As a family physician who also practices addiction medicine, it is common for me to find that patients are confused about the difference between physical dependence on a substance, and addiction. Any substance that causes withdrawal symptoms when discontinued has created a physical dependence. Withdrawal symptoms can be caused by many classes of medications and drugs – from alcohol, opiates, and benzodiazepines to some blood pressure medications, sleeping pills, and cold medicines. Withdrawal symptoms may or may not be accompanied by other features that are characteristic of addiction. If you have a surgery and take opiate medications regularly for two months and suddenly stop – you will probably have withdrawal symptoms. Having withdrawal doesn’t mean that you have become addicted to opiates – it merely means that your body has adjusted to having these medications on board and need to come off of them more gradually to avoid feeling sick. If you are taken off opiates because you are no longer in pain, and aren’t having withdrawal symptoms and just want more pain pills because you like the way they make you feel (not because you are still hurting) and you are craving them – that is more characteristic of addiction – now called substance use disorder, or SUD.
Types of Substance Use Disorder
Substance Use Disorder is a new way of looking at and diagnosing addiction that came with the DSM-V, the most recent diagnostic tool put out by the American Psychiatric Association in 2013. These criteria are based on several decades of research. The category of SUD is broken further into different categories based on type of substance used, and how severely the substance has impacted the individual’s life. The following are the different categories:
- Alcohol Use Disorder
- Tobacco Use Disorder
- Cannabis Use Disorder
- Stimulant Use Disorder (ex. meth, cocaine, Adderall)
- Hallucinogen Use Disorder (ex. LSD, Mushrooms, PCP)
- Opioid Use Disorder (ex. Percocet, heroin, fentanyl)
- Sedative Use Disorder (ex. Xanax, sleeping pills)
- Inhalent Use Disorder
- Caffeine Use Disorder
Criteria for Substance Use Disorder
Substance use disorder covers a wide range of symptoms and it focuses on problems that people may have as a result of taking a substance. There are 11 different basic criteria that make up a diagnosis of Substance Use Disorder, and they can be lumped into different groups – impaired control, social impairment, risky use, and pharmacological indicators.
People can have impaired control can show up in a number of different ways –
- Taking a substance in larger amounts or for longer than you meant to
- Wanting to cut down or stop using a substance but not being able to
- Having cravings for the substance
- Spending a lot of time getting, using or recovering from using the substance
As SUD worsens it can effect more different aspects of people’s lives –
- Struggling to meet your responsibilities at home, school or work due to substances
- Giving up activities due to substance use – social or work-related
- Continuing to use despite causing relationship problems
Continued use despite the harm that it can cause to your person –
- Continuing to use despite knowing you have a physical or mental health problem that could have been created by or made worse by the substance – like cirrhosis and continuing to drink
- Using the substance in a way that could put you in danger – such as using drugs while driving
These can develop as part of regular use, but may or may not be indicators of SUD –
- Tolerance – needing more of a substance to get the desired effect
- Withdrawal Symptoms – which are relieved by taking the substance.
The Severity of Substance Use Disorder
If an individual has 1 of these 11 above symptoms – ex. just the withdrawal symptoms – it does not indicate that they have a substance use disorder – just that they have become physically dependent on that substance.
- If a person has 2 or 3 of the above symptoms then that may indicate a mild substance use disorder,
- 4-5 symptoms indicate a moderate substance use disorder,
- 6 or more indicate a severe substance use disorder.
I have had some patients who thought that because they were still functioning well at their job, and their family wasn’t aware, and they were still participating in their same activities – they didn’t have a substance use disorder. It is true that person likely doesn’t have severe substance use disorder. However, if they are now having health problems that are related to their substance use, have tried to stop and haven’t been able to, then they probably have at least a mild substance use disorder. If you think about the person who has been diagnosed with COPD and told by their physician that they need to stop smoking – and find that they are unable to quit – that person probably has at least mild tobacco use disorder.
Treatment for Substance Use Disorders
The first thing that people need to realize is that they are not alone. There are millions of people in the US who deal with substance use disorders every year – and many of them recover from it. The earlier a person is in their substance use disorder, the easier it is for them to make changes. However, it is never too late. The thought that a person has to hit bottom before they make a behavior change is not true. The goal of getting someone into treatment is to keep them from hitting that bottom and allowing them to get back what they have lost due to the substance use disorder, and minimizing future damage.
I recommend that people talk openly with their physicians about their substance use so that they can learn about how it may be affecting their health and what is the best way to get healthier. Also, there are some substances, such as benzodiazepines and alcohol, that when stopped abruptly can be dangerous to one’s health – leading to withdrawal symptoms such as anxiety, agitation, hallucinations, and seizures. These problems can often be avoided by appropriate treatment. Talking with your physician also gives the doctor a chance to be aware of any things that they may need to do differently when treating you – so that they don’t hurt you by accident. I have seen multiple cases of someone with an opioid use disorder that is in remission, end up relapsing due to being prescribed opiates for an injury “just in case they need them.”
I base recommendations for substance treatment on the severity of the disorder, home environment, patient preference, prior treatment experiences, and several other factors. Frequently, I recommend a combination of counseling and medications. It is important to address any underlying issues that may have led the person to develop the substance use disorder in the first place, as well as the substance use itself. If someone started using opiates in response to psychological distress, treating the substance use disorder without also addressing the mental health issue is going to be less effective. Some people find that participating in groups such as AA, NA, Celebrate Recovery or Smart Recovery provide them with support as well as skills on their path to recovery. Other people may participate in group sessions that meet several times a week for several hours at a time or may have individual sessions on a weekly or monthly basis with a counselor trained in addiction.
There are a lot of different paths to recovery and sometimes it takes a while to find what is right for you! Just because you have tried to quit in the past and started using again, doesn’t mean you can’t stop in the future. The most important thing is to learn from your past attempts, forgive yourself for not being perfect, and reach out for help again.
If you have a friend or family member who you think may be struggling with a substance use disorder, or if you think you may have a substance use disorder yourself – please consider talking with your/their physician. There is help available, but the first step is realizing there may be a problem and asking for help.
For more information on substance use disorders, please check out www.samhsa.gov or www.drugabuse.gov or talk with your personal physician.
***Note *** This post, like all my other posts, is for general medical information only and is not to be taken as direct advice. Please consult your personal physician for more information.