Table of Contents
Table of Contents
Tell Me Everything I Need to Know About Addiction
Addiction is a mental illness that leaves people feeling empty and alone. It’s feel-good-now-regret-it-later behavior that impairs the ability to self regulate. Here’s what to know, how to recognize a problem, and how to get help.
It’s a cry for help that no one hears. The conversation goes like this: “No one likes me. No one understands me. I’m a loser. If I had been better at X, Y would have happened. I’ll never be successful. I’ll never find a partner…”
That’s the sound of emotional pain—the root of most addictions. Negative thinking. Bitterness, regret, resentment, the inability to forgive yourself or look to others for help. Non-stop toxic self-talk frequently fuels the impulse to grab the beer, pop the pill, or watch porn obsessively. These types of habits/behaviors temporarily numb the pain. Addiction is a way to escape self-loathing or some other brand of pain like loneliness, emptiness, boredom, anger, depression, or anxiety. And it almost works.
“At least when I’m high (or engaging in a pleasurable activity, i.e., eating something I love, shopping, gambling, having sex, etc.) I’m happy…”
Addiction is NOT a lack of willpower or a moral failing. It’s compulsive, out of control feel-good-now-but-pay-for-it-later behavior that destroys lives, careers, and marriages. Its victims suffer greatly, leaving them feeling empty and alone.
It’s not easy to be a friend or loved one, to someone who seems to choose drugs, alcohol, gambling, insert toxic substance or behavior here, above everything else. How is it that people suffering from this illness continue to addict even when they know it’s destroying their lives and harming everyone they touch?
The family who lives in constant fear of losing their home thanks to dad’s gambling habit; the teenager who puts his future at risk with drug use because he’s unable to see his potential; the young adult who can’t hold onto a job because of her drinking problem.
The behavior is baffling because it betrays our common-sense notion that if it hurts, you don’t do it. No one chooses to be powerless over a substance they know is harmful.
The causes of addiction are complex—a mix of genetic, environmental (neglect and trauma are big areas here), and social influences contribute to this heartbreaking disease (more on that later, too).
Addiction has a powerful influence on the brain, and it manifests in three ways: cravings, loss of control, and continuing involvement despite adverse consequences.
Understanding addiction and helping those caught in its snare is a matter of life and death.
Consider these stats:
Smoking (nicotine addiction) kills about 450,000 people every year—it is the #1 cause of preventable deaths.
Another 100,000 die each year due to the consequences of alcohol use disorder (AUD).
If you include food addiction and the consequences of obesity, about 1 million people die each year from the consequences of addiction.1
All told, roughly three million people die every year in the US—one-third from the consequences of addiction.
Think about that.
During my 30-year career in psychiatry, I have worked with hundreds of patients struggling with addiction says Dr McGee. My patients can’t ask for help. They don’t feel worthy, and they don’t trust. Addiction is a disease of isolation, deceit, secrecy, fear, and shame. Victims are isolated from the truth of the disease, the consequences of the addiction, and through minimization and deceit, from others.
It is possible to recover from addiction but it’s painful and arduous work. Sadly, despite effective treatments, only 10% of people ever receive them (see below).
Pursuing Pleasure to Avoid Pain
Old school thinking believed that people who developed addictions were morally inferior and overcoming addiction simply a matter of mustering up the willpower to “just say no”. That catchy slogan from the 1980s, unfortunately, perpetuated the idea that addictions aren’t mental health illnesses. They ARE.
Today, we know through science and research that addiction is a chronic disease. Addiction changes brain structure and function, just as cardiovascular disease damages the heart or diabetes disables the pancreas.
Addiction develops as dysregulation of our brain’s drive-reward system when stimulated by pleasure-inducing substances and/or behaviors in vulnerable people. Vulnerability is generally a combination of genetic, biological, psychological, social, and spiritual factors.2
In vulnerable people, addiction impairs the ability to self-regulate and leads to the compulsion for different reasons.
