“The book elucidates the agony of addiction in a fresh, new way. It emphasizes the role of trauma in setting the stage for debilitating behaviors, and explains the importance of community support in the healing process. With anecdotes of many people who grapple with addiction and have survived, as well as sad stories of addicts who died, this book provides healthy doses of grit and inspiration.” –Christopher Key Chapple, Loyola Marymount University
Medicine has struggled to understand addiction. This may be because it’s not entirely a medical problem. But science doesn’t consider spiritual aspects, and for the purposes of this discussion I’m willing to leave those aside.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the “bible” for diagnosis by professionals. The current version is DSM-V. Not surprisingly, the previous version was DSM-IV. The newer version introduced some major changes to the way substance abuse disorders are diagnosed.
DSM-IV, issued in 1994, generally offered two categories of substance abuse disorders: substance use disorder, and dependence. These corresponded to chronic abuse of a substance, and physical dependency on the substance. There were codes for various substances, distinguishing for example between opioid dependency and alcohol dependency. The DSM-V (2013) combines there and streamlines the diagnosis. As this summary explains, DSM-V
does away with separate “dependence” and “abuse” diagnoses and combines them into “substance use disorder.”
The current version sees substance abuse as a spectrum rather than two separate conditions.
While this does make diagnosis easier, it appears to me to move substance abuse treatment backward by failing to recognize the complexity of factors at play.
For example, let’s consider physical dependence. Anyone who takes opioids (or other physically-addictive medication) over a long period will become physically dependent. It doesn’t matter whether they began using for pleasure, or if they were prescribed the drug by a doctor because of a medical need. They will need the drug to avoid going into withdrawals, which are typically both painful and disorienting. And in the case of alcohol (and certain other drugs), withdrawal can be life-threatening. Someone dependent on alcohol, for example, will crave it. And the cause of this craving is biological: they’ll go into withdrawals if they don’t get it. This is what DSM-IV described as “dependence.”
Yet dependency alone does not indicate whether that person will return to the drug once separated from it. When the physical dependency is relieved through a withdrawal process, medically supervised or not, there is no further need for the drug. Many people, once relieved of their dependence, take what might be described as the sane response: they never touch it again.
On the other hand, let’s consider what is sometimes described as “risky use.” A person who is not dependent on a substance nevertheless seeks it out and abuses it. The cause of this is not physical but psychological. Whether they seek pleasure or to kill the pain of some past trauma, the drug serves a purpose in their lives. They choose to pursue it of their own free will. This is what DSM-IV described as “substance use disorder.”
Interestingly, substance use disorder does seem to be a spectrum. Some people are able to choose to quit of their own volition. Others need help to quit. And some pursue their obsession with the substance, as Alcoholics Anonymous observes, “into the gates of insanity or death.”
These two, very different, facets of substance abuse are combined in DSM-V into a single spectrum. Yet the opioid crisis should show us the fallacy of this “improvement.”
One of the popular news items in the opioid epidemic is the number of people who began using because an opioid was prescribed by their doctor for a medical condition. (Here’s an example.) This theory presumes that chronic physical pain is the cause of opioid use that results in dependence. And this may well be for some people.
Yet many, perhaps most, opioid addicts struggle with a condition I can only describe as “addiction.” Yes, they are physically dependent. Yet once separated from the drug, whether through rehab or incarceration, they return to it despite its adverse effects on their lives. Not because of physical pain, but because of a psychological obsession with what the drug does for them.
At the very least, in these people we can see an overlapping of two distinct conditions: dependency and an obsession to use. These are not the same. One is physical, the other is psychological. Both need to be treated for successful recovery. Yet without recognizing the difference between the two conditions, how can they be treated?
This is true for any drug user. For a successful result, a person who is dependent because of chronic pain must be treated differently from one who is not dependent but seeks the drug by choice. Yet in the case of the addict, who has both conditions, treating one or the other is simply pointless. Not only is it ineffective, but the failure of this approach erodes confidence that recovery is possible.
