ADDICTION: Signs, Symptoms & Treatment

INTRODUCTION

Addiction does not happen overnight, although people seeking treatment have shared stories of how they experienced strong cravings almost immediately after their first drink or use of a drug.  It is important to understand that they are the exception and that it is not the norm for becoming an addict.

The norm is that most people slide gradually into addiction and can stay in one of the stages of addiction for long periods until they finally reach the addiction stage where they must admit that they have lost control over their behavior and the substance(s) they have been using.

This gradual descent into addiction is the reason why addiction is such a controversial and difficult subject.  While moving through the stages the addict does not think of him/herself as an addict and often still has a sense of being in control and feel that they know what they are doing.

Until they are not, and they do not.

Addiction is not like any other disease where you start feeling sick, go to the doctor, get medicine and then get better.  A substance use disorder is more than its symptoms, it is a chronic disease that develops slowly and lasts a long time.

It is also an often-relapsing diseases, which means that recovery will go hand in hand with relapse.  What is interesting is that the relapse rates for substance use disorders are very similar to other chronic conditions including diabetes, hypertension and asthma.

Chronic substance use affects memory, motivation, learning, movement, emotion, judgment, and the reward-related circuitry in the brain.  This happens because chronic substance use floods the brain with dopamine.  First teaching a person to use more of the substance that produced such a pleasurable effect and secondly keeping the brain from producing enough dopamine on its own, leading to a cycle of continued use to feel alive, happy or even normal.

At the core of all addictive behaviors is the recurring use of a substance or the recurring engagement in an activity and before anyone can be diagnosed with a drug or behavioral addiction certain symptoms of the disease must be present and prominent in someone’s life.

Various addiction groups have their own sets of questions you can answer before deciding if you want to join a group. 

One of these tests was prepared by the John Hopkins University Hospital in 1930 to help people self-assess whether they have a drinking problem.

The first problem with this “test” is that it is severely outdated and out of step with reality and the focus is on inappropriately broad definitions.  The second concern is that it is used so widely at rehab centers and addiction group meetings during the introduction sessions that it can cause someone new to feel overwhelmed by the questions and the “results” of the test. 

Even though the disclaimer reads that the test “is not a professional screening tool, nor has it been validated and judged reliable” (NCPHP | Johns Hopkins Questionnaire | North Carolina Physicians Health Program (NCPHP), 2020) in some cases people are wrongly “diagnosed” as alcoholics and “labelled” (or label themselves) as alcoholics after answering the questions.  It can make them feel like they must be alcoholics because they have all or most of the “symptoms” described in the questions.

Using this test isn’t “bad/wrong”, when used in the correct context while keeping in mind that the “results” cannot be interpreted as a clinical diagnosis, it can be a very useful tool to help determine if someone’s alcohol use is becoming problematic.

(NCPHP | Johns Hopkins Questionnaire | North Carolina Physicians Health Program (NCPHP), 2020)

In May 2013, the American Psychiatric Association (APA) released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, also often called the DSM-V or DSM-5.

The DSM-5 is non-theoretical and the standard text on the names, symptoms, and diagnostic features of every recognized mental illness.  It is used by medical health professionals, like psychiatrists to make a clinical diagnosis of psychiatric illnesses, including substance use disorder.

To assess an individual using the DSM-5, a professional must be aware of the signs and symptoms revealed during sessions with clients and know the difference between them.

  • Symptoms are subjective and they are what a person can feel and that is what they complain about, physical illness.
  • Signs are objective and what the professional, family and friends can observe when looking at someone.

The DSM-5 also makes a cautionary note regarding symptoms that reads:

“The symptoms contained in the respective diagnostic criteria sets do not constitute comprehensive definitions of underlying disorders, which encompass cognitive, emotional, behavioral and physiological processes that are far more complex than can be described in the summaries.” (Diagnostic and Statistical Manual of Mental Disorders, 2013)

The DSM-5 section on “Substance-Related and Addictive Disorders” includes two sub-categories:

  1. Substance use disorders catalogue the negative consequences of continued and frequent use of substances, which are not immediate but occur over time as the addiction progresses.
  2. Substance-induced disorders refer to the immediate effects of substance use, called intoxication and the immediate effects of discontinuing a substance, called substance withdrawal.

Below we look at the criteria that are based on decades of research and clinical knowledge, for diagnosing a person with a substance use disorder.

Regardless of the substance, the diagnosis of a substance use disorder is based upon a pathological set of behaviors (signs and symptoms) related to the use of that substance.  They are:

  1. Taking the substance in larger amounts or for longer than you’re meant to.
  2. Wanting to cut down or stop using the substance but not managing to.
  3. Spending a lot of time getting, using, or recovering from use of the substance.
  4. Cravings and urges to use the substance.
  5. Not managing to do what you should at work, home, or school because of substance use.
  6. Continuing to use, even when it causes problems in relationships.
  7. Giving up important social, occupational, or recreational activities because of substance use.
  8. Using substances again and again, even when it puts you in danger.
  9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
  10. Needing more of the substance to get the effect you want (tolerance).
  11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.