Our neurobiology drives us to do things that promote our survival and propagate our DNA. We experience these drives as motivations, compulsions, impulses, urges, desires, or cravings. Desire compels us to be safe, to feel good (pleasure) and to not feel bad, and to reproduce.
The brain has evolved to experience rewards as a way to satisfy desire. These rewards are relief of distress and pleasure. We seek relief from pain, anxiety, discomfort, and other unpleasantness. Pleasure can include satisfaction or enjoyment (playing, eating, having sex, etc.).
Often, our actions generate both relief and pleasure. For example, eating a good meal when we’re hungry. Neurobiologically, pleasure and the relief of distress are closely coupled and can be intertwined with addiction. Relief and pleasure are mediated by four main chemicals: endorphins, dopamine, serotonin, and oxytocin. Gamma-aminobutyric acid (GABA) and endocannabinoids may also be involved in the brain’s reward system.
Distress can be biological (physical pain, hunger, and fatigue), emotional (fear, anxiety, loneliness, depression, and anger), and spiritual (lack of joy, awe, reverence, and gratitude or a sense of being connected to something greater than ourselves).
Substances (medication, alcohol, etc.) and behavior (shopping, sex, video games, etc.) can alleviate distress/pain and provide pleasure.
If you are genetically vulnerable, the experience of a pleasurable reward causes excessive stimulation of the drive component of the brain’s drive-reward system. The result? An even stronger desire for the pleasure-inducing substance or behavior that often leads to intense cravings and compulsions. If we lose control and act upon these compulsions to our detriment, we have engaged in the process of addicting.
The drive/reward system of the brain exists in the middle of the brain where a group of structures that are part of the limbic system plays a key role. The limbic system mediates, along with other parts of the brain, emotion, and drive, or motivation.3
They include a circular strip of deep cortex called the limbic lobe, the cingulate gyrus, the orbitofrontal cortex (OFC), which rests just above our eyes, the amygdala, and the nucleus accumbens (NAc).
These structures work together with other parts of the brain to mediate motivations and emotions, including desire, pleasure, and cravings.
The amygdala determines if an experience is painful or pleasurable. It directs the brain to either repeat or avoid the experience. A part of the amygdala, the extended amygdala, is involved in both drug reward and in the negative experience produced by the stress of withdrawal that helps drive the compulsion to addict. It induces negative emotions like unease, anxiety, and irritability during withdrawal and interacts with the brain’s stress system through connections to the hypothalamus.
The hippocampus records memories, including happy memories along with details such as where, when, and with whom a pleasurable experience occurred. These associations can trigger cravings.
The frontal lobes synthesize information in order to decide whether to act and what action to take. They put the brakes on impulses to act if they discern that an action is unwise. Impairment in frontal lobe functioning (due to addictive substances like alcohol) contributes to the loss of control that characterizes addicting.
Victims of addiction do what they feel urges to do regardless of what they know to be right. They have lost their “prefrontal brakes.” Part of successful treatment entails rewiring frontal lobe functioning so a person with an addiction learns how to do what is right regardless of urges/cravings to do otherwise.
Addiction per se is not recognized as an official diagnosis. An addiction to drugs or alcohol is diagnosed as a substance use disorder (SUD). Right now there’s only one behavioral addiction disorder that is recognized by the American Psychiatric Association and included in the DSM-5-gambling disorder.4
Here are the substances most closely associated with addiction:
Inhalants like paint thinners and glue
Opioids, such as the painkillers codeine and oxycodone, and heroin
Sedatives, hypnotics, and anxiolytics
Stimulants like cocaine and methamphetamine, among others
Brain changes that result from drug addiction can make the substance feel as necessary as food and water to the person that uses it. Over time people who abuse drugs and alcohol develop a tolerance to it, meaning they need higher doses of it to receive the desired effect.
With continued use, the brain and body become dependent on the presence of an addictive substance. When you try to quit abruptly, the body enters withdrawal, triggering a host of unpleasant symptoms, which vary by substance.
