loved-one is struggling with addition? You can confront them with the age-old question: Are you on drugs? However, denial is a hallmark of the disease of addiction - they believe they don't have a problem. An intervention may be needed for a loved-one to accept that they need help.


Good Reasons Why the Family Should Participate in a Loved One's Treatment

Millions of Americans suffer from substance use disorders, but, for the 11% who go on to seek treatment, it's not always the end. With family members often unaware of how addiction works, no support at home, and a return to nearly the same environment that drove substance abuse in the first place, many people often relapse. Treatment centers work to combat this problem by involving family, offering extended support outside of treatment with aftercare and facilities, and bringing family and friends into treatment.

The national picture of rehab or addiction treatment is often one of seclusion, where loved ones are locked away for 28 days or longer to face extensive counseling and group therapy. But, while some element of seclusion or removal from stress and substances to abuse is still often prevalent, research is now showing that family and loved ones play a vital and important role in addiction treatment. Whether it's your loved one's first time in treatment or they're reentering treatment after a relapse, addiction treatment must work to dismantle destructive or toxic family behaviors and dynamics in order for you and your loved one to move on.

Choosing to participate in your loved one's treatment will improve their motivation, help you tackle problems and relationship issues caused by addiction, and helps family members step out from under enabling behaviors, which they often build up over time. While there is no single family dynamic created by substance abuse and addiction, family therapy helps every member of a family recover from the effects of addiction.

These are 7 reasons why you should participate in your loved one's treatment, and highlight the importance of getting treatment for yourself as well as for your addicted loved one.

  1. Addiction Affects Everyone in the Family

  2. Whether your family member is a spouse, lover, sibling, parent, or aunt or uncle, addiction affects everyone in the family. Persons suffering from substance dependence change, they fail to consider their family's well-being, they react in negative and destructive ways, and they often manipulate and lie to get their way or more of a substance they are addicted to, creating trauma, relationship changes, and stress for every other member of the family. Changes to family dynamic and hierarchy are especially crucial for those who are traditionally dependents or providers and who switch or subvert roles because of addiction. And, in cases where caretaking becomes enabling, family members must unlearn behaviors contributing to addiction in order to ensure that they do not contribute to a relapse.

    Family therapy creates a safe space to identify and tackle family problems caused by addiction; to both recognize how substance abuse plays a role in behavior patterns and actions, and to recognize the role they play in their loved one's life.

  3. Your Loved One Needs You

  4. Overcoming substance addiction requires profound mental and physical strength. Detox is often painful and stretches out over weeks or months beyond when drugs or alcohol physically leave the system. Resisting cravings, fighting triggers, and unlearning old behavior require consistent mental resilience. Most of us are aware that we are stronger together, and that is truer in context of family and relationships. Supporting your loved one through treatment will help them to recover.

  5. Family Involvement Increases Motivation and Outcomes

  6. While not every family contributes to the mental wellbeing of their loved ones, family involvement in therapy and treatment often increases positive outcomes. Patients with strong relationships with (clean and sober) family members are more likely to feel motivated, inspired, and have something to work towards when loved ones are involved in treatment. With family members visiting, learning, and offering non judgmental listening, recovering addicts become more committed to change because they have consistent and frequent reminders of why they are changing.

  7. Family Can Play a Role in Relapse

  8. You would likely never intentionally push a loved one into relapse. But, factors including stress, tension, emotional instability, and negative emotions greatly contribute to relapse. Individuals who recover only to find that family cannot move on from treating them like an addict, or give them chances even when they are trying, are often pushed into relapse through a lack of understanding and social support. Participating in your loved one's treatment gives you the tools and the training to understand what to expect, how to treat your loved one, and how you can play a role in their recovery by working to remove feelings of fear and anxiety, offering support and love but not help or rescue, and creating a positive environment where you allow your loved one to rebuild your relationship if they choose.

