The Cause of Substance Abuse
Why do people use alcohol or drugs? There are many ideas. Let me name a few.
The biological, or genetic marker theory states that some people are more genetically predisposed to become substance users based on biological factors.
There are also social reasons for use. This idea suggests drinking or using drugs is more accepted and practiced in some cultures or sub-cultures than other cultures, thereby increasing the likelihood of any person within that culture or sub-culture to use.
There is the idea that people use alcohol and drugs to self medicate. This theory states that people find relief in chemicals due to psychological reasons or to numb uncomfortable feelings.
There is also the simple theory that drugs work. If a person feels like “A” and taking drug “B” results in feeling like “C” and “C” is better than “A”, then why not?
We really don't know what causes substance abuse since there can be many reasons why a person continues using but knowing why a person uses is not a requirement to changing a person’s use.
It is not a requirement for a person to understand their use in order to change their use.
Knowing why a person uses does not mean they will do anything differently. They might simply become a smarter drunk. Changing use requires changing behavior, which does not require changing intelligence.
Why Someone Stops Using
There may be many reasons why someone starts uses alcohol or drugs. But why does someone stop using?
Different people stop using at different stages, but everyone stops using for the same reason.
The simple reason people stop using - and the only reason - is they have accumulated and experienced enough consequences from their use that they want to stop.
In Twelve Step language this is called "hitting bottom". It has finally gotten bad enough and the person wants to stop making things worse.
All people stop abusive use of chemicals when the consequences have become too great.
What might you guess is the greatest reason prompting adults to stop using alcohol or drugs? Loss of family? Loss of driving privileges? Loss of life or limb? Loss of freedom, being put in jail?
The strongest reason for an adult to decide to change their drinking or drugging is real or potential loss of job.
Strange, but true.
I’m not sure why this is true. Perhaps it is due to the fact that we are often identified by our occupation. When you go to a party, what your name is and what you do for a living are often asked one in front of the other. Or perhaps it’s simply harder to buy drugs without money. Or perhaps there is a greater stigma attached to getting fired than to becoming divorced, hospitalized or a drunk.
Stages of Use
We know everyone stops using for the same reason and everyone starts at the same place. (Unless you were born addicted.) There are a few different models regarding the stages of use. The sequence I use is: Experimentation, Misuse, Abuse and Dependence.
There has to be a first-time use. This time must be experimental in nature as there is no personal or internal experience to compare it to.
There are plenty of stories of kids sneaking cigarettes behind the store, being given a splash of beer at a summer party, raiding the liquor cabinet before a home football game or being ‘turned on’ to drugs or alcohol by an older family member.
Everyone starts at the stage of Experimentation, unless a person was born addicted.
During the stage of Experimentation the person:
- The person does not know the effects of the chemical, the duration of the high and the correct dosage levels.
- The consequences a person may experience are likely due to their inexperience.
During Experimentation, the individual is learning the effects of any particular drug. Mistakes - or unintentional overdoses - can take place.
Throwing up in your neighbor’s hedge, staying up uncomfortably wired through the night into the day, car accidents, and worse yet, waking up next to someone you barely know can be common examples of consequences due to inexperience with the effects of a particular drug. During this stage of use most consequences are the result of poor judgment.
Why do some people stop at this stage and others merely consider any consequences as bragging rights? Again, people stop when it has gotten bad enough for them. Therefore, some might not want to repeat an incident of vomiting on the neighbor’s porch, or waking up to a stranger. Other folks may find these same results as hilarious.
Some people will stop at this stage, and some won’t. When people continue with their use, they may easily continue to the next stage – Misuse.
|In Misuse, the individual is:|
- Likely deciding their drug of choice.
- Continue to use and accumulate consequences from poor judgment.
- The individual begins to develop a more observable drug lifestyle.
- Likely beginning to experience larger consequences.
In Misuse, social groups are formed based on they types of preferred drugs. Pot smokers are hanging out with other pot smokers, acid heads keep to their own, drinkers know who each other are, and so on.
In Misuse, the individual may glorify using. They will likely know who to get their alcohol or drugs from. They can better handle dosage and duration of use.
As larger consequences start to show up adolescents’ grades may begin to slip. Family and friends may begin to express concern for the individual. Teens may have a run in with the law, or their first car accident while under the influence. More severe consequences can be alcohol poisoning, unwanted pregnancies or abortions, falling grades, and decreased performance in sports.
Some people decide these consequences are enough and stop or successfully curtail their use. Others see these problems as temporary and do not want to interfere with the fun they are having.
When people continue with their use, they likely will continue to the next stage – Abuse.
In Abuse the person:
- Has already decided upon their drug of choice. They have a good working knowledge of dosage, duration and effects.
- The person has stable sources of supply and funds to keep their use going.
- The person is strongly identified with a partying and drugging lifestyle.