Pleasurable behaviors can become problematic when they take over your life. Though gambling disorder is the only addictive behavior in the DSM-V (see more on the symptoms of gambling disorder, below) other behaviors can be just as devastating, including 5
Sex (sex addiction)
Watching porn (porn addiction)
Eating (food addiction)
Using the internet (internet overuse)
Playing internet/video games
Akin to drug and alcohol cravings, research suggests that people with behavioral addictions can feel intense urges to engage in their choice behavior. They may even feel a need to increase the intensity or frequency of that behavior to achieve the same high.
Habit Forming vs. Addiction: What’s the Difference?
Have you ever driven home from running an errand and realized you were on autopilot the whole way? When brushing your teeth,do you have to think about what you’re doing? Things you do from memory without really thinking about them are habits. Addiction, however, is behavior we compulsively repeat despite what we know to be negative consequences. While addiction can become routine like a habit, it is much more than a habit.
Having a glass of wine after work is a common way to relax. For some people it adds pleasure to their day and, by itself, doesn’t constitute alcoholism. If wine becomes the only way you know how to unwind—and you can’t relax without it…well then, Houston, we have a problem.
The symptoms and signs of addiction depend on what you are addicted to and the severity of the addiction. For substance use disorders, some of the primary symptoms are:
Cravings. Intense desires to addict. People caught in addiction can feel possessed by relentless preoccupations with using or engaging in addictive behaviors.
Compulsion. This is the strong urge to do something, in the case of addiction using a drug or engaging in some other behavior
Lack of self-control. In addiction, people lose control over their compulsions to addict. They addict even though they know it is harming them and others.
Social problems. Substance use disorders can cause you to fall behind on important tasks at work, school, or home. You may deprioritize relationships and vital elements of your life, such as work projects or leisure time activities, due to your preoccupation with substance use. People with drug addiction, for example, often spend much of their time getting drugs, using drugs, and recovering from their effects.
Risk-taking. You may engage in risky behaviors like driving while under the influence or stealing when you are high. You’re likely to continue to abuse substances despite obvious consequences that arise as a result, like being arrested and losing your driver’s license.
Drug effects. Tolerance and withdrawal symptoms can be clear warning signs. People who abuse drugs and alcohol may increasingly need more of the substance to get the same effect and show withdrawal symptoms when they stop using.
Occupational interference. As victims become preoccupied with addicting, they can let work responsibilities slide.
Health consequences. This includes lung cancer from smoking, hepatitis from using alcohol, and infections from using IV heroin.
Continued use despite adverse consequences. Victims of addiction often cannot stop without help even though they know their addiction is destroying their lives.
The symptoms of behavioral addictions are slightly different. Like substance use disorders, behavioral addictions may come with persistent urges to engage in a behavior, followed by a positive mood shift while engaging in said behavior. Behavioral addictions may become more habitual and ingrained.5
The American Psychiatric Association lists the following sign of gambling disorder, the only officially recognized behavioral addiction:
Spending an increasing amount of money on gambling
Needing to gamble more and more money to achieve the desired level of excitement
Difficulty cutting back or quitting gambling
Feeling restless or irritable when attempting to cut back or quit
Persistent, frequent thoughts about gambling such as planning bets, thinking about past gambling experiences, and strategizing how to get more money to gamble with
Turning to gambling when feeling down or distressed
Continuing to gamble even after losing money in an attempt to break even
Suffering financial or social consequences as a result of gambling
Relying on others for financial support due to gambling losses
Inescapable, unavoidable emotional pain—frequently caused by some form of trauma or neglect (more on that, below)—frequently triggers addiction. Essentially addiction is an ineffective pain management strategy for many who fall prey to it. Sometimes physical pain leads to addiction when vulnerable people use opioids for longer than a few days. But for some victims of addiction, there isn’t an identifiable pain that triggered the use of addictive substances or addictive behaviors.