  9. Learning Effective Communication is Crucial to Long-Term Recovery

  10. Most families don't communicate well or effectively, largely because many family members know each other too well, allowing them to make assumptions instead of listening and understanding. Family therapy works to provide a structured and supportive environment, where you can learn effective ways to communicate that don't involve treating a recovering family member like an invalid. Moving beyond family traumas – especially traumas that can lead to addiction – means discussing those traumas, addressing problematic and painful points in history, and actually moving past rather than ignoring emotional trauma; and therapy will help.

  11. The More Reluctant You Are to Join, The More Likely You Need It

  12. If you feel as though you aren't welcome, aren't needed, or don't need therapy yourself, chances are that you do. Family therapy and involvement in treatment work to remove and absolve feelings of guilt and blame, yours and theirs. If families are to work together, they have to know how each contributes to the larger piece of the puzzle, how time, energy, and money contribute to addiction, and how changing behavior patterns and relationships give each other a solid ground to move forward and heal.

  13. Education Gives You Control Over Your Own Behavior

  14. Most people know very little about addiction or how it affects the mind and behavior. Getting treatment with your loved one allows you to empower yourself to understand their actions and choices so that you can make better choices, more empathetic decisions, and build healthier boundaries. Educating yourself in family therapy and in support groups like Al-Anon give you the tools to understand your loved one and what they are going through, so that you can respond and react accordingly. This will give you a better space to take care of yourself as well as your loved one, so that both of you can heal. This is important because many family members often feel guilty or responsible for a loved one's addiction. Getting help and learning to create healthy boundaries will allow you to work through the complexity of family relationships, to take what is needed, and reestablish healthy communication and behavior.

Addiction impacts everyone, it drains your time and energy, it causes stress, and it often strips you of a person you love and care about. When that person agrees to seek out treatment, it's just the beginning of a long uphill battle. They may relapse, they may not always be grateful or thankful for your support, but by working together as a family, you can not only provide them the support they need to get clean or sober, but also the healing you need to recover.

Family dynamics in an addicted household are often complex. Family therapy can help you to recover family hierarchy, to rebuild communication, and to unlearn negative or toxic family dynamics like unhealthy modes of communication learned during addiction. Being there, taking part in therapy, and getting help and therapy for your own as well as their problems will help you to rebuild as a stronger family, more capable of supporting each other, and more capable of creating an environment in which your loved one can heal.

If you or someone you love is struggling with substance abuse, contact us today and speak with one of our experienced and professional counselor-interventionists, we're here to help. Accredited Counseling & Intervention Services is located in San Jose California in beautiful San Francisco Bay Area, which has one of the most active recovery communities in the United States.


Although it may sound strange, when we say that alcoholism or drug addiction is a disease, we are not talking about the behavior of drinking or using. Behavior might signify the presence of a disease, but behavior itself cannot be a disease. A disease isn’t something you do (voluntarily or otherwise); it’s something you have. The common sense inherent in our language reflects this same idea. We don’t speak of someone “high blood pressure-ing” or “pneumonia-ing.” We say a person has high blood pressure or has pneumonia. This is true for all diseases. The behavior we call a “seizure,” for example, might indicate an infection, a hemorrhage or a tumor in the brain. The seizure is the sign of a disease, not the disease itself.

If the behavior of drinking or using drugs is only the sign of addiction, then it is no surprise that measuring drinking or using behavior brings no uniform picture of the disorder. In virtually all illnesses, especially early in their course, signs and symptoms are remarkably variable. Just as fevers may be high or low, pain severe or mild, alcoholic drinking or addictive drug use may be heavy or light, intermittent or continuous, boisterous or quiet - all depending on biological, social and psychological factors influencing the individual with the disorder.

So if by calling addiction a disease we mean that sometimes drinking or using is a sign of something else, a result of something a person has, then we need to be clear about what that something is. Without a simple conception of what an addiction is (on par, for example, with what an infection is), we have no strong argument for the disease concept of addiction.