DSM-5 guidelines for the diagnosis of a substance use disorder requires that the individual have significant impairment or distress from their pattern of substance use, and at least two of the symptoms listed below in a given year. (Diagnostic and statistical manual of mental disorders, 2013)

The 11 diagnostic criteria are divided into the four main categories as shown below.

Godier-McBard, Lauren & Park, Rebecca. (2015).

The DSM-5 further uses a dimensional scale to estimate the severity of addiction and is based on the total number of symptoms matching the diagnostic criteria and ranges from mild-to moderate-to-severe.

The scale as part of the diagnosis:

MILD                     : 2 – 3 symptoms

MODERATE         : 4 – 5 symptoms

SEVERE                 : 6 or more symptoms

We can conclude from the discussion above that diagnosing anyone, with a substance use disorder or addiction of any kind, is a challenging task, sometimes even for the experts. 

It is especially difficult in cases where substance abuse and mental health disorders occur together, making it very challenging for health professionals to figure out what exactly is going on. 

For a person who is not trained in this type of work, it can be hard to understand how doctors and addiction experts determine whether someone has an addiction or are simply abusing a substance, or whether what seems to be a mental health disorder may be a substance abuse problem.

These situations can be even harder to understand for the person seeking treatment and their loved ones involved in or affected by the issue.

TREATMENT OPTIONS

The first step towards recovery is acknowledging that substance use or addictive behavior has become a problem in your life and that it is actively disrupting the quality of your life and those around you.

Once someone recognizes the negative impact of a substance or behavior on their life, a wide range of treatment options is available. 

I t is important that someone have access to treatment, if they need to walk miles or travel from town to town, they will most likely not go for treatment.  For most people, treatment may last for the rest of their lives and for that reason the access to treatment on a continual basis is very important.

Treatment options for addiction depend on several factors, including the type of addictive disorder, the length and severity of use and the effects the addiction had on someone.  A doctor will also treat or refer for treatment any physical complications that have developed, such as liver disease in a person with alcohol use disorder or respiratory issues in people with an addiction to substances which have been smoked.

Several treatment options are available and most people experiencing addiction will receive a combination of treatments from a multi-disciplinary team, consisting of a psychiatrist, psychologist, social worker, and an occupational therapist. 

It is important to remember that every addict is different, it does happen that family or friends can get discouraged and sometimes even blame the addict for not getting better due to a lack of understanding that treatment is not a “one size fits all” approach.

Detoxification

Detoxification is normally the first step in treatment and involves clearing a substance from the body and limiting withdrawal reactions.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA) in 80% of cases, a treatment clinic will use medications to reduce withdrawal symptoms. (America’s Need for and Receipt of Substance Use Treatment in 2015, 2017)

If a person is addicted to more than one substance, they will often need medications to reduce withdrawal symptoms for each.

In 2017, an electronic device called the NSS-2 Bridge became available to reduce opiate withdrawal, the device sits behind the ear and gives off electrical pulses to trigger certain nerves that might provide relief from withdrawal symptoms. (BRIDGE Device | Innovative Health Solutions, 2018)

Counselling and behavioral therapies

This is the most common form of treatment following detoxification.

Therapy might occur on a one-to-one, group or family basis depending on the needs of the individual and is usually intensive at the outset of treatment with the number of sessions gradually reducing over time as symptoms improve.

  • Cognitive-behavioral therapy, which helps people recognize and change the way they think about the associations they have made with substances.
  • Multi-dimensional family therapy; designed to help improve family function around an adolescent or teen with a substance-related disorder.
  • Motivational interviewing, which maximizes someone’s willingness to change and adjust behaviors.
  • Motivational incentives that encourage abstinence through positive reinforcement.

Counselling for addiction aims to help people change behaviors and attitudes around using a substance, as well as strengthening life skills and supporting other treatments.

Some forms of treatment for addictive disorders focuses on the underlying cause of the addictive disorder in addition to behaviors characteristic of the addiction.

Rehabilitation programs

Longer-term treatment programs for substance-related and addictive disorders can be highly effective and typically focus on remaining drug-free and resuming function within social, professional, and family responsibilities.

Fully licensed residential facilities are available to structure a 24-hour care program, provide a safe housing environment and supply any necessary medical interventions or assistance.

The following facilities can provide a therapeutic environment:

  • Short-term residential treatment focuses on detoxification and preparing someone for a longer period within a therapeutic community through intensive counselling.
  • Therapeutic communities are for someone seeking long-term treatment for severe forms of addictive disorders and they live in a residence for between 6 and 12 months with on-site staff and others in recovery.  The community and staff serve as key factors in recovery from and changes in attitudes and behaviors toward substance use.
  • Recovery housing provides a supervised, short-term stay in housing to help someone engage with responsibilities and adapt to a new, independent life without on-going substance use. 