- The person is not meeting his or her responsibilities and schoolwork or job performance is suffering. Others are now more openly concerned for the individual.
- The person may have even lost some relationships due to use and may be starting to accumulate legal and financial consequences.
- The person is likely to develop tolerance and withdrawal.
As use continues, so do consequences. At this stage, the abusing person may have others covering for him or her at work or school. Within this stage treatment will usually require some form of organized structure and support.
As before, some people may find these consequences to be too much. Others will not and will disregard the concern of friends and family.
It is not uncommon to see denial, displacement of responsibility and rationalization as handy tools utilized to justify and keep use going.
Click here for a printable checklist of the DSM-IV Criteria for Substance Use Disorders made available from Project CORK.
- The individual is fully identified with a using lifestyle.
- Drug of choice has long been established.
- The individual has a good working knowledge of dosage and duration.
- They have established routes of supply and funding for their continued use.
- They have developed tolerance and will likely develop withdrawal from stopping use.
- Withdrawal in this stage may require medical supervision.
- Treatment will require lengthy structure and support.
- The individual’s primary relationship is with the chemical.
- The individual will likely have developed progressive consequences related to health, legal, financial, relationship and work/school.
In earlier stages, use creates an alternate reality. In dependence an individual will use to feel normal. Others are required to play a codependent role to help the individual keep their use going within work and family systems. The relationship with the chemical becomes more important than personal or professional relationships. Denial, blaming others and lack of responsibility are well entrenched reactions to people, information or experiences which threaten continued using.
Point of Transition
As mentioned before, a person will only stop when the consequences have gotten bad enough. This marker is relative to the person. Some people will tolerate more suffering than others.
Someone having a moment of clarity realizes they must change their alcohol or drug use and may come to a professional for help. At this point of transition the person cannot go back to using but doesn’t know how to go forward without using. They are caught ‘betwixt and between’. Knowledge the behavior must stop becomes apparent. Only how remains elusive.
Abstinence Then Recovery
Learning why a person uses drugs or alcohol is helpful, but not a requirement to stop using.
Learning how to not use is a requirement to stop using.
As a person learns to stop using they can, in time, gain insight on why they used and continued to use.
Abstinence is learning how to not use drugs. Recovery is learning to live life without using drugs. These are two distinct things.
In recovery a person learns how to handle their emotions, deal with frustration, repair or have relationships, and how to deal with themselves. In abstinence a person learns the behavioral actions to prevent continued use.
Nancy Reagan was right with her “Just say No” campaign. It is great advice for grade-schoolers.
The problem is that some people have a practiced history of using; using has become a part of their regular lives. They have using friends, they have using bosses and spouses. Using is a part of their identity and activities.
Saying ‘no’ is both an act of courage and desperation since others in their life may want them to continue using. Ultimately, saying ‘no’ is the right and required thing, but it’s just not that easy.
In order for a person to be successful in the period of Abstinence they need to focus on structure and support.
Structure is how a person utilize their time:
- Go to Twelve Step meetings instead of the bar.
- Call one's sponsor instead of one’s dealer.
- Make time to read recovery literature. Replace times spent using with more productive activities.
Structure is scheduling what to do with time instead of using. Structure is also developing behavioral plans to deal with cravings or the potential of relapse.
- People providing thoughts and information which helps the abstinent person not think in the ways a using person does.
- Information that helps the person learn how to maintain abstinence and live recovery.
Abstinence and recovery are a behavioral, emotional, psychological and sometimes spiritual process. To be successful a person would do well to address all areas.
Once abstinence is achieved, a person can begin to move into the process of recovery.
A general rule of thumb is that the chronological age at which a person started using with consistency is the emotional age at which they will later begin to learn how to live life without the aid and detriment of alcohol or drugs.
As an example, you have a person who starts consistent use at age seventeen. They consistently use until the age of thirty six. When the person decides the consequences of their use are too great and they must change or stop their use, they will bring to the table all the emotional skills of a seventeen year old adolescent to help them make the changes needed.
Can a Person Return to Social Use?
This is the question many addicted people want to know.
Can a person who previously had a problem with alcohol and drugs return to a level of use that does not cause problems? Are there people who have accomplished this? Yes. Are there people who can never return to social use? Yes.
How, then, can someone tell if they will be lucky to have their cake and eat it too? In other words, can they have the social and chemical fun of use, without the consequences?
The danger in asking this question is the individual must risk progressive consequences in order to find out.
The questions I ask are, “What consequence (loss of job, divorce, physical injury) are you willing to risk in order to find out if you can return to social drinking? What would be the worst consequence you could experience convincing you that you cannot be a social drinker?”
Can a Person Achieve Recovery Without Treatment?
Yes, but it is difficult.
And, what do we mean by treatment? If a person decides to stop, but does not attend a formal treatment program, nor attend AA, but finds enough structure and support from their church, as an example, can they recover?