The experience of ‘powerlessness’
Part of the difficulty in establishing the disease concept of addiction is that the essence of the condition is known to us primarily through the reported experience of the person who has it. Although advances in brain imaging have begun to show us the disordered biochemistry underlying addiction, diagnosis is still based mostly on what patients tell us about their experience. As a result, the data are largely subjective and can be quantified “objectively” only indirectly. That’s why it is so important to listen carefully to the stories of alcoholics and addicts themselves - to hear what they say about what’s going on inside them. When we do that, we learn that they describe their experience as “powerlessness.”

But the idea of powerlessness is paradoxical. After all, many alcoholics and addicts do quit drinking and using for good. What happened to powerlessness, then? Choosing, “one day at a time,” not to drink or use sounds like having power, not like having lost it.

More than 100 years ago, in describing his own struggles with tobacco, Mark Twain gave us the solution to this puzzle when he said: “To cease smoking is the easiest thing I ever did. I ought to know because I’ve done it a thousand times.” Twain put his finger directly on the essential experience of addiction - when it is fully developed, it is an all-or-nothing experience. Although addictive behavior is remarkably varied, in the end virtually all addicts discover that abstinence is the only reliable foundation for recovery. “Quitting,” it turns out, is hard, but it isn’t the major problem. The bigger problem, brilliantly expressed in AA, is “staying quit - not starting again.

Like many other illnesses, addictions progress. The beginning is marked by the struggle for control (“never before 5 p.m.,” “only on weekends,” and so on). But as time goes on, control becomes increasingly difficult to achieve. Eventually, it is attained only by quitting. Indeed, episodes of quitting and relapsing are almost an unmistakable indication of the diagnosis of addiction (as opposed to mere abuse or misuse). At this stage, if people begin again, they spend increasing amounts of time and effort trying to maintain “control,” but in the end it is lost. This is what AA’s founders described as having become “powerless” over alcohol - not just for a particular episode of drinking, but repeatedly and inevitably for all drinking. In the end, all addicts discover that there is just no such thing as one.

Now comes another paradox. I call it the “control conundrum.” Non-alcoholics don’t have to work at controlling their drinking. Whether they are stronger or better people (as they sometimes like to think) is a matter of opinion. The fact remains that a normal drinker doesn’t have to struggle to control it. So here’s the puzzle: How can an illness be characterized by the loss of control when the healthy state of affairs is experienced as not needing control? How can an alcoholic lose what a non-alcoholic doesn’t have in the first place? The answer is that an addiction isn’t so much a loss of something as it is the development of something that has a life of its own, that takes control for itself. That something is an “automatism.”

Automaticity: toward a theory of addiction
The answer to all the confusion over the disease concept of addiction lies in conceiving of addictions as “automatisms,” or disorders of automaticity. Automatisms are permanent developments in the central nervous system. Some are instinctive (the control of breathing and heart rate, for example), and belong to what we call the autonomic nervous system. But others are acquired as we mature (standing, walking, talking) and become permanent parts of the voluntary nervous system. All such automatisms have two things in common. First, they are irreversible. Second, once they have been initiated, they function outside conscious control.

Swimming offers an excellent example of a common automatism. Once you “get” swimming, you can never go back to being a non-swimmer. Stay out of the water for 50 years, fall off the end of a boat dock, and watch what happens. Automatically, whether you intend to or not, you’ll swim. Of course, since you don’t want to drown, that’s a good thing. But suppose that for some reason it became extremely important for you never to swim again (dangerous currents, sharks, motor boats). What choice do you actually have? Since you cannot forget or “unlearn” being a swimmer, you literally cannot choose not to swim. Your only choice is to stay out of the water.

True, a swimmer might try to enjoy the water but avoid swimming by staying in the shallows. This would be analogous to the “setting limits” stage of an addiction. The problem is that it just isn’t going to work in the long run. Sooner or later, whether or not the swimmer intended to, if he’s back in the water, his feet will leave the bottom and he’ll be swimming again - automatically. As long as he doesn’t drift out into the deep water, there may well be no problems. But that isn’t the point. The point is that despite having resolved not to swim again, he is.

