10 and 12

The 10 Commandments  Exodus 20:1-17 KJV (AV7)                                 

                         (part of Gods Program)

 

1. God spoke saying: I am the Lord your God.... You shall have no other gods before me.

2. You shall not make for yourself any graven image or any likeness of anything that is in heaven above or that is in the earth beneath or that is in the water under the earth. You shall not bow yourself down to them nor serve them, for I the Lord your God am a jealous God, visiting the iniquity of the fathers upon the children to the third and fourth generation of those who hate me and showing mercy to thousands of those who love me and keep my commandments.

3. You shall not take the name of the Lord your God in vain, for the Lord will not hold those guiltless who take His name in vain.

4. Remember the Sabbath day to keep it holy. Six days shall you labor and do all your work, but the seventh day is the Sabbath of the Lord Your God. In it, you shall not do any work: You nor your son nor your daughter, your servant nor your maid, nor your cattle, nor your visitor who is within your gates.

For in six days the Lord made heaven and earth, the sea and all that is in them, and He rested on the seventh day. Therefore the Lord blessed the Sabbath day and hallowed it.

5. Honor your father and your mother so that your days may be long upon the land which the Lord your God has given to you

6. You shall not murder

7. You shall not commit adultery

8. You shall not steal

9. You shall not bear false witness against your neighbor

10. You shall not covet your neighbor's house and you shall not covet your neighbor's wife nor his manservant nor his maidservant nor his ox nor his ass nor anything that is your neighbor's

 

                            The 12 Steps

 

 

1.We admitted that we were powerless over our addiction, that our lives had become unmanageable

2. We came to believe that a power greater than ourselves could restore us to sanity.

3. We made a decision to turn our will and our lives over to the care of God as we understood Him.

4. We made a searching and fearless moral inventory of ourselves.

5. We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

6. We were entirely ready to have God remove all these defects of character.

7. We humbly asked Him to remove our shortcomings.

8. We made a list of all persons we had harmed, and became willing to make amends to them all.

9. We made direct amends to such people wherever possible, except when to do so would injure them or others.

10. We continued to take personal inventory and when we were wrong promptly admitted it.

11. We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to addicts, and to practice these principles in all our affairs.

Phillippians 3: 12-16

 

12: I don't mean to say that I have already achieved these things or that I have already reached perfection! But I keep working toward that day when I will finally be all that Christ Jesus saved me for and wants me to be.

 

13: No, dear brothers and sisters, I am still not all I should be, but I am focusing all my energies on this one thing: Forgetting the past and looking forward to what lies ahead,

 

14: I strain to reach the end of the race and receive the prize for which God, through Christ Jesus, is calling us up to heaven.

 

15: I hope all of you who are mature Christians will agree on these things. If you disagree on some point, I believe God will make it plain to you.

 

16: But we must be sure to obey the truth we have learned already.

 

How do you use the 10 Commandments and the 12 Steps in your day to day lives?

 

All Articles (1)

THE 12 STEPS as written by the Na (Followed by how I personally got through them and continue to do so)

 

1. WE ADMITTED THAT WE WRE POWERLESS OVER OUR ADDICTION, THAT OUR LIVES HAD BECOME UNMANAGEABLE

 

     This was a step that I had already accomplished, and I'd already heard about the concept. Basically in order to deal with a problem you first have to admit that there is one.

 

2. WE CAME TO BELIEVE THAT A…

Overcoming Addictions

Overcoming Addiction: Paths toward recovery

Dear Reader:

For many years, experts believed that only powerful drugs that co-opted the brain caused addiction. More recently, we've recognized that excessive versions of normal behaviors such as gambling, shopping, and sex also can lead to addiction. The notion that pleasure-seeking exclusively drives addiction also has fallen by the wayside. We now think that people often engage in addictive activities to escape discomfort — both physical and emotional.

Several scientific advances have shaped our understanding of this common and complex problem. For example, brain-imaging technologies have revealed that our brains respond similarly to different pleasurable experiences, whether derived from psychoactive substances, such as alcohol and other drugs, or behaviors. Genetic research has uncovered that some people are predisposed to addiction, but not to a specific type of addiction. Finally, medications developed to treat one addiction have, in some cases, proven helpful for treating a different type of addiction.

Together, these findings suggest that the object of addiction (that is, the specific substance or behavior) is less important than previously believed. Consequently, in this report, we refer to addiction in the singular. The thinking is that addiction is an underlying disorder with multiple expressions.

The harmful consequences that arise from addiction can be devastating. One of the most common expressions of addiction, alcohol dependence, causes an estimated 100,000 deaths annually — the equivalent of an airliner carrying 274 passengers crashing every single day.

The good news is that there are a number of effective treatments for addiction, including self-help strategies, psychotherapy, medications, and rehabilitation programs, all of which are detailed in this report. You'll also find targeted advice on specific types of addiction, as well as information about coping with a loved one's addiction.

You can protect (and heal) yourself from addiction by having diverse interests that provide meaning to your life. Understand that life's problems usually are transient, and perhaps most importantly, acknowledge that life is not always supposed to be pleasurable. Therefore, you don't have to use a psychoactive substance to get away from the negative things that happen in life. Instead, you can use the strategies presented in this report to discover new ways to cope with life's difficulties.

Sincerely,

Howard J. Shaffer, Ph.D. Medical Editor

The problem of addiction

Pick up the newspaper or turn on the TV any given day, and chances are you'll hear about yet another famous person grappling with addiction. It might be an actor who overdosed on prescription medications, a sports star who drove drunk, or a rocker who entered rehab. Still, for all the media attention addiction seems to get, it's difficult to gauge the true scope of the problem, particularly as it applies to everyday people.

How common?