Instead, they are driven (sometimes genetically) to experience pleasure in a way that throws caution to the wind. Impulsivity, too, without thought of the possible negative consequences of use, may contribute to an increased risk of addiction via pleasure-inducing substances.
No one uses addictive substances or engages in addictive behaviors with the thought of becoming addicted. They may be aware of the risk but tell themselves “it will never happen to me.”
About 70% of Americans are social or occasional drinkers. Even though they all drink the same liquor, wine, and beer, not everyone develops a problem. Around 15 million people in America have an alcohol use disorder or are addicted to alcohol. It’s not the alcohol that’s the problem, it’s the vulnerability and the person. 6
What makes someone vulnerable to addiction? Like other chronic conditions and mental health disorders, the causes of addiction can be broken down into two main categories:
Environment. Environmental factors, including stress, history of trauma or neglect, and family, friends, and relationships, seem to affect someone’s vulnerability to addiction. Prevalent use of substances among your social groups and encouraging attitudes toward drugs in these groups may heighten the chances of initial drug use. Accessibility to substances, cost, and cultural norms also play a role.
Genetics. Some risk of addiction is genetic. Depending on your genes, you might be more or less vulnerable to addiction. Certain genetic traits may increase the feeling of reward you experience after using a drug or engaging in addictive behavior. Once you’ve started using a drug, the progression toward full-blown addiction may be delayed or expedited depending on your genetic tendencies.
More specifically, risk factors for addiction include:
Family history. Drug addiction is more common in some families. Having family members with addiction increases your risk.
Peer pressure. Peer pressure, especially in teens and young adults, can play a substantial role in encouraging drug use and abuse.
Family problems. Difficult family situations, lack of parental oversight, and weak bonds with family members can increase addiction risk.
Using drugs at an early age. When the brain is still developing, substance use can more easily influence neural networks and increase the likelihood of addiction.
Taking a drug that’s highly addictive. Some drugs are more addictive than others. Addiction may develop faster if you take drugs such as stimulants, cocaine, or opioids.
Having another mental health disorder. Many people experience mental illness and addiction together. An existing mental illness may make someone more vulnerable to addiction, or an existing addiction may trigger or worsen a mental disorder. People with mental illnesses may turn to drugs to numb emotional pain and cope with their feelings or for other reasons related to symptoms of their condition. People with attention-deficit hyperactivity disorder (ADHD), for example, are at greater risk of addiction in part because impulsivity is a hallmark of ADHD.
Addiction and mental illness are highly interrelated. Approximately 50% of people who suffer from a mental illness will also develop a substance use disorder and vice versa.
Some of the mental illnesses that are often diagnosed alongside addiction include:
Generalized anxiety disorder (GAD)
Post-traumatic stress disorder (PTSD)
Borderline personality disorder and other personality disorders
Trauma—whether emotional or physical—is a significant risk factor for addiction. Trauma overwhelms a person’s capacity to cope and the effects can last for decades. The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood abuse and neglect and resulting challenges in health and well-being ever done. 7
The original ACE Study was conducted from 1995 to 1997. Thousands of children were studied, and the results found a strong correlation between exposure to abuse or household dysfunction during childhood and multiple risk factors including the development of addiction.
Trauma can include experiencing fairly common events like divorce, surviving a bad car accident, or a natural disaster. Perhaps you grew up in a household with a mentally ill parent or a parent addicted to drugs or alcohol. Maybe you were raped or sexually assaulted.
All of these experiences have the potential to leave traumatic scarring. Trauma can leave its heartbreaking mark on the mind, heart, and body. One (unhealthy) way to cope with the impact is through addiction.
Many clinicians find trauma to be common among those suffering from addiction, although the exact relationship of trauma to addiction is still unclear.8
Trauma can impair the ability to self-regulate and to form healthy attachments. If you grew up with a parent who ignored or trivialized your needs, you learn that asking for help is dangerous.