In order to succeed in controlling an automatism, one must become abstinent. For a swimmer, that means staying out of the water. For an alcoholic or drug addict, it means not drinking or using.

I am not saying that all automatisms are necessarily harmful. On the contrary, our lives are filled with, and indeed made possible by, automaticity. Complex automatisms - coordinated physical movements and speech, for example - free our attention for higher levels of consciousness and choice. But that freedom comes at a cost - the loss of choice at a lower level of consciousness - experienced as powerlessness.

Again, an example will be more useful than more description: DO NOT READ THIS!

In order to experience the meaning of the phrase (and the humor), you have sacrificed choice at the level of recognition - if you look at it, you cannot not read it. Had I written instead, “Ne olvasd ezt!”, chances are pretty good you wouldn’t have understood what a Hungarian would have found so amusing. You don’t have that automatism. In that case, you would be rather like a non-alcoholic drinker who doesn’t “get” why alcoholics simply don’t control themselves better.

Addictions, then, are complex automatisms, involving the progressive automatization of feelings (urges), thoughts (obsessions) and actions (behavior). In the end, an addiction becomes Mark Twain’s all-or-nothing experience of loss of control or powerlessness. Something inside has acquired a life of its own. When that something threatens the well-being of the whole (just like runaway blood pressure), then it is rightly considered a disease.

Is addiction like other diseases?
If this conception of addictive disease fits the class of events called “illness,” it shouldn't have to be forced into place. It should fit in the same the way other, well-accepted conditions do (the “Is the sky blue?” test). Does it?

In every disease, there is an agent of harm: a hostile germ, a defective protein, an abnormal growth that disrupts the harmonious balance of physiologic and psychological functions. Alcohol, cocaine, heroin, nicotine, etc., certainly fit that definition. They are neurotoxins - nerve poisons. But mere exposure to an agent of harm doesn’t always lead to illness. Most of us are exposed to potentially harmful germs all the time. We don’t become sick because our immune systems fight those germs off. Similarly, many people are exposed to alcohol and drugs, but many of them have resistance to becoming addicted. Many different factors combine to provide this protection, and, as with other illnesses, some people are more vulnerable to developing the disease when exposed to an agent of harm of this kind. Just as the failure of resistance to a germ is a consequence of biological (hereditary and acquired), social and psychological factors, so too is the development of an addiction shaped by heredity, biochemical effects of the toxin, social conditions (availability, cultural expectations), and co-existing psychopathology.

Dangers of the disease concept
Are there dangers in the disease model of addiction? Yes, and in this, valid criticism of the medical perspective must be acknowledged. Addictions are chronic conditions in which the capacity for and exercise of choice play the major role in recovery. Like other patients who have lost control of a part of themselves (e.g., becoming paralyzed after a stroke), alcoholics and addicts must not only want to recover, they must be willing and able to work at recovery and rehabilitation. Regimented clinical studies over the past 30 years with alcoholics and addicts, show that it is best accomplished if they will become a dedicated, active member of a 12-Step group. Indeed, I conceive of my role and the role of treatment programs as helping people overcome obstacles to doing just that. There are many different kinds of obstacles: physiologic (withdrawal), psychological (denial, co-existing psychopathology), social (family dysfunction, unemployment), and treatment needs to address all of them. But the ultimate goal, to my way of thinking, is to help our patients find their way to a 12-Step group - not to substitute for it.

If the disease concept of addiction gives alcoholics and addicts the message that treatment providers are somehow going to do the work of rehabilitation for them, then it does them great harm. On the other hand, if the concept of addictions as disorders of automaticity clarifies the question of who is responsible for what, then it can be very helpful. The whole question can be summed up pretty simply, and the summary is consistent with illness in general: No one is responsible for having become sick, but everyone who has an illness is responsible for doing what they can to recover from it. It is an error, and a potentially harmful one, to call addiction a “chronic, relapsing brain disease.” Addictions do not relapse of themselves. People who have addictions relapse. That’s why they also can recover.