Solid estimates of how many people struggle with addiction are hard to come by. According to one nationwide estimate, roughly 28% of Americans will have an alcohol or drug use disorder during their lifetime. A more conservative estimate suggests the number is closer to 15%. That's more than one in seven people, and that number does not include the 24% of Americans who are addicted to nicotine at some point in their life. More than 80% of drug abusers also smoke, so these percentages cannot simply be added. The 15% estimate also does not include the 2% of Americans who have problems with excessive gambling. Finally, this estimate also ignores the countless others struggling with addiction involving sex, shopping, or possibly even eating. These substances or behaviors are now commonly referred to as “objects of addiction” or “expressions of addiction” by addiction researchers, who define the problem more broadly than the general public normally does (see “What is addiction?”).

Estimates of addiction among adolescents show that for many, the problem starts at an early age. In 2010, one in 10 American youths ages 12 to 17 reported using illicit drugs in the past month. Among people ages 12 and older, about 22.1 million people (8.7% of the total population 12 and older) were classified with a substance use disorder (that is, either dependence or abuse; for definitions, see “Substance dependence” and “Substance misuse and abuse”). That number included people abusing alcohol and illicit drugs (see Figure 1).

Among the commonly used psychoactive substances, nicotine and alcohol account for most addiction problems. Psychoactive refers to any substance that changes your mood, thinking, or behavior. The use of some specific psychoactive substances has declined, most notably nicotine, and to some degree LSD and Ecstasy.

Whatever the prevalence of addictive behaviors, one thing is clear: the problem is very costly. Among brain disorders, addiction incurs more expense than Alzheimer's disease, stroke, Parkinson's disease, or head and neck injury. According to the National Institute on Drug Abuse, the overall costs of substance abuse in the United States exceed half a trillion dollars, including health and crime-related expenses as well as losses in productivity.

Figure 1: Prevalence of alcohol and illicit drug addiction

During 2010, an estimated 22.1 million Americans ages 12 and older — about 8.7% of the population in this age group — were classified with substance abuse or dependence disorders. The vast majority (more than two-thirds) abused alcohol, while 19% abused illicit drugs and 13% abused both alcohol and illicit drugs.

Source: 2010 National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration.

Risks to health and life

Addiction harms individuals, as well as their families and friends. Substance abuse can lead to family disintegration, school failure, domestic violence, and child abuse. Drug and alcohol addiction, for example, are among the most important influences on behaviors contributing to risky sexual practices, which can spread HIV and other diseases, lead to unplanned pregnancy, and raise the risk of violence. Intravenous drug users can also spread HIV by sharing needles.

Drug and alcohol abuse can land people in the hospital, too. During 2009, nearly 4.6 million people ended up in emergency rooms due to drug-related consequences. About 45% of these visits involved abuse of over-the-counter, prescription, or illegal drugs. Many of the drug- and alcohol-related visits to the emergency room involve car accidents. According to the National Highway Traffic Safety Administration, there's an alcohol-related highway fatality in the United States every 48 minutes. Drugs other than alcohol, such as marijuana and cocaine, are involved in about 18% of motor vehicle deaths, but it is worth noting that people generally use these illicit drugs in combination with alcohol. These numbers are perhaps not surprising, considering that 15% of drivers ages 18 or older report having driven under the influence of alcohol during the past year, and 5% report having driven under the influence of illicit drugs.

The harmful effects of alcohol and drugs are not limited to injuries related to accidents. Long-term use of these substances can lead to serious health consequences. More than two million Americans suffer from alcohol-related liver disease. Alcohol abuse also raises the risk of heart disease and several forms of cancer. Stimulant drugs such as amphetamines and cocaine, meanwhile, attack the cardiovascular system, sometimes bringing on stroke or heart attack.

Glimmers of hope

Despite the sobering statistics about drug and alcohol misuse, there are some positive trends. According to one study, 72% of Americans with substance use disorders eventually seek treatment for their problem (although they wait an average of 10 years to do so). For those who don't, the consequences might not be as dire as most of us would expect. Research shows that seeking treatment is not an essential part of recovery. For example, up to 30% of people with alcohol dependence learn to abstain or limit their drinking on their own, without a formal treatment program.

For those who do seek treatment, the landscape might be different than it was in the 1980s. Most clinicians no longer subscribe to the “tough love” approach to substance abuse treatment, which dictated “no tolerance” policies and advocated marginalizing people with addiction if they relapsed. Instead, clinicians are more respectful of the individual and realize that relapse is an almost unavoidable — and potentially useful — step in recovery.

Also, clinicians and others have changed their views on addiction. People see addiction as a disease, not a character weakness, and most, if not all, recognize its important biological component. That shift is due in part to advances in imaging techniques, which allow scientists to peer into the brains of people with addiction. Indeed, scientists' understanding of the biological basis of addiction has led to the development of several drugs to treat the disorder, and dozens more are in development.

What is addiction?

People allude to addiction in everyday conversation, casually referring to themselves as “chocolate addicts” or “workaholics.” But addiction is not a term clinicians take lightly. The term does not appear in any diagnostic manual; current classification systems favor other categories, such as dependence, abuse, and impulse control disorder. In the absence of an official diagnosis of addiction, clinicians and laypeople alike often use a conventional definition that invokes three C's:

  • Craving for the object of addiction, which can be mild to intense

  • loss of Control over use of the object of addiction

  • Continued engagement with the object of addiction despite adverse consequences.

This definition bears some relation to those for substance dependence and substance abuse found in the reference book that physicians and psychotherapists use to categorize mental health disorders, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

Also, as described in the letter that opens this report, addiction experts are beginning to move away from the notion that there are multiple addictions, each tied to a specific substance or activity. An object of addiction can be anything — drug or otherwise — that alters a person's subjective experience.

Substance dependence

According to the DSM-IV, people who are dependent on substances exhibit at least three of the following symptoms or behaviors during the same 12-month period:

Greater tolerance: using higher doses of the substance to reach the same level of intoxication, or being able to use more than others without becoming intoxicated.

