A NEW PIECE OF THE JIGSAW
Most people who use illegal drugs do not fit the image of a dysfunctional addict. At one end of the spectrum are abstainers, at the other are people with a diagnosable substance-use disorder – the grey zone in between includes the “almost addicted”. J Wesley Boyd bridges the gap.
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In almost 20 years of psychiatric practice, I have worked with people from all walks of life and treated patients with a full range of addictive behaviours in each of these groups. I have worked in settings including private practice, public and private hospitals, addiction clinics for adults and one for teenagers, academic and community facilities and even a programme assisting doctors with substance-use disorders. For the past eight years, I have worked as part of a general adult psychiatric teaching team specialising in patients with substance-use disorders in addition to general psychiatric issues. Across these settings, I have seen people with true addiction and many whose occasional drug use does not appear to be a problem. But between these people is another important group: the “almost addicted”.
These are the people whose drug [including alcohol] use does not rise to the level that would meet the criteria for a formal diagnosis of addiction but who are suffering from their drug-related behaviours. I believe there is a huge swathe of people who are almost addicted – but how do you identify them?
Someone who is truly addicted to a drug shows tolerance (needing ever-increasing amounts of their drug in order to get high), withdrawal symptoms, loss of control, inability to stop using and obsession about the drug or obtaining it. People who are ‘almost addicted’ don’t meet these criteria. Instead, their use:
>> falls outside what is regarded as normal behaviour, but comes short of meeting traditional psychiatric criteria for a diagnosable disorder
>> currently causes problems for the person or for loved ones or other bystanders
>> has the potential to progress to a diagnosis of drug abuse or dependence – but, even if it does not, can cause substantial problems.
Almost addiction falls easily into the increasingly accepted category of problems which need to be recognised and treated much earlier than they have been in the past. But many substance users who meet the definition of almost addiction see no reason to stop using drugs.
WHY SHOULD I CHANGE?
Perhaps you suspect that you are almost addicted but are still weighing the evidence one way or the other. If you are a friend or loved one of someone who is almost addicted, you might be building a case for confronting this person. In either situation, a good place to start is by considering if the drug use has already led to problems.
First, if you use drugs, examine the ways that even casual use might have impacted your life. Go through the following questions with care. Be honest. If you cannot answer any question with certainty, consider asking a friend or family member to help.
Work or school – have you ever:
> given less than your full effort at work or school because you used drugs?
> written work emails that you later regretted while you were under the influence of drugs?
> been reprimanded for performance issues?
> been asked at work if you got enough sleep?
> signed a deal while under the influence?
> divulged a business secret while under the influence?
> berated your boss or coworkers in a way you would never do if you were clean and sober?
> submitted shoddy work or schoolwork because of drug use?
> been called to a manager’s office because of something that occurred while you were using drugs or alcohol?
Family repercussions – have you ever:
> deliberately broken something of value at home?
> been asked by your family to stop using drugs?
> been told by your family that you were acting strangely?
> embarrassed your family due to drugs?
> missed an important family function due to drug use?
> used drugs in front of your child or been under the influence around your child?
> yelled at or berated a family member while under the influence, then regret it when sober?
> cheated on a partner/spouse while you were under the influence and regretted it later?
Legal repercussions – have you ever:
> been arrested for drug use or possession?
> worried about being arrested because of your drug use?
> committed a crime to pay for your drug use, even if you were not caught?
Health repercussions – have you ever:
> injured yourself while high?
> skipped a planned workout because of drugs?
> forgotten to take prescribed medication because of your substance use?
> downplayed or lied about your substance use to a healthcare provider for fear of consequences?
> went to an emergency room because of something which happened while you were using drugs?
> caught a sexually-transmitted disease because of sex while under the influence?
> had sex that you later regretted while on drugs?
If you or a loved one are almost addicted, your answers to these questions might be enough to convince you that a change is necessary. Your drug use is still manageable but you feel that an unlucky incident could knock your life off the rails. If you have become accustomed to taking drugs, you are probably conflicted about even looking at the issue, much less making changes. But ask yourself these questions as honestly as possible. And ask if there are any gaps or discrepancies between your current behaviours and the goals you have set for yourself.
If you sense that your life could be better in some way, try to determine specifically what you would like to see improved. Now consider if your drug use will interfere with meeting those goals – even to a small degree. Is it masking the roots of anxiety or depression? Do I have even one reason to change?
THE INITIAL APPEAL OF DRUGS
The reasons people use drugs are probably as varied as the people who use them. That said, over and over in my practice, I have seen clients who were self-medicating their depression, anxiety or other mood, emotional or focus disorders. I have known plenty of people predisposed toward depression whose use of drugs momentarily lifted them out of the prison of their low mood.
In the same manner, when someone is prone to anxiety, many substances of abuse calm them, especially drugs which slow the mind like benzodiazepines, alcohol or marijuana. I have also seen people with psychotic processes, such as hearing voices in their heads or seeing things that were not really there, who viewed illicit drugs as a salve for their psychiatric troubles. For those who feel awkward, angry and impatient, using drugs can help normalise their appearance and mood.
Another trait is a need for excitement or thrills. There are also plenty of exceptions, such as using drugs merely for nonconformity.
People with both mental-health issues and substance problems face greater hardships across almost every arena of life. The repercussions of combining drugs with a mood or emotional problem are massive.
But I can almost hear the person with almost addiction objecting that “I don’t use enough drugs to worry... That’s something an addict faces. OK, I am a little depressed here and there, but come on...”.
That might be a fair response. But the combination of mental-health problems and substance use that goes untreated does not bode well for anyone’s future happiness.
TIME TO GET PROFESSIONAL HELP?
If you experience any of the following, then it is probably time to get professional help:
>> persistent sadness or crying
>> anxiety beyond what is reasonable for a situation
>> excessive irritability/anger
>> apathy/not caring about things usually important to you
>> not being able to carry out the basic functions
>> thinking about suicide or that it would be better not to be alive
>> psychotic symptoms, such as feeling that you are losing touch with reality, seeing things not there, hearing voices in your head
>> feeling like you cannot control your reactions to events, especially things which previously did not bother you
>> feeling so good that you think nothing bad could ever happen to you.
Why should you explore whether you are self medicating? The answer is easy: there are many better and safer ways to treat your problems than with drugs that are potentially dangerous, usually illegal, and poorly regulated at best.
While you are covering up mental-health problems with illicit drugs, you are missing opportunities to deal with them in a more effective manner – while exposing your health and lifestyle to threats. The most obvious alternative is to seek help from a mental-health professional.
WHAT FAMILIES CAN AND CANNOT DO TO HELP A LOVED ONE
One of the most important ways to help someone who is almost addicted is what not to do: do not enable the person by covering up for his or her behaviour or helping the drug use to continue.
The reason is that not only does enabling allow the user to continue their behaviour without significant change but also that it involves you compromising yourself, doing things that probably feel wrong, and causing you to feel like less of a responsible human being than you want to be.
Also, since so much of another person’s behaviour is out of your control – and because you might be too emotionally invested in the situation to make good choices – it is a good idea to insist that your loved one attend Alcoholics or Narcotics Anonymous. Someone who is almost addicted does have something in common with the people in AA or NA: all used drugs, the drugs cause problems, the drugs could cause a life-changing catastrophe at any time, and the drug use could become worse.
And insist on a mental-health evaluation.
J WESLEY BOYD MD PhD and ERIC METCALF MPH have co-authored Almost Addicted: Is my or my loved one’s drug use a problem? (Hazelden, ISBN 978-1616491017)