Self-help groups

Group therapy can help someone with a substance use disorder feel less isolated and may help them meet others with the same addictive disorder which often boosts motivation and reduces feelings of isolation.

Examples of self-help groups include Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).

People who are struggle with other types of addiction can find out about self-help groups in their community either by an internet search or by asking a doctor or nurse for information.

Medications

Sometimes it is necessary for someone to take medication on a continuous basis when recovering from a substance disorder and its related complications.

It is very important to note that when medications are necessary it can usually only be prescribed by the psychiatrist treating the addict, trying to self-medicate or take medicine from anyone not qualified will lead to more complications and addictions.

The medication will vary depending on the substance that the person is addicted to and the longer-term use of medications helps to reduce cravings and prevent relapse or a return to using the substance after having recovered from addiction.

Specific medications are required for the treatment of specific substances, below a list of medications that can assist with addiction to alcohol:

  • Naltrexone, prevents the action of opioid receptors in the brain that produce rewarding and euphoric effects when a person consumes alcohol and reduces the risk of relapse.
  • Acamprosate, might reduce long-term withdrawal symptoms, including sleeplessness, anxiety and a general feeling of unhappiness known as dysphoria.  This has a more beneficial effect in people with severe substance-related and addictive disorders.
  • Antabuse, is medication that disrupts the breakdown of alcohol, leading to adverse effects including facial redness, feeling sick and an irregular heartbeat should the person in recovery attempt to consume alcohol.  It basically acts as a deterrent for people who have high motivation levels toward recovery.

Doctors and rehabilitation specialists may prescribe other medication to address other possible mental health conditions, including depression and anxiety that may be the underlying cause or result of substance use disorders.

People in treatment programs should also receive testing for infectious diseases that might have resulted from certain high-risk situations associated with their addictive disorders such as HIV, hepatitis, and tuberculosis, in order to be treated for that as well.

Whatever the treatment under consideration, there are number of features to look for to identify an effective program:

  • Patients undergo comprehensive medical and psychiatric screening.
  • Treatment addresses individual needs, including co-occurring conditions, whether chronic pain, anxiety, or hepatitis.
  • Families must be allowed to be involved in treatment.
  • There is continuity of care via active linkages to resources in subsequent phases of recovery.
  • The facility maintains a respectful environment.
  • Treatment services are evidence-based and reflect best practices.
  • Staff members are licensed and certified in the disciplines they practice.
  • The program is accredited by a nationally recognized monitoring agency.
  • Patient response to treatment is monitored and the program or facility offers outcome data reflecting treatment performance.

Statistics on addiction recovery

(Information extracted from Addiction Statistics | Drug & Substance Abuse Statistics, 2020)

  • In 2017, an estimated 20.7 million people aged 12 and older needed treatment for a substance use disorder.  Only 4 million people received treatment or about 19% of those who needed it.
  • In 2017, of the more than 18 million people who needed but did not receive treatment for substance use, only 1 million or 5.7%, of those people felt they needed treatment.
  • Alcoholics Anonymous (AA) has more than 120,000 groups in more than 175 countries around the world with more than 2 million members.
  • There are over 14,500 specialized substance abuse treatment facilities in the United States providing a variety of care options, including counselling, behavioral therapy, medication, case management and other forms of care.
  • The relapse rate for substance use disorders is estimated to be between 40% and 60%.
  • Addiction is considered a highly treatable disease and recovery is attainable.
  • About 10% of American adults who are at least 18 years say they are in recovery from an alcohol or drug abuse issue.

CONCLUSION

Substance use disorder / Addiction doesn’t have to end a person’s life.  When the signs and symptoms are seen by those around the addict and they get the proper treatment they need with the support of loved ones it can be overcome.

REFERENCES

  • DSM-5. 2013. Diagnostic And Statistical Manual Of Mental Disorders. Washington (D.C.): American Psychiatric Publishing.
  • Ncphp.org. 2020. NCPHP | Johns Hopkins Questionnaire | North Carolina Physicians Health Program (NCPHP). [online] Available at: https://ncphp.org/johns-hopkins-questionnaire/ [Accessed 1 May 2020].
  • Recovery Direct Rehab in Cape Town. 2020. Most Commonly Abused Substances In South Africa. [online] Available at: https://www.recoverydirect.co.za/commonly-abused-substances-south-africa/ [Accessed 24 May 2020].
  • Studylib.net. 2020. 20 Questions AA Alcohol. [online] Available at: https://studylib.net/doc/9278241/20-questions-aa-alcohol [Accessed 1 May 2020].
  • Very well Mind. 2020. The Symptoms Used To Diagnose Substance Use Disorders. [online] Available at: https://www.verywellmind.com/dsm-5-criteria-for-substance-use-disorders-21926 [Accessed 1 May 2020].