Withdrawal symptoms: experiencing certain physical symptoms when use of the substance is stopped or cut back, such as anxiety, sweating, trembling, trouble sleeping, nausea, or vomiting.

Ongoing desire to quit using: attempting to cut down or quit, without success.

Loss of control over quantity or involvement: using greater amounts, or using over a longer period than intended.

Greater focus on the substance: spending a lot of time thinking about using, making plans to use, using, and recovering from the effects of the substance.

Less focus on other things: spending less time doing other things — engaging in sports, being with family and friends, and pursuing hobbies.

Ignoring problems: continuing to use despite recognizing that it's causing problems, such as interfering with relationships or worsening health.

An ongoing (real or perceived) need for the substance and physical withdrawal symptoms may indicate a more severe level of dependence.

Substance misuse and abuse

The term substance misuse reflects cultural values and refers to the inappropriate use (which may be intentional or accidental) of any type of drug (including alcohol). Misuse can be a warning sign or precursor to abuse.

Substance abuse is the term the DSM-IV uses for people who have a less intense relationship with their object of addiction than those with dependence. Unlike those who are dependent on substances, people who abuse substances don't have the same compulsion or physical need to use, but they do use excessively on a regular basis. People who abuse may do so to help themselves cope with emotional problems and life crises.

While substance abuse differs from substance dependence, the difference might be a matter of degree. People who abuse substances and those who are substance dependent can experience many of the same problems.

The DSM-IV defines substance abuse as use that produces one or more of the following situations within a year:

  • repeatedly failing to fulfill major work, school, or home responsibilities (for example, regularly missing school or performing poorly at work because of substance use)

  • using the substance in situations where it's physically dangerous to do so, such as while driving a car, boating, or operating machinery

  • recurring substance-related legal problems, such as arrests for driving while intoxicated, disorderly conduct, or damaging property while intoxicated

  • continued substance use despite ongoing relationship problems either caused worsened by substance use (for example, arguing with a spouse about the effects of substance use).

An impulse problem?

The definitions of dependence and abuse given earlier are clearly related to drugs or other substances, but what about behaviors? The DSM-IV does not include any behavioral addictions — or at least they're not named as such. Some of the behavioral addictions show up in a different but related class of disorders, namely, impulse control disorders. Impulse control disorders include kleptomania (compulsive stealing) and pyromania (compulsive fire-setting), for example.

At the moment, pathological gambling also falls under this same conceptual umbrella. However, many mental health specialists believe that pathological gambling should be categorized as a behavioral addiction, and grouped with addictions to shopping, sex, and other activities (see “Gambling and other behavioral expressions of addiction”).

Understanding tolerance, physical dependence, and withdrawal

People sometimes confuse the terms tolerance, physical dependence, and withdrawal. These terms are not interchangeable, though they are related.

Tolerance means that, over time, a person will need larger doses to get the same effect first experienced with smaller doses. Because tolerance to some side effects does not occur, people with tolerance often face worsening side effects as they take larger and larger doses.

Physical dependence means that the body gets used to having the substance or activity and “misses it” if it's taken away. People with physical dependence who stop using their object of dependence or who decrease their dose might develop uncomfortable withdrawal symptoms.

Withdrawal refers to a range of typical symptoms that vary depending on the substance or activity in question, but they often reflect the opposite of the high. How long withdrawal symptoms last and how severe they are depends on which substance (or activity) a person uses, at what dose, and for how long. The fear of withdrawal symptoms sometimes makes people nervous about stopping or lowering their dose. That's sometimes true even for people who no longer derive pleasure from their object of addiction.

Physical dependence and addiction are two different things. People who are physically dependent might be addicted, but not necessarily. People with addiction are not necessarily physically dependent. For example, many people who undergo surgery use enough pain medication to become tolerant and physically dependent, though they would never engage in the activities that are characteristic of addiction, such as engaging in illegal acts to acquire drugs. On the other hand, while about half of pathological gamblers who do not misuse any psychoactive substance still experience physical symptoms of withdrawal when they stop gambling and therefore might be considered dependent, the other half don't experience withdrawal symptoms but still have addiction.

The use continuum: From harmless to harmful

As most people realize, substance abuse and dependence are the exception rather than the rule. The vast majority of people who drink alcohol, take prescription medications, and even experiment with illegal drugs do so without experiencing adverse consequences or addiction (see Figure 2).

This situation was first documented in a landmark paper published in 1976, which described five case studies of “chippers,” people who'd been using heroin for years (in some cases decades) without ever becoming dependent on the drug. This phenomenon — use that does not lead to abuse — applies to many substances historically thought of as “highly addictive.”

According to the National Survey on Drug Use and Health, only about 13% of people who try heroin become dependent on the drug within two years of first use. For new users of crack cocaine, about 9% become dependent. And for marijuana, the proportion is about 6%.

These numbers debunk the myth that someone need merely sample a psychoactive drug to become hooked. That's important to acknowledge, because many antidrug campaigns that promote this myth have lost credibility among people who are familiar with drug use and addiction patterns. Still, the fact that most people who use drugs do not become addicted does not mean using drugs isn't harmful at times.

How much and how often people use substances or engage in behaviors certainly influences the course of addiction. But addiction isn't defined by a specific amount or frequency, but rather by how it affects your life. In other words, if you smoke just two or three cigarettes a day, you might not be physically dependent upon nicotine, but you might have addiction if you can't control that use and it disrupts your life. Conversely, if you take a prescribed pain medication and become physically dependent, experiencing withdrawal symptoms when you don't take it, you might not have addiction, as long as your use doesn't adversely affect your daily life.

Figure 2: The drug use continuum

Many people experiment with drugs, as represented by the large base of the pyramid. But only a small percentage of those people end up with substance abuse or dependence disorders, as depicted by the smaller top two areas of the pyramid.