They can learn to live life without alcohol and drugs because they will have learned and practiced a different way of thinking and acting that is no longer similar to the ways addicts think and act.
Formalized treatment or AA are not the only two ways a person can practice recovery.
Without some form of systemic change though, a person may be abstinent, but not in recovery. They are called a “dry drunk”. The person does not use, but still acts and thinks in a way that addicts and alcoholics do.
Sometimes people do not have the goal, desire or requirement to stop all use. Some only want to modify their use, or modify one particular substance. Some people don’t want to modify their use at all, but want to decrease the accumulation of consequences.
Harm reduction is the action of looking at behavioral ways a person can lessen the harmful consequences of continued using.
Harm reduction is not abstinence and it is not recovery. And, perhaps, something done in the direction to improve the quality of one’s life by limiting consequences is better than nothing.
Choosing a designated driver is harm reduction. Needle exchange is harm reduction. Practicing safe sex is harm reduction. While these actions may not change the pattern of a person’s use, they are designed to lessen the accumulation of personal and societal consequences associated with a person’s use.
Relapse is a predictable reality for many people trying for abstinence and recovery. Relapse is a behavioral action whose end point is use. Relapse, in fact, starts long before the use takes place.
The process of relapse begins as an individual is tries navigating a problem in their life. The person tries different solutions learned through structure and support. The person does the suggested reading, makes their best effort to get supportive consultations (talks with sponsor, talks with counselor, talks with a religious advisor, calls hot lines, etc.) but the problem continues unresolved.
As internal tension mounts and healthier ways of problem solving don’t seem to be working, the person may begin to think about using as a return to earlier ways of trying to solve the problem. Drugs work and the individual knows it.
In these crucial times, as the internal tension mounts, it is so important for the individual to put even more emphasis into the recovery plan. Some, however, will find the idea of using to relieve tension too great and they begin to have ‘stinking thinking’ as Twelve Step programs say. The individual begins to return to thoughts of minimization, rationalization, displacement of responsibility, denial…and eventually use/Relapse takes place.
Cravings are short lived, intense experiences where an individual has a strong desire to use.
Cravings are experienced in abstinence, withdrawal and early recovery and require a strong behavioral plan, developed ahead of time. As the saying goes, ‘When the house is burning down, that is a bad time to develop your fire escape plan.’ Such is true for cravings.
When a person experiences a craving they need their behavioral plan well thought out and put in place. Go to a meeting, call your sponsor, read something positive, DON’T go past your dealer’s house!
I always advocate a person develop Plan A, Plan B and Plan C for the same reason NASA has redundancy built into their systems. It can be dangerous to rely on only one plan or method for continued safety.
Treatment and Referral
There are various forms of interventions for an individual with a substance abuse problem, based on the nature of the problem and goal of the client.
Is a medically supervised process during which the person withdraws from the drug.
- Should only be done under medical supervision as the consequences can be life threatening.
- Referral to a hospital is often required.
- Admission is handled by the treating facility or client’s primary doctor.
Is the likely extension from hospital based detox. In-patient treatment is highly structured and brings with it the other services of a hospital based program.
These services may be:
- Occupational Therapy
- Nursing care
- Social Services
- Family Therapy
In-Patient is extremely expensive and many insurance companies will push for some form of cheaper step down care as soon as the individual shows signs of progress/stability.
Day Treatment/Intensive Out-Patient
This non-hospitalized approach is where the individual retains the benefit of the structure and support of a regimented hospital based program, without having to stay overnight.
Within Day Treatment:
- The patient will likely be followed by a physician, counselor and/or social worker.
- Individual, educational and Twelve Step group sessions are common.
Is the standard 28 day program in which a person lives at a facility during the process of early abstinence.
- Residential programs may be able to handle detox.
- Most of these programs will be affiliated with a local hospital and/or medical treatment team.
- Residential programs offer a sobriety based environment, with a highly structured program, offering multiple levels of support (for the family, too) and an After Care program.
A less structured service in which the person meets with professionals or self help groups a number of times per week.
- The focus is usually education and support.
- Twelve Step’s most intensive approach is called, “90 in 90”, or 90 meetings in 90 days.
Is an Out-Patient approach after a person has completed more intensive treatment.
This approach often includes:
- Consistent attendance at self-help group meetings.
- Some form of individual meetings with a therapist or counselor.
- Some form of education or support meetings held at the previous treatment facility.
It is important to know that the information presented above is intended to provide a beginning understanding of substance abuse. If you are concerned about your own or another’s substance use you should consult with a licensed professional who can provide a proper evaluation and recommendation(s). If you are an unlicensed counselor or therapist in training, you should consult with your clinical supervisor when questions arise and before presenting any form of treatment options/interventions to your client(s).
To learn questions commonly used in conducting a chemical dependency assessment, you can click on C/D Assessment.