Chapter 4

Abuse versus Dependence: What does the Doctor Say?

It is important for people who are not sure if they have an issue with substances to understand how the medical/psychiatric/psychological community sees the issue. None of these folks will necessarily use the term “addict”, they don’t like it because it is to vague. They are correct, it is just to obscure. We use it in this book for reasons mentioned in the introduction. Be that as it may, the psychiatric community has developed its own terminology. The two terms they will use are substance abuse vs. substance dependence.

This section is taken entirely from the Diagnostics and Statistical Manual of the American Psychiatric Associations, 4th edition, which is affectionately known as the DSM-IV. It is the book that Doctors, social workers, and mental health professionals will use to make a “diagnosis” of a condition. Therefore, what it says about substances is very relevant to our discussion. It is important for us to see what the Doctors sees and what He/She will say. What they “say” will be the determining factor for which treatment modality is required. Thus, in order for us to see what the doctors sees we must look at certain factors through their glasses. Before we put on their glasses, let us first set the stage.

No one who begins using substances initially is an abuser or someone who becomes dependent. In the beginning, the behavior or the substances is not really an issue. But, for whatever reason, we continue to use substances until we cross the line from social use and into abuse. If use is continued, we will cross another line from abuse into dependence. In the beginning, it starts as a social function until it becomes pathological and moves into the abuse phase. That is when substances begin to become an issue.

The DSM states, “Symptoms of substance abuse include one or more of the following occurring during a given 12 month period.” (1) Meaning, that just one of these characteristics in your live in the last year, and the Doctor can give the diagnosis of abuse. Here are the four:

1. “Substance use resulting in a recurrent failure to fulfill work, social, or home obligations.” We all have roles in the culture within which we live. I have a role as a nurse, a teacher, a husband, and a father. What this is saying is, if my use of substances has resulted in a failure in one of these roles, then there is an issue. The DSM gives the example of “work absences, school suspensions, neglect of children.” Basically, the substance in interfering with my success in my roles in life.

2. “Substances use in physically hazardous situations:” Pretty self-explanatory. Using meth wild driving a truck, using cocaine while driving a school bus, and drinking and driving. There are many common examples that could be offered here.

3. “Substance use resulting in legal problems.” An arrest on any substance related issues will always result in some mandatory form of treatment. DUI, PI, Possession, and Paraphernalia, are common charges.

4. “Continued substance use despite negative social and relationship consequences of use.” When the people that you party with begin to tell you that you need to cut back and you don’t, then they will label you. For example, pot-head, meth-head, pill-head, and crack-head or just plain old “Drunk!” are just a few examples. ?Social circles do this when they see someone who lacks the ability to “cut-back.” Generally, this is the point where the addictive user finds a more drug friendly peer group to hang out with and leaves those “light-weights” behind.

There are the four criteria for the Doctor to diagnosis someone with a “substance abuse” issue. This is very relevant to the individual who thinks they don’t have a problem. If just one of these four has occurred in the last year, the doctor sees an issue. So, who is right? We can’t both be right? Either the user is right and it is a non-issue, or the Doctor is right and there is something there. Personally, I don’t always agree with doctors. However, in this case, to disagree with the doctor would only be an example of the delusional thinking that we discussed in chapter two. Simply because one is an abuser of substances doesn’t make them dependent upon it, there must be more for that to happen. What does the Doctor say about Dependence? Lets take a look. Again, the DSM-IV.

The DSM-IV identifies seven criteria (symptoms) , at least three of which must be met during a given 12-month period.” In this case, just three of the seven in the last year would warrant a diagnosis of substance dependence. Here are the seven:

1. “Tolerance: as defined either by the need for increasing amounts of the substance to obtain the desired effects or by experiencing less effect with the extended use of the same amount of the substance.” Basically, it takes more “junk” to get your head right or the same amount of “junk” you’ve been using doesn’t get your head right anymore.

2. “Withdrawal, as exhibited either by experiencing unpleasant mental, physiological, and emotional changes when taking the drug ceases or by using a substance as a way to relieve or prevent withdrawal from substances.” The latter part of the statement is easy to understand. If someone needs the substance everyday to prevent the physical, mental, emotional sickness that they feel without the substance, then that qualifies. The former part states that primary definition that people think of when someone says drug withdrawal. They think of the guy with the shakes, seeing strange stuff that nobody else sees, itching, and “freaking out” because they don’t have the stuff. Nausea and diarrhea are common withdrawal from opiates. However, there is a very common form of withdrawal that is very seldom diagnoses. It is called, Post Acute Withdrawal Syndrome or PAWS. It is defined as, Post-acute-withdrawal syndrome (PAWS) (also sometimes referred to as post-withdrawal syndrome or protracted withdrawal syndrome) is a set of persistent impairments that occur after withdrawal from alcohol, opiates, benzodiazepines and other substances. Post acute withdrawal syndrome affects many aspects of recovery and everyday life, including the ability to keep a job and interact with family and friends. Symptoms occur in over 90% of people withdrawing from a long-term opioid (such as heroin habit), three-quarters of persons recovering from long-term use of alcohol, methamphetamine, or benzodiazepines and to a lesser degree other psychotropic drugs. Symptoms include mood swings resembling an affective disorder, anhedonia (the inability to feel pleasure from anything beyond use of the drug) insomnia, extreme drug craving and obsession, anxiety and panic attacks, depression, suicidal ideation and suicide and general cognitive impairment.” (2) So, if after about a two week abstinence period, one begins to experience the above mentioned symptoms, it means they could be experiencing this withdrawal syndrome. One of the most common features that I have seen in working with adolescence is insomnia. Folks just don’t sleep good even when they are clean. If this is you, then you qualify here for withdrawal.

3. “Longer duration of substance us or using in greater amounts than was intended.” We addressed this in the section on physical powerlessness and identified it as the phenomena of craving. The identifying factor here is the inability to stop after one starts.

4. “Persistent desire or repeated unsuccessful efforts to stop substance use.” An overall admission by the client of absolute powerlessness. The individual is incapable of stopping as evidenced by their desire to desist juxtaposed with their repeated unsuccessful efforts toward abstinence.

5. “A relatively large amount of time spent in securing and using the substance, or in reordering from the effects of it.” Much of this is a culmination of the sections on emotional, mental, and physical powerlessness. To paint a picture of what those looks like, it looks like someone who can’t get up in the morning because of all their partying the night before. Finally, when they do get out of bed, they spend their time developing resources to get more the substance or spend the rest of the day recovering from the effects of it. Then, they execute the plans that have been made and repeat the same night partying as the previous night. The cycle then repeats itself over and over until something stops the individual, usually law-enforcement officials. It is an ugly painting in real life.

6. “Important work or social activities reduced because of substance use.” The addict is never able to commit to anything requiring a great deal of time outside of using drugs. Simply, because it cuts into my using time.

7. “Continued substance use despite negative physical and psychological effects of use.” I wish their were not so many stores available about how this lifestyle will eventually cause some negative effects in our lives and, if we continue to use, we will die. I once knew a woman who needed a liver transplant because of her alcoholism. She was clean for eight years, in and out of hospitals, until finally, she was the next on the donor list. Two weeks before receiving her new liver, when relapsed which disqualified her for the transplant. She passed away shortly thereafter. Tragically, I could go on and one with very similar stories of how continuing to use despite negative effects has destroyed peoples lives. Don’t let it get yours.

If you qualify as substance dependent, as the doctor sees it, you will have three of these seven criteria in the last year of your using career. Please consider what is going to happen if you continue to use. At a very minimum, we could disagree with the doctor. At a minimum, three of these present in you life in the last year, makes a statement about how much you love the substance. If those who have died in functional substance abuse or substance dependence could tell us one thing from the grave, it would not be “Keep on partying.” It would be, “Listen to the Doctor!” Get help now before things get worse, because, they will.

Endnotes

1. DSM-IV

2. http://en.wikipedia.org/wiki/Post-acute-withdrawal_syndrome.

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