Cultural context

People drink alcohol, take drugs, gamble, shop, and perform similar activities along a gradient, which ranges from none to a great deal. The lines demarcating how much is too much are almost entirely culturally dictated.

Take the quintessential American college experience, for example. While in college, some American students regularly engage in binge drinking, meaning they consume five or more alcoholic beverages within one day. Most of them continue to take part in their normal school activities, and some have exemplary academic records. This type of alcohol consumption is considered relatively normal by many, and does not necessarily warrant the attention of parents or school officials (unless students harm themselves or others). Once students leave college, however, the social landscape changes, and the same amount of alcohol consumption is no longer considered acceptable. A person labeled as a “partyer” in one context might be labeled a “problem drinker” in another.

Context also can color how withdrawal symptoms are viewed. Withdrawal is one of the hallmarks of addiction, but not everyone who experiences withdrawal has addiction. You can be physically dependent on many things — painkillers or coffee, for example — but that dependence need not interfere with your life. Many people drink coffee in sufficient quantity that they experience withdrawal headaches when they stop using coffee; however, they are not impaired by this dependence. Similarly, patients who receive methadone for chronic pain do not get intoxicated and can function without daily interference from the drug, because they are maintaining a consistent level of dependence and tolerance.

On the other hand, just because a person is able to function fairly normally on a daily basis doesn't mean he or she doesn't have addiction. Many people with addiction are able to hold down jobs, raise families, and even manage to keep their addiction a secret.

How people develop addiction

Nobody starts out wanting to develop addiction, but people do gravitate toward certain substances or behaviors for specific reasons. Most of these objects of addiction offer people pleasure or, at the very least, the absence of displeasure. But often, the picture is more complex.

To a degree, people choose substances or activities that fill a real or perceived need. People who are anxious by nature, for example, sometimes turn to alcohol because it calms them and makes them feel more comfortable in social settings. Likewise, people who have persistent pain sometimes start taking opioids to relieve their pain. People who are concerned about their finances sometimes gravitate toward gambling, particularly if they had a formative experience in which they won a lot of money.

In some cases, people discover the benefit of a certain substance or behavior in a social setting. Others go in search of a benefit they hope to find. The point is that objects of addiction offer people psychological, social, or biological rewards. Often those rewards are compelling, so the substance or behavior remains appealing, even if it also comes at a cost.

One key element in overcoming addiction involves recognizing the value it holds. Once you understand the value you derive from your addiction, you can seek alternate — and less destructive — methods for filling that need.

Clearly, not every anxious person who tries alcohol becomes dependent on it; not every person who is in pain and tries opioids becomes opioid dependent; and not every financially challenged person who gambles becomes a compulsive gambler. Why, then, do some people develop addiction while others do not? Experts are still struggling with this question, but they do know that genes, the environment, and mental health all play a role.

Risk factors for addiction

Studies of twins and of families that are prone to addiction suggest that about 50% of the risk for drug addiction is genetically based. The genetic ties to behavioral addictions have not been studied as thoroughly, but there is evidence that genes play a similar role in gambling disorders. A few reports even hint at a genetic link to compulsive shopping. More importantly, experts in the field propose that there is a genetic “load” or constellation of genes that predisposes people to addiction, but not necessarily to a specific type of addiction. In other words, the same genes that drive substance dependence may also drive compulsive shopping and compulsive gambling.

The environment in which people grow up and their personal histories also affect how likely they are to develop addiction. People who were abused or neglected as children, for example, have a higher risk of developing addiction than people who were nurtured as children. Similarly, people who have gone through traumatic events, such as rape or a natural disaster, are more prone to addiction than those who have been spared trauma.

People with mental illness also seem to be particularly vulnerable to addiction, and addiction and mental illness often overlap. By some estimates, as many as 65% of people who have drug addiction also have a mental illness such as depression, anxiety, or a personality disorder. Many experts believe that untreated mental illness may lead people to self-medicate with substances to ease their suffering.

A common brain pathway

Although some people are more at risk for addiction than others, nobody is immune to the disorder. Even those who do not use psychoactive drugs or engage in risky behaviors have a chance of developing addiction. That's because we are all wired to respond to rewards similarly.

The brain registers all forms of pleasure in the same way, whether they originate with a psychoactive drug, a monetary reward, a sexual encounter, or a satisfying meal. In the brain, pleasure has a universal signature: the release of the neurotransmitter dopamine in a part of the brain called the nucleus accumbens. Dopamine release in this part of the brain is so consistently tied with pleasure that neuroscientists refer to the region as the pleasure center (see Figure 3).

Every drug of abuse, from nicotine to heroin, causes a surge of dopamine in the nucleus accumbens. What's more, drugs of abuse can release two to 10 times the amount of dopamine as do natural rewards, such as sex or other pleasurable activities, and they do it more quickly and more reliably.

What dopamine does once it's released is not fully understood. Scientists used to believe that it alone was responsible for the joy and pleasure that comes with rewarding behaviors. That belief stemmed from studies that linked the amount of dopamine released with the degree of the high that drugs produced. It now appears, however, that dopamine has a much more sophisticated role. While dopamine in the brain might coincide with pleasure, it does not necessarily produce pleasure. Studies of the neural effects of nicotine show, for example, that nicotine causes a surge of dopamine but does not produce euphoria that smokers would consider a high. Meanwhile, events that are unpleasant and stressful also prompt the release of dopamine in the nucleus accumbens. Consequently, dopamine cannot simply be the brain's pleasure switch, though it clearly has an important role in pleasure.

A growing body of evidence suggests that — in at least some contexts — dopamine is the switch for “wanting,” rather than “liking,” which would explain its ability to reinforce behaviors. Another body of evidence points to a role for dopamine in learning and memory. Those studies suggest that dopamine release allows the brain to compare expected outcomes with actual outcomes. In that scenario, dopamine surges tell the brain that an outcome is “better than expected.” Conversely, the interruption of dopamine release tells the brain that an outcome is “worse than expected.”