Loving is a skill that is learned in early development and if you don’t have those skills you can’t teach what you don’t know. Trauma makes the world feel unsafe and the person who experiences it feel unlovable.
Recovering from addiction for victims of trauma and neglect means learning how to feel loveable, how to love oneself, and how to give love to others.
Shame, or the experience that one is bad, is very common in addiction. People who addict do bad things, which leaves them vulnerable to feeling bad about themselves. Unfortunately, shame only perpetuates addiction, because victims don’t feel they deserve to recover. In a weird way, shame can drive people to continue to addict to punish themselves.
Over the course of my career, I have been privileged to help many hundreds of people struggling with addiction. I have seen an executive that once lived under a bridge go on to rebuild his career and start a family. One patient went from being unemployed and homeless to becoming a successful attorney, a homeowner, and a loving husband. Another patient was penniless and on the verge of divorce. He went on to become the vice president of a corporation and raise two beautiful children.
Addiction provides temporary pain relief but creates more pain in the long run. In the end, addiction either destroys us or brings us to the gates of recovery. The choice is ours. We do everything we can to avoid our pain. We engage in denial (I’m not drunk, I’m just drinking), minimization (I only have a couple of beers a night), rationalization (my drinking helps me to relax, cigarettes calm me, I need pills for my pain), externalization (I wouldn’t drink if my wife wasn’t such a…), and projection (The real addicts are those junkies. I’m not like them).
Just 10% of people seek treatment in part because of shame. The other reason is that the nature of addiction compels them to addict to manage the pain of addiction. Most people don’t seek treatment for addiction because the pain of stopping seems greater than that pain of addicting and they don’t see any other alternative.
Addiction also impairs decision-making. The “value” of addicting crowds out other important life values such as relationships. This distortion of decision making of course impairs people’s ability to ask for help to stop the addiction. To recover from addiction, you must learn other ways of feeling good and NOT feeling bad.
So, if you get yelled at by your boss for making a mistake at work, instead of having a drink to deal with that anxiety, you investigate the anxiety. Rather than run from it with a drink, you learn to meditate or take a walk in nature. Healing from addiction requires the development of psychological skills, craving management skills, but most of all love skills.
Through recovery, you learn to feel that you are worthy but must also learn how to ask for help and how to give love to yourself and others, too.
No one recovers alone from addiction. Recovery is possible for those who want it and are willing to work for it. It takes time, hope, and support.
Although there is no cure for addiction, and there is always a risk of readdiction, it’s also highly treatable. Treatment strategies will depend on the person and the addiction. You may need multiple rounds of treatment, a combination of treatment approaches, and even lifelong management.
Treatment options include:
Medication. Various medications can be used to control drug cravings and relieve severe symptoms of withdrawal. For example, at specified doses, drugs like buprenorphine and methadone keep opioid withdrawal symptoms at bay without triggering the same high. Instead of only activating the opioid receptors they work by blocking withdrawal symptoms and brightening mood. Disulfiram is a drug that can help break the cycle of alcohol abuse because it triggers an unpleasant reaction when people consume alcohol.9 People with addiction as well as another mental health disorder will benefit from treatment for that disorder as well, such as managing depression with antidepressants.
Treatment programs. People with substance use disorders need to be able to safely and quickly detox from the substance they are addicted to. This may involve a stay at a hospital or treatment center to manage withdrawal symptoms, which can be quite severe, depending on the substance. Treatment programs may be outpatient, residential, or inpatient, depending on what level of care a patient requires. They usually mandate a drug-free environment and offer individual, group, or family therapy sessions.
Therapy. On its own or as part of a treatment program, therapy can help you recognize and understand your addiction and learn strategies to break the cycle.