The terrible problem for the recovering addict is revealed in the first noble truth of Buddhism: “Life is suffering.” Put simply, none of us, recovering addict or “normie,” wants to suffer. Nevertheless, some suffering is inevitable. All of us strive to avoid it when we can and to escape it as quickly as possible when we cannot. But alcoholics and drug addicts have the extra burden of knowing precisely how to get rid of pain - drink or use. After a lifetime of changing their state of consciousness at the drop of a hat, the alcoholic or drug addict must become willing to experience “life on life’s terms - not because it’s morally better, but because it’s the only viable alternative to a path that leads to relapse.

This is why participation in one of the 12-Step groups, with their emphasis on spirituality, is so important. However one conceives of a Higher Power (the group, humanity, nature, God, whatever), without a sense of something greater than myself to which I am responsible, there is simply no reason to endure the pain inherent in living, let alone recovery. In this also, addiction is just like other illnesses. As the great French surgeon Ambroise Pare said nearly 500 years ago, “I merely dress the wound. God heals it.” There’s something in that lesson for all of us.


Why can’t addicts quit on their own?

Many addicts initially believe they can stop on their own. Most try to stop without treatment. While some do succeed, others need additional help. This could include attending self-help meetings such as Alcoholics Anonymous (AA), or reaching out to an addiction treatment center or counselor.

Research shows long-term substance abuse or behavioral addiction results in significant changes in brain function. This remodeling may cause behavioral changes, including the compulsion to act out despite the adverse consequences. This is the defining characteristic of an addiction.

Understanding this important biological component may help explain why some individuals find difficulty in achieving and maintaining abstinence without treatment.

What are the risk factors for addiction?

It is difficult to understand why some people get addicted and some do not. Many factors can add to an individual’s risk for developing an addiction. Research has identified four underlying or predisposing factors that can lead to addiction.

  • Physical
    • Family history / Genetics
    • Acute/chronic illness or pain
    • Tolerance levels and addictive substance metabolization processes
  • Psychological
    • A sustained desire to change the way you feel - for relief, to increase pleasure, to conform, etc.
    • A history of trauma or abuse (sexual, physical or emotional)
    • Psychological disorders such as depression and anxiety
    • Other behavioral addictions such as sex addiction, problematic gambling, etc. or an eating disorder
  • Social
    • Problems at home or work, stress, isolation etc. affecting your psychological state
    • Easy access to addictive substances or activities
    • Social customs and norms
    • Dysfunctional social environment and addictive pattern of family members and friends
  • Spiritual - A low level of spirituality, including not having a meaning of life, lack of strong values and religious beliefs

What is the key to long term recovery?

One of the most important components of recovery is aftercare or continuing care - the counseling, support, and tools you receive following the formal treatment process. Externally validated research studies show an 83% success rate for clients who participated in an aftercare program, i.e., relapse prevention therapy, weekly counseling sessions, recovery coaching, self-help support groups, and when present, psychotherapy for co-occurring disorder.

What Happens to Your Brain When You Take Drugs?

Drugs contain chemicals that tap into the brain’s communication system and disrupt the way nerve cells normally send, receive, and process information. There are at least two ways that drugs cause this disruption: (1) by imitating the brain’s natural chemical messengers and (2) by over stimulating the “reward circuit” of the brain.

Some drugs (e.g., marijuana and heroin) have a similar structure to chemical messengers called neurotransmitters, which are naturally produced by the brain. This similarity allows the drugs to “fool” the brain’s receptors and activate nerve cells to send abnormal messages.