Whatever dopamine might be doing, one thing is clear: the strength of the dopamine signal is directly tied to the risk for addiction. That explains why addiction to psychoactive substances is more common than addiction to behaviors.

The likelihood that the use of a substance or participation in a rewarding activity will lead to addiction is directly linked to the speed with which it promotes dopamine release, the intensity of that release, and the reliability of that release. Even taking the same drug through different methods of administration can influence how likely it is to lead to addiction. Smoking or injecting a drug intravenously, as opposed to eating it, for example, generally produces a faster, stronger dopamine signal and is more likely to lead to drug misuse.

Figure 3: Activating the reward pathway

When you experience something pleasurable (whether from a substance or behavior), you unleash a flood of brain chemicals known as neurotransmitters that activate various parts of your brain. Neurotransmitters cross the synapse (a gap between brain cells) to reach receptors, or docking points, on the surface of target cells. All substances of abuse and rewarding activities trigger the release of dopamine, which activates brain cells in the reward pathway, a circuit in the brain that includes areas involved in motivation and memory as well as pleasure. In time, visual cues that remind a person of the addiction — such as a crack pipe, a bottle of liquor, or a betting chip — might be enough to activate the same pathway, which is one reason addictions are so hard to change.

Dopamine differences

Even though all psychoactive drugs promote dopamine release in the nucleus accumbens, they do not make everyone who tries them feel the same way. Some people have robust responses to drugs of abuse, while others seem dulled to their effects. That's probably because some people's brains are more predisposed than the brains of others to “liking” drugs.

It is difficult for scientists to study the brains of people with drug addictions to see if they differ from those of people without addictions, because the drugs themselves change the brain. As a result, it would be impossible to tell whether any observed differences were there to begin with or were a consequence of the drug use.

For ethical reasons, scientists also cannot give illicit drugs to people who have never used them just to see how the drugs affect their brains. They can, however, give people FDA-approved drugs whose effects are similar to those of illicit drugs. In one such study, researchers injected men who had never abused illicit drugs with methylphenidate (Ritalin), a drug normally used to treat attention deficit hyperactivity disorder. Methylphenidate has properties similar to cocaine, and, when given in large doses (especially if injected), it can produce a high. According to the study, men who described methylphenidate as pleasant had far fewer dopamine D2 receptors (see “Neurotransmitter receptors: Biological switches,” below) in the nucleus accumbens, compared with the men who described methylphenidate as unpleasant. In other words, the men who liked methylphenidate were probably getting a weaker dopamine signal, by virtue of having fewer dopamine receptors.

This study and others like it support the theory that people who gravitate toward psychoactive drugs do so because they don't get enough dopamine stimulation through normal channels. Scientists believe that people sometimes use psychoactive drugs to compensate for a “reward insufficiency.” Conversely, they suspect that psychoactive drugs are unpleasant among people who already get enough stimulation from everyday rewards, like a pleasant social interaction or a pat on the back at work. For them, as the theory goes, the exaggerated effects of psychoactive drugs are simply too overwhelming.

Genetic studies support the reward insufficiency theory. A form of the dopamine D2 receptor gene called TaqI A1, which impairs the function of the receptor, has been linked with alcoholism. That same gene also appears to be more common among pathological gamblers and might be relevant to smoking and obesity.

Genes, of course, are not the only factors that influence how the brain responds to dopamine. An animal's social environment and stress level actually can change the number of D2 receptors in the brain and change the proportion of the nucleus accumbens that is dedicated to pleasure. Thus, the environment can alter how pleasurable a given reward can be. For example, foods considered delicacies in a certain culture are sometimes repugnant to those raised in a different culture. That might explain why some social and environmental conditions are more likely to be associated with addiction than others.

The insidious thing about addiction is that the phenomenon itself paradoxically robs the brain of dopamine stimulation. When bombarded by drugs of abuse or activities that promote a lot of dopamine release, the brain tries to compensate for the heightened stimulation — turns down the volume, as it were — by releasing less dopamine and making fewer dopamine D2 receptors. This adaptation might explain, at least in part, why people wind up needing higher and higher doses to get the same level of stimulation they once experienced when using lower doses, or when gambling with less money.

As this cycle spirals, natural rewards become less and less able to compete with objects of addiction. The brain becomes dulled not only to the effects of the object of addiction, but also to any other reward. One study demonstrated this cycle when it examined the brains of smokers and nonsmokers while they performed a cognitive task, which — if done correctly — could earn them a cash reward. In nonsmokers, getting the right answer activated the dopamine reward system. In smokers, on the other hand, the dopamine system did not respond. There's some evidence that this phenomenon reverses itself after people quit, but so far, the findings regarding this complex process are limited.

Drug, set, and setting

Although objects of addiction can have profound effects on the brain, the brain itself exerts some control over how it allows itself to change. Your mindset and expectations when you're using a psychoactive substance or engaging in a rewarding activity — what psychologists call your “set” — can have a significant effect on how you respond to the experience.

For example, just believing that you'll experience an effect from a drug — even if you don't actually take it — can alter your behavior. This well-known placebo effect even applies to pleasure-enhancing substances, as evidenced in a series of experiments with college students. The students were put into a mock barroom setting and served what they believed were alcoholic beverages. In fact, only some of the students were drinking alcohol, while the others were drinking placebo drinks. Nevertheless, students who had drunk no alcohol behaved in just as inebriated a manner as those who had.

The social and environmental context within which a person uses a psychoactive substance or engages in a rewarding activity — what psychologists call the “setting” — also alters the subjective effect of the substance or activity. Having two beers at home in front of the TV, for example, might make a person sleepy. The same two beers at a party, on the other hand, might make the same person feel excited and free of inhibitions.