And recovery is possible! While success with opioid addiction recovery from a medical perspective remains dismally low, tens of thousands have recovered through other, non-medical methods. These include Twelve Step groups like Narcotics Anonymous, religious based programs like The Bridge Ministry, and many others.
Because when withdrawals end, that’s when the real healing begins. Now that we don’t have a physical need, how do we live without the psychological need? Medicine doesn’t do that. Even psychology tends to fall short in offering resources.
Perhaps this is because they don’t really understand what an addict needs, because the vast majority of medical professionals have never experienced it.
But those who have been there and recovered do know. It is to them we should look for answers. Oddly, that seems to be the one place science hasn’t looked. Which may be why their understanding of addiction and recovery sometimes seems to be moving backward.
For more on addiction, read my book, The Soul of an Addict, available in Paperback and Kindle editions.
It’s available! In both paperback and Kindle formats. The Soul of an Addict: Unlocking the Complex Nature of Addiction, by D.J. Mitchell.
Addiction is more complex than it may seem. Written for the non-addict who seeks to understand substance addiction, The Soul of an Addict shows that addiction not just a disease or a choice. Using statistics, anecdotes from the lives of addicts, and the author’s personal experience with addiction and recovery, the book argues that addiction affects all aspects of human existence, including identity, purpose, life structure, and morality. It serves as a religion in the addict’s life, and any approach to recovery must also provide these essential needs. With one in seven Americans struggling with substance abuse, this book brings a timely analysis for anyone concerned about addiction.
“A must-read… As a therapist I will be recommending this book to my clients.” –Milt McLelland, CMHC, Roots Counseling Center
For more information, click here.
Want a free look? Download the Introduction and first chapter here!
My first non-fiction book is coming soon. The Soul of an Addict: Unlocking the Complex Nature of Addiction argues that addiction is far more complex than most models accept. Is it a disease? A choice? Yes. But it’s also more than either of these. In fact, addiction has the sociological characteristics of a religion.
The book is supported by statistics, anecdotes from my work with addicts, and stories from my own struggle with addiction. It will be available in two weeks.
Here’s an excerpt from Chapter Twelve, “What Is Recovery?”
Jenna was in her fifth round at a treatment facility when I met her. She dropped out before the end of the program and went back to using drugs.
Nate got clean and sober the first time he went to treatment and never used again.
Ben was sentenced to treatment by the court after his fifth conviction for DUI. He went to avoid prison, yet he got clean and stayed clean for many years.
Vivian had a spiritual experience after an alcoholic binge, attended Twelve Step meetings and never drank again.
Dan found sobriety in a church run by a pastor in recovery.
Al got sober through Twelve Step meetings while in prison for vehicular manslaughter.
Vern failed at treatment facilities and methadone clinics for years, but after doing some time in jail and living in his car for a year, he finally got clean in a Twelve Step program.
Treatment takes many forms, and has varying rates of success. But, whether an expensive rehab facility, a publicly funded treatment center, a church-based support group, or a cost-free Twelve Step meeting, some form of support is usually necessary to help us get out and stay out of our addiction. The reason is simple: If we knew how to stay clean and sober without treatment, if we could envision a way of life sufficient to replace addiction, we would have given up drugs already.
Treatment for drug and alcohol addiction is big business in the United States. In 2017, nearly three million people underwent treatment. It’s estimated that Americans spend $30-35 billion a year attending rehabilitation centers for drug and alcohol abuse.
That doesn’t include the nation’s largest single “treatment” system: prison. According to researchers Wendy Sawyer and Peter Wagner, nearly half of all federal prisoners, about 100,000 people, are incarcerated for nonviolent drug offenses. It’s estimated that half a million nonviolent drug offenders are incarcerated in state and local prison systems.  At an estimated $30,000 per prisoner per year, that’s another $15 billion expense that falls to the taxpayers.