Other drugs, such as cocaine or methamphetamine, can cause the nerve cells to release abnormally large amounts of natural neurotransmitters (mainly dopamine) or to prevent the normal recycling of these brain chemicals, which is needed to shut off the signaling between neurons. The result is a brain awash in dopamine, a neurotransmitter present in brain regions that control movement, emotion, motivation, and feelings of pleasure. The over stimulation of this reward system, which normally responds to natural behaviors linked to survival (eating, spending time with loved-ones, etc.), produces euphoric effects in response to psychoactive drugs. This reaction sets in motion a reinforcing pattern that “teaches” people to repeat the rewarding behavior of abusing drugs.

As a person continues to abuse drugs, the brain adapts to the overwhelming surges in dopamine by producing less dopamine or by reducing the number of dopamine receptors in the reward circuit. The result is a lessening of dopamine’s impact on the reward circuit, which reduces the abuser’s ability to enjoy the drugs, as well as the events in life that previously brought pleasure. This decrease compels the addicted person to keep abusing drugs in an attempt to bring the dopamine function back to normal, except now larger amounts of the drug are required to achieve the same dopamine high - an effect known as tolerance.

Long-term abuse causes changes in other brain chemical systems and circuits as well. Glutamate is a neurotransmitter that influences the reward circuit and the ability to learn. When the optimal concentration of glutamate is altered by drug abuse, the brain attempts to compensate, which can impair cognitive function. Brain imaging studies of drug-addicted individuals show changes in areas of the brain that are critical to judgment, decision making, learning and memory, and behavior control. Together, these changes can drive an abuser to seek out and take drugs compulsively despite adverse, even devastating consequences - that is the nature of addiction.

Are Alcoholics Really Different than Addicts?

“When I first got sober, I remember going to AA meetings and identifying as an alcoholic and an addict,” explains Tom, a 57-year-old businessman from Santa Cruz, CA who’s seventeen years sober. “But then my sponsor told me that if I was going to identify as both, I better put two dollars in the basket: one for each. I got the feeling that I had to choose between them - that I was either an alcoholic or an addict, but I couldn’t be both.”

Candy, another member of Alcoholics Anonymous, says, “There’s almost an unspoken taboo in AA where you’re not supposed to talk about drugs or refer to yourself as an alcoholic and addict.” With only 18 months of sobriety, Candy, who has blonde looks and an easy smile, admits that she’s just as judgmental as the next person. “I can tell there’s a resistance because I think the same way,” she admits. “I snicker when someone identifies as an alcoholic and addict, but the fact is that everyone in that room is an addict - they’re just addicted to alcohol.”

Dan identifies solely as an alcoholic, yet he realizes that his addiction looks no different than the meth user sitting next to him in a meeting.

How much do alcoholics and drug addicts really have in common?

Let's look at the similarities as well as the differences. Dr. John Sharp, an addiction-focused psychiatrist who specializes in the integration of mood disorders and addictions, says, “Alcoholism is an addiction - it’s just one type of addiction. When you break out the specific things that someone who is suffering from alcoholism contends with - impaired control, preoccupation with a drug, using despite adverse consequences, distortions in thinking, most notably along the lines of denial - they are no different from any other type of addict.” Sharp explains that the definition of addiction as been even further tweaked. “Recently, the American Society of Addiction Medicine came out with an updated definition of addiction, which identified five other aspects: inability to abstain consistently, impairment of behavioral control, cravings, diminished recognition of significant problems, and dysfunctional emotion responses. I think it’s fair to say you can apply those aspects to both drug users and alcoholics.”

Either way, when someone’s brain reacts in an addictive way to one substance, they will no doubt act that way to any substance, which is why so many struggle when they quit one drug only to pick up another. For many heroin addicts, alcohol is their way out of their primary addiction. For others, it might be marijuana. But at the end of the day, for many addicts/alcoholics, it all becomes the same. As Tom, the Santa Cruz alcoholic/addict, says, “I can be addicted to anything: women, booze, meth, cigarettes, food. The fact that I call myself an alcoholic is really just so that I can relate to other alcoholics. We’re all the same when we say that. I’m no more different or special than the drunk next to me, and chances are, we’ve both been addicted to drugs.”