A more extreme example is that of the thousands of Vietnam veterans who regularly used heroin during their time at war. While in Vietnam, these soldiers were dependent upon heroin, but when they returned to the United States and left the devastation of war behind, the vast majority (about 90%) of them also quit using heroin.

Part of the reason psychoactive substances can have such situation-specific effects is that physiology can change to match the context. Soldiers who are in active combat, for example, produce a lot of adrenaline and other stress hormones. Those hormones in turn change the chemistry of the brain, possibly making it more vulnerable to addiction within that setting.

The dose people use also can shape their response to a psychoactive substance or rewarding activity. Although people tend to think that there is a one-to-one relationship between dose and effect, that's not necessarily true. Substances that do one thing at one dose can do the opposite at another. What's more, most of the substances and behaviors that have the potential to become objects of addiction actually can be beneficial at low doses. Alcohol, for example, might protect against heart disease and stroke when taken in limited amounts. At higher doses, on the other hand, it can promote heart disease and stroke, as well as a slew of other health problems.

How addiction affects the brain

Although different substances and behaviors associated with addiction have some similar effects on the brain, each also has some unique effects on the brain and the body. Substances of abuse — both legal and illegal — mimic naturally occurring neurotransmitters, or they interfere with the way those neurotransmitters function. Behaviors associated with addiction, on the other hand, tap directly into the chemistry of the brain, shifting the relative activity of naturally occurring neurotransmitters (see “Gambling and other behavioral expressions of addiction”).

These effects are complicated by the fact that the brain's chemistry is shaped by the environment (setting) and the person's mental state (set) at the time of use — and by the fact that any change in one system causes ripple effects throughout the brain. As a result, every person with addiction is different, even when the same substance is involved. Each person has different reasons for starting and continuing to use, as well as different cues or trigger situations, and many people abuse more than one substance at a time. As such, detailed advice specific to a particular substance or behavior can resonate with one person yet be meaningless to another.

The shift toward addiction

When people first try psychoactive substances or behaviors that can be associated with addiction, they almost always find them rewarding in some way. For most people, the relationship with these substances or behaviors either dissolves or remains recreational and harm-free. For some people, however, continued use leads to physiologic and behavioral changes that can increase the risk for addiction and possibly harm. Examples of these changes are those that lead to tolerance and withdrawal symptoms, because these experiences can prompt people to continue using just to avoid the adverse consequences of stopping.

The risk of addiction is somewhat proportional to the magnitude and reliability of the reward associated with use. That's why potent drugs such as heroin and cocaine are more likely to lead to addiction than food, sex, or gambling.

As discussed earlier, also relevant are the set and the setting. A person might be a casual drinker for years, but on the day he or she gets fired, alcohol might taste different or produce a different and more pleasurable effect. Likewise, a random win of $1,000 at the racetrack on the day you get fired might have a very different effect than it would have the day before.

Recovering from addiction

Overcoming addiction can be a long, slow, painful, and often complicated process. But contrary to popular belief, you don't necessarily need to go to a rehabilitation center or receive formal treatment to overcome addiction. Many people recover from addiction on their own. Others do it with the help of peers, psychotherapy (see “Working with a therapist”), medications, outpatient or inpatient treatment centers, self-help groups, or a combination of these elements. Whatever the case, the basic necessary steps to recovery are the same:

  • First, find meaning in your life by replacing your addiction with alternative interests that engage and challenge you. Often that means reconnecting with something — a hobby, a career, a relationship — that was meaningful before your addiction emerged. Sometimes it means discovering a new interest that can take the place of the relationship with the addiction.

  • Second, start exercising, even if it's something as simple as walking. Exercise is a natural antidepressant: it relieves stress and helps you think more clearly. Exercise also prompts the body to release its own psychoactive substances — endorphins — that trigger the brain's reward pathway and promote a feeling of well-being.

Exercising sometimes ties in with finding or renewing meaning. For example, walking, running, or other outdoor activities can get you in touch with nature, which has a calming effect on many people. Or the exercise might involve joining a team or taking a class, which requires discipline and persistence, and often provides a healthy social context. Regular exercise can help you adopt a routine that leads to positive change, providing an opportunity to learn ways to influence your life favorably.

Both of these essential recovery steps lead to a common and important outcome: you become reinvested in other people and your community. To recover from addiction, you need to re-enter the social fold, where there is a support system that discourages use of the object of addiction.

The nice thing about the two essential elements of recovery is that they are within the grasp of anyone who decides to overcome addiction, whether or not he or she seeks formal treatment. Although peer groups and clinicians can facilitate the recovery process, these people are not essential to recovery.

Natural recoverers

Addiction researchers use the term “natural recoverers” to refer to people who are able to overcome addiction on their own, without treatment or self-help groups. Researchers suspect that former smokers are the largest group of natural recoverers. Unfortunately, natural recovery is difficult to quantify, because people who take that route do not necessarily make themselves known to researchers. But according to several case studies, people with addiction — for example, to cocaine, heroin, or alcohol — are often able to recover on their own. A study of people who once met the clinical criteria for pathological gambling also found that more than a third had not experienced any gambling-related problems during the past year, even though only 7% to 12% of them had ever sought formal treatment or attended meetings of Gamblers Anonymous.

Often, natural recoverers try to quit many times; ultimately, many are successful. Each attempt represents a lesson learned and progress toward the ultimate goal of quitting. In fact, research shows that each attempt has its own probability of success, and therefore repeated attempts to quit increase the likelihood of eventual success.

If you're interested in natural recovery, realize that this approach is more difficult if the addiction is severe or if other psychological disorders are present. Those who have severe addiction, depression, anxiety, or other mental health issues might have a better chance at success if they enlist the help of health professionals. In addition, people who are addicted to anti-anxiety medications or tranquilizers should never attempt to quit on their own, as withdrawal symptoms can be very serious and sometimes fatal (see “Sedatives and hypnotics”).