In 2016, some 168,000 people on parole or probation were returned behind bars not because they committed a new crime but because of technical violations such as staying out past curfew. Sawyer and Wagner argue that the justice system is structured to promote failure, not to reward success.
It’s worth noting that those who go through treatment are more likely to be white (about 80%). Those who go to prison are more likely not to be white (about 70%). The rate of addiction does vary slightly between races, but perhaps not as expected. Of the three most populous races, whites lead in substance abuse problems with 7.7%. Blacks have a rate of 6.8%, and 6.6% of Hispanics struggle with substance abuse. Yet blacks are six times more likely to be incarcerated for drug offenses than whites.
Jacob, a young African-American man, was arrested for drug-related offenses. While represented by a public defender, he was sentenced to four years in prison. Later, he managed to pay an attorney several thousand dollars to have the judge reconsider the sentence. It was reduced to one year followed by a court-ordered drug treatment program. Financial resources clearly make a huge difference in the outcome of drug offenses in the criminal justice system.
There’s another troubling statistic. In 2017, more than 20 million Americans sought treatment for a substance abuse problem. Only 12% of them actually received treatment. That’s a huge improvement over prior years. In 2014, for example, only 7.5% of those seeking treatment actually received it. But still: out of every eight people who seek treatment, seven do not receive it. The most common reason cited, by almost half of those who could not obtain treatment, was lack of insurance coverage. They couldn’t afford the cost.
 Bose, Table 5.10A.
“What America Spends on Drug Addictions,” Addiction-Resources.com, 2005 (https://www.addiction-treatment.com/in-depth/what-america-spends-on-drug-addictions/, accessed August 14, 2019). There are many more recent estimates on what Americans spend on the substances themselves, but I was unable to find a more current estimate of the cost of rehab. Gabrielle Glaser, “The Irrationality of Alcoholics Anonymous,” Atlantic Feb 2015 (https://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/, accessed August 15, 2019). “Offenses,” Federal Bureau of Prisons, Aug 9, 2019 (https://www.bop.gov/about/statistics/statistics_inmate_offenses.jsp, accessed August 14, 2019).
 Bose, “Results from the 2017 National Survey on Drug Use and Health: Detailed Tables, 2018 (https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.pdf, accessed May 15, 2020).
 NAACP, “Criminal Justice Fact Sheet” (https://www.naacp.org/criminal-justice-fact-sheet/, accessed May 15, 2020). Numbers for Hispanics were not included. Also see Alana Rosenburg, et. al., “Comparing Black and White Drug Offenders: Implications for Racial Disparities in Criminal Justice and Reentry Policy and Programming,” J Drug Issues 2017 47(1), 132-142 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614457/, accessed May 15, 2020): Blacks are more likely to be incarcerated for smaller offenses; 49% of Blacks and only 10% of whites in the study were convicted of marijuana possession compared with 7% of Blacks and 50% of whites convicted for heroin possession.
 Rachel N. Lipari and Struther L. Van Horn, “Trends in Substance Abuse Disorders among Adults Aged 18 or Older,” The CBHSQ Report, SAMHSA, Jun 29 2017 (https://www.samhsa.gov/data/sites/default/files/report_2790/ShortReport-2790.html, accessed August 15, 2019). Compare Rachel N. Lipari, Eunice Park-Lee, and Struther Van Horn, “America’s Need For and Receipt Of Substance Abuse Treatment in 2015,” The CBHSQ Report, SAMHSA, Sep 16 2016 (https://www.samhsa.gov/data/sites/default/files/report_2716/ShortReport-2716.html, accessed August 15, 2019) reports that 10.6% of those who sought treatment received it in 2015. The percentage receiving treatment has
 Bose, Table 5.50A, shows 421 of 1,033 (41%) surveyed either didn’t have health insurance, or had health insurance that didn’t cover treatment.