Mutual-Help Groups. Both online and in-person groups can be effective forms of peer support and as a forum for discussing addiction without shame. Having a sponsor, recovery coach, or recovery mentor can be a real game-changer for people struggling with addiction. Research shows that popular 12-step based programs such as Alcoholics Anonymous and Narcotics Anonymous only work if you go to meetings, talk to a sponsor and do all 12 of the steps. SMART Recovery and Celebrate Recovery (for Christians) are addiction recovery programs I frequently recommend.
According to the latest government statistics, nearly 23 million Americans—almost one in 10— are addicted to alcohol or other drugs. More than two-thirds of people with addiction abuse alcohol. The top three drugs causing addiction are marijuana, opioid (narcotic) pain relievers, and cocaine.10,11
The cost of addiction is high and impact life expectancy, crime, and the economy. Here a few of the startling numbers:
$740 billion: The annual cost related to crime, lost work productivity, and health care as a result of abuse of tobacco, alcohol, and illicit drug use in the United States.
165.4 million: The number of people aged 12 or older who used a substance, including alcohol, tobacco, or an illicit drug, in the past month.
20.4 million: According to the 2019 National Survey on Drug Use and Health, this is the number of people aged 12 or older, with a substance use disorder. More specifically:
8.3 million people had a past year illicit drug use disorder
1.6 million people had a past year opioid use disorder
1.4 million people had a past year prescription pain reliever use disorder
904,000 people had a past year methamphetamine use disorder
2.4 million people had both an alcohol use disorder and an illicit drug use disorder in the past year.
67,300: The number of Americans who died from a drug-involved overdose in 2018, including illicit drugs and prescription opioids.
37,329: The number of alcohol-induced deaths in 2018, excluding accidents and homicides (CDC).
23,172: The number of alcoholic liver disease deaths in 2018 (CDC).
28.8 million Americans have an eating disorder. Eating disorders claim 10,200 deaths each year and cost the economy $64.7 billion.12,13,14,15
People who struggle with addiction need our love, sympathy, and support. Without it, recovering from addiction is not possible. It turns out that loved ones have an enormous impact on the victim of addiction. The combination of kindness and behavioral reward strategies called Community Reinforcement and Family Training (CRAFT) can make the difference between life and death for a loved one with addiction.
Books About Addiction for People Struggling and Their Loved Ones
Addiction is a chronic brain disease that compels you to repetitively use a substance or engage in a behavior despite detrimental consequences to mind, body, and general well-being. The reward or high that addictive substances or behaviors trigger acts as an incentive. Over time, people with addiction become reliant on addictive substances or behaviors, causing long-lasting brain changes.
Addiction is caused by a combination of genetic, psychological, social, and environmental factors, including stress. Certain genetic traits or a family history of addiction can make you more vulnerable. A wide range of life experiences and exposures, such as trauma, neglect, weak social ties, and other mental health conditions, can make someone more likely to try addictive substances in the first place or increase the likelihood that they become addicted.
To break an addiction, the brain and body need to relearn how to exist and cope without the presence of an addictive substance or behavior the victim must learn to manage cravings and triggers to addiction, especially stress, pain, and social influences. This usually requires support, treatment, and lifelong follow-up to avoid relapsing. The type of treatment will depend on the individual and substance or behavior you’re addicted to.
Like other chronic diseases, addiction damages the normal and healthy functioning of a critical organ in the body, in this case, the brain. The brains of people with addiction become dependent on the presence of an addictive substance or behavior and the reward or high that it triggers.
Gordon EL, Ariel-Donges AH, Bauman V, Merlo LJ. What Is the Evidence for “Food Addiction?” A Systematic Review. Nutrients. Published 2018 Apr 12.
Koob GF, Volkow ND. Neurobiology of addiction: a neurocircuitry analysis. Lancet Psychiatry. Published 2016.
Sokolowski K, Corbin JG. Wired for behaviors: from development to function of innate limbic system circuitry. Front Mol Neurosci. Published April 26 2012.
American Psychiatric Association. What is Gambling Use Disorder? Available at: https://www.psychiatry.org/patients-families/gambling-disorder/what-is-gambling-disorder.