Says Dan, a 42-year old college professor from California who realized he was an alcoholic after years of coming to class drunk, “I always figured that there are different types of Anonymous organizations so we have the ability to connect to other people’s stories, but whether its gambling or sex or booze, addiction creates the same obsession of the mind and the inability to remove yourself from the addiction when you’re in it.” According to addiction psychiatrist Dr. Reef Karim, he’s right. “There is no clinical term for addiction,” he says. “It is more of a pop culture term than a scientific one. The true definition is substance use disorder, which can be anything - meth, cocaine, alcohol. And then there are non-substance use disorders, which could be sex, gambling or porn. We define all of it as addiction. What’s the difference between alcohol and addiction? Words. Addiction describes the brain changes and behavioral changes that create consequences in your functioning.”

And for many alcoholics and addicts, these changes are the same. Dan identifies solely as an alcoholic but he realizes that his addiction looks no different than the meth user sitting next to him in a meeting. “I think the reasons for having an addiction are the same,” he says. “We’re all trying to fill that same hole, that same void, with outside things. I do think that different addictions mean different effects on the brain chemistry and different chemicals affecting the body, but at the end of the day, we are both battling the same disease.”

Dr. Karim concurs, explaining how different drugs can affect the physiology of a substance user differently. “Each drug has its own specific challenges and battles,” he says. “When you’re looking at meth, there is a really strong neurotoxicity for the brain. Meth addicts not only have impairment but they can destroy neurons in the brain. With cocaine, there is more of a cardiovascular problem. One of the biggest troubles with alcohol is actually cultural. It is a social lubricant, and it is really big business. That’s why it’s everywhere. You can work an AA program, and do therapy, and get medication, but there are going to be triggers everywhere with alcohol. People go to bars all the time; they don’t go to crack houses.”

For Tom, alcohol ultimately became the deadliest addiction. “There were times when I put down the hard drugs, and that’s when it really got scary,” he confesses. “Alcohol compromised me in ways that cocaine, and even meth, never could. It turned me into a different person - one who made decisions that the sane and sober Tom never would. And I would think, ‘It’s only booze.’ But booze for an alcoholic is just as dangerous as crack.”

Dr. Sharp agrees. “Alcoholism shows up like all addictions do,” he says. “The only difference is that alcohol is more prevalent. It’s the most widely used drug in the world, and it’s a normal part of many cultures. But people who are vulnerable to addiction run into trouble with it in the same way they would run into trouble with substances that they might need to reach out for more, like illegal drugs which aren’t as widely available.”

For Candy, ultimately it didn’t matter whether she was battling booze, pain medications, or an eating disorder. “Addiction is addiction,” she states. “I have bulimia and it’s been just as hard to recover from as it has been to recover from alcoholism, and recovering from pills is just as hard as recovering from drinking. It’s all f---ing hard. Ultimately, as long as we think the drug or the behavior will make us feel better, it will always be difficult to find recovery or abstinence.”

“Both addicts and alcoholics have a disease that’s impacting their brain from a reward circuitry standpoint by telling them that drinking or using is a positive behavior,” says Kirim. “And there’s probably something else going on - like an anxiety or a spiritual problem. But then you also have the direct affect of the drug on the brain. So in one way, you’re dealing with one drug /alcohol disorder in terms of its causes but then you’re also dealing with two different disorders in terms of their consequences on the brain and the body.”

Tom has seen the different effects of both, but believes it’s all one disease. “There are many alcoholics who become addicted to other substances, and there are a lot of people who are addicted to drugs and when they stop the drugs, they become to addicted to alcohol,” he says. “I almost wish that Bill Wilson (founder of AA) had defined himself as an addict, too. I don’t think the disease is selective to the substance; some people just have a preference for the type of escape they like to have.”