Are you ready to change?

If you have addiction and you'd like to change your behavior, consider all the costs and benefits of the choices you could make. Don't think only about the negative aspects of your object of addiction; think, too, about the benefits it offers. One important step to recovery involves understanding what you get from your substance or activity of choice, and how you might achieve the same benefit through other, less harmful means.

Experts recommend doing an impromptu cost-benefit analysis by filling out a table such as Table 1. The example here addresses the issue of compulsive gambling, but it could be repurposed for any addiction. You can make a chart using your own addiction and your own costs and benefits on a blank piece of paper. When you fill it out, write as many items as you can think of to go under each heading. Weigh the importance of each answer. Do the benefits of continued use or participation outweigh the costs? If not, you may decide you want to change your behavior.

Table 1: Is it worth the cost?

Benefits of not gambling

Benefits of gambling

  • I would have more money to spend on other things.

  • I would have more time to spend with people I care about.

  • My friends and family would probably be happier with me.

  • I have fun when I gamble.

  • I love the feeling of excitement when I gamble.

  • I have occasionally won lots of money gambling.

Costs of not gambling

Costs of gambling

  • I would have to face the responsibilities I've been ignoring while engaged in my addiction.

  • I would have to somehow fill up my time.

  • I would lose my social connection to my gambling buddies.

  • I am heavily in debt.

  • I am depressed and anxious.

  • I have angered my friends and family.

What, why, when, and how?

If you decide to make a change, you'll have to sort out exactly what, when, and how you want to change. That will depend a lot on your view of the problem. Those who are most invested and motivated to change will have the best chance of success.

Assuming you want to make a change, the next step is to choose your goals. Ask yourself:

  • When do I want to make a change?

  • Do I want to stop altogether or do I want to simply cut down?

If you decide you want to cut down, determine the level to which you want to limit your use or participation and be specific. As with any behavior change, you might find the following “SMART” goals helpful. Your goal should be

  • Specific, meaning you should set a specific goal, such as, “I will stop drinking any alcohol between the hours of 1 a.m. and 10 a.m.”

  • Measurable, meaning that your success should be easy to quantify. In the case of the goal mentioned above, you might keep a log of your consumption to be sure that you adhere to your goal.

  • Achievable, meaning your goal should be something you are physically capable of doing today, and something that would be safe for you to do. If you drink chronically, round-the-clock, the sample goal might not be safe without the help of a doctor, because the interruption in drinking could bring on life-threatening withdrawal consequences.

  • Realistic, meaning that it is something you believe you can do.

  • Time-based, meaning that you should set a date and time when you start the goal, and you should examine your progress at regular intervals.

Change is a gradual process and takes time. The first three to six months of change are usually the most difficult. The period after that will be hard, too, but not quite like it was in the beginning. If you get discouraged, remember that others before you have overcome addiction.

Seeking treatment

Although natural recovery works for some people, others find that they want or need the support of their peers or the help of health professionals as they negotiate recovery.

The most effective treatment is the one that you will stick to, so first figure out what you need, and then find the treatment that can offer you a program that matches your needs best. For example, treatment can be low-key and self-directed, or intense and militant. You'll have to decide where on that continuum you want to be. Plus, you may decide to combine elements to meet all of your needs. Regardless of where you start, addiction treatment and lifestyle change will take time. There is no quick fix.

Peer support

When people first realize that they want support in the recovery process, they often turn to peer support groups, such as Alcoholics Anonymous (AA). By some estimates, as many as one in 10 Americans, including two-thirds of those ever treated for alcohol addiction, has attended at least one AA meeting.

Programs like AA, including Narcotics Anonymous, Gamblers Anonymous, Overeaters Anonymous, and similar so-called 12-step programs, can be very effective fellowships. But people seeking help should consider “shopping around” for the group that suits them best. As with most things that involve a human connection, peer support programs work when the group and the individual are compatible. Luckily, most support group systems have multiple groups to choose from.

Also, self-help 12-step fellowships can be used in combination with psychotherapy. At one time, the relationship between AA and mental health professionals was somewhat tense and distant. The two groups had different opinions about the best way to treat addiction. But today cooperation is more common than conflict.

AA does not reject or compete with medicine or psychiatry. Many members seek psychotherapy or professional counseling, and some take psychiatric drugs. Most mental health professionals readily refer patients to 12-step programs, and many draw on these principles or use 12-step–related counseling (often called 12-step facilitation) in their approach to therapy (see “12-step counseling or facilitation”).

In treatment developed by researchers for the National Institute on Alcohol Abuse and Alcoholism, 12-step facilitation therapists provide patients with reading materials about AA and encourage attendance at meetings. They also might arrange contacts with volunteers from AA and other 12-step groups. Patients might be asked to keep a journal of experiences at AA meetings and discuss them with a counselor or therapist. In hospitals and clinics that treat chemical dependency, 12-step facilitation is often part of detoxification (supervised withdrawal).

Residential treatment centers

Residential (live-in) treatment centers provide the most intensive addiction treatment. Such centers are ideal for people who have been unsuccessful recovering through less intensive approaches. Often these treatment settings are most attractive to people who need to separate from their current living situation and the temptations of everyday life. Within a residential treatment setting, there are structured daily activities and therapeutic sessions. You might want to start your treatment experience in a residential facility if you think an intensive experience will serve you best.

However, some people are not willing or able to spend the money or time required to enter a full-time treatment program. These programs are often expensive and take at least one to several months to complete. Little evidence suggests that the long-term success rates of residential programs are better than outpatient programs. However, these success rates are based upon averages — that is, evidence collected from many people and over a long period of time. Treatment need is very personal. Which treatment approach you need must be determined by your current situation, whether other treatments have been helpful, and how much structure you need. If you need a safe and very structured setting to begin your recovery, a residential treatment center might be the best choice for you.

