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The Almost Addicted

Where substance use may be disrupting one's relationships and showing signs of worsening, it may be an "almost addiction." A new book makes the case for attending to the regular user whose habit causes pain but fails to meet the criteria of addiction.

In my years as a psychiatrist, nearly all of the people I have encountered who used marijuana swore to me that their pot smoking wasn't harmful. That's because, as far as they could tell, it never caused any problems in their work, school performance, health, or well-being. To the contrary, they were convinced that their lives were actually better because of marijuana use, even if those around them told them otherwise.

People who use marijuana often relieve any guilt about smoking it by adopting the philosophy that, because marijuana is a natural substance, it's not a drug. Just for good measure, they will often throw in the fact that marijuana has been legalized or decriminalized in some states. As a result, many people who use marijuana have no intention of cutting back.

But people who smoke pot aren't alone. Drinkers who look forward to several beers at night to relax or people who snort a few lines of coke at a party several times a year so they can be part of the action have their own lines of defense.

These folks often reassure themselves that they don't have a problem with their substance use because they, like everybody else, know what someone with a "true addiction" looks like and their use doesn't compare. When they picture a person with a true addiction, they're probably picturing someone whose life is visible unstable.

But between these people who can take drugs occasionally without incident and those with hard-core addiction is another important group: the "almost addicted." These are the individuals whose drug use does not rise to the level that would meet the criteria for a formal diagnosis of addiction but who nonetheless are suffering to some extent from their drug-related behaviors.

Drug use among the almost addicted falls outside of normal behavior but doesn't quite meet any diagnostic criteria for drug abuse. Still, this type of drug use causes real problems in the moment for either these individuals or those around them. If left unchecked, it might progress to full-blown addiction. For these reasons, identifying almost addiction and taking measures to change the behavior is vital.

Even if you don't have a full-blown addiction and you haven't had major difficulties in your life because of substance abuse, your drug use can still negatively impact your life. You can still have a "drug problem." Indeed, I believe that there is a huge swath of people out there who are almost addicted.

If you have an image of what a person with a true addiction looks like, how do you identify someone with an almost addiction? It's not always easy. A stranger would never readily identify someone who is almost addicted as a person with a drug problem. When people chat about America's problems with drugs, the image of those who are almost addicted isn't what comes to their minds. It isn't hard to understand why some people (including many health care professionals) conclude that there are only two kinds of people in the world: addicts and non-addicts.

Yet in reality the drug-using world is not so black and white. Being addicted to, or dependent on, a substance is different from abusing a substance [the DSM-IV criteria on substance use disorders]. Although many people use drugs to obtain a buzz, relax, or otherwise feel good, people who are almost addicted go beyond occasional use and cross into a gray area--the territory in which problems arise because of drug use. Examples include the following:

  • People who only feel good when they are under the influence and who get irritable when they don't have a drug in their system.
  • Those who occasionally fail to show up for functions and obligations because they're high
  • People whose school or work performance has fallen off because of drug use
  • Anyone who is experiencing a lack of intimacy or conflicts in relationships with family members, friends, spouses, or co-workers that can be tied to increased drug use

There are several key differences between substance dependence and substance abuse. People who are substance abusers aren't fixated on the drug like someone who is dependent; they haven't developed physical dependence on it, and they don't experience withdrawal symptoms when deprived of it.

It's important to note that, as I write this, a revision is underway for the diagnostic manual for psychiatry, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR). Its authors recognize that these two categories--dependence and abuse--are too rigidly defined and don't acknowledge the full spectrum of drug use that spans recreational, nonproblematic use all the way to full-blown dependence. Just as I am recommending that addiction be viewed on a continuum, the professionals behind the forthcoming fifth edition (DSM-V) are arriving at the same conclusion. Whole working on the manual, they have proposed a single diagnosis, "substance use disorder," with one qualifier being "moderate" and the other being "severe."

What does this planned change mean? It means that the best minds in psychiatry see substance use as occurring on a spectrum and that the current categories of diagnosis do not suffice. Furthermore, the planned changes for the DSM endorse the idea that a level of problematic substance use exists that falls below levels that are diagnosable. People at this level are those I am calling almost addicted.

Excerpted from Almost Addicted: Is My (or My Loved One's) Drug Use a Problem? by J. Wesley Boyd with Eric Metcalf. Published by Hazelden, 2012.

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