Acknowledge your ambivalence

Whatever means you choose to address your addiction, chances are you'll have to wrestle with some degree of ambivalence — before, during, and after treatment or self-directed change. Your substance or activity of choice once did something positive, and the memory of that positive effect can be very alluring and enduring. People with addiction often waffle about their desire to stop the addiction-related activity. Many relapse during the first year after stopping. If this happens, you can still recover, particularly if you plan how to handle a relapse.

Working with a therapist

Therapy can fill different needs for different people. When and how long you need therapy and what type of therapy you choose depend on where you are along the road to recovery, whether you have another psychological disorder, and what type of therapy you prefer.

Some people need help evaluating their addiction — that is, determining the nature and severity of the problem. Others already have decided that their addiction is a problem, but they need help starting the process of change. Still others need help adjusting their perceptions of themselves and their relationships with those around them, so that recovery actually can take place. Individual needs also evolve during the process of recovery.

Clinicians tend to use the approach they know best, so if you are interested in a particular type of therapy, find someone who is comfortable with it. Still, the approach a therapist takes is just one of the things you should consider in making your choice. Keep in mind that your eventual success will have less to do the therapeutic technique and more to do with the quality of the therapist you find and the therapeutic relationship you forge.

Choosing a clinician

The single most important determinant of success in therapy is known as the therapeutic alliance. That's the term mental health professionals use to describe how well a therapist and his or her client function as a team.

If treatment is to work for you, you must feel thoroughly comfortable and have a sense of connection with the therapist you choose. It's also important that your therapist show you respect and display a genuine interest in your goals for therapy.

A therapist who stands in judgment of you, who chastises you for using drugs or gambling and failing to stop, or who tells you what to do usually is not as engaging as a therapist who helps you find your own way. That said, a therapist might become more directive at times, in an effort to help you stay safe.

Given the importance of the therapeutic alliance, you might need to shop around to find a therapist that suits you. It should take no more than two or three sessions for you to “test-run” a therapist and decide if he or she is right for you. Even so, finding the right therapist can take a lot of time and effort, especially if there aren't a lot of providers in your area or your health insurance limits your choices. Still, investing some time in choosing a therapist will pay off, because the second most important determinant of addiction treatment success is the length of time you spend in treatment. Studies show that the likelihood of recovery increases with the duration of treatment. However, people do not typically remain in treatment for long if they do not have a good rapport with their therapist.

Types of therapy

To a degree, different psychotherapeutic techniques target different needs. For example, motivational enhancement therapy helps people sort through their feelings about their addiction and the influence it has on their lives to clarify and increase their motivation for change. Cognitive behavioral therapy, on the other hand, works to change the relationship between thought patterns and behaviors that can impede recovery.

The techniques described below are examples of the best-studied therapeutic approaches; many others can also be useful. In addition, these various techniques are not mutually exclusive. Good clinicians often use several different techniques for each of their clients.

Motivational enhancement therapy

Motivational enhancement therapy is a catch-all term for techniques that attempt to enhance motivation. Examples include motivational interviewing and resistance reduction.

The psychologists who developed motivational enhancement therapy recognized that people have a natural tendency to play devil's advocate. In other words, if one person pushes a particular viewpoint or agenda, those around him or her often naturally raise the opposing viewpoint.

Historically, most therapists treating people with addiction tried to convince their clients that addictive behavior was problematic, unhealthy, and detrimental. This approach sometimes alienated the client, further entrenching the problematic behavior.

Motivational enhancement therapies encourage clients to develop their own agenda and set their own goals. The therapist's role is to listen carefully and to ask provocative but judgment-free questions about the value of using the substance of addiction and how such use has affected the client. The answers should help the clients increase their motivation for stopping such use, identify reasons to change, and establish a recovery plan. Clinicians typically use this treatment strategy in conjunction with other therapeutic approaches.

Studies are backing up this approach. Six federally funded, multisite studies concluded that motivational interviewing was better than standard community treatment for drug problems and dependence on several measures, including reducing drug use and sticking with treatment. Findings from Project MATCH (see below) also found motivational enhancement therapies helpful for alcoholism. For quitting smoking, motivational therapy was most likely to help when sessions with a clinician lasted at least 20 minutes, and when the patient saw the therapist multiple times rather than just once.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) works to identify and change thought patterns and the relationship between these thoughts and behaviors that might be contributing to addiction or interfering with recovery. For example, CBT works to dispel the belief many people with addiction have — that they cannot function without their object of addiction. It also helps people develop strategies to reduce the chances that they will have a relapse. Through CBT, people learn to avoid triggers (in the environment and in relationships) that are likely to lead to engagement with their addiction. CBT also teaches people to avoid risky situations, and how to anticipate, prepare for, and manage cravings when these emerge.

A specific form of CBT, called mindfulness-based cognitive therapy, helps people become aware of painful or negative thoughts and feelings. Clients are taught to experience and accept those thoughts and feelings without trying to avoid them. This form of therapy is useful for people who seek refuge from negative thoughts by turning to their object of addiction. It differs from traditional CBT in that it does not try to eliminate or reframe negative thoughts. Instead, mindfulness-based cognitive therapy attempts to weaken the effect those thoughts have on the person's mood and well-being.

Dialectical behavior therapy

Dialectical behavior therapy (DBT) is a specialized form of CBT originally developed to treat borderline personality disorder. It focuses on helping people develop skills to better tolerate stress and emotional discomfort. It also teaches people to become more aware of and comfortable with their emotions. Clinicians practicing DBT help their clients negotiate opposing forces; for example, by encouraging them to tolerate and accept difficult circumstances while also taking steps to change behaviors that might be contributing to those circumstances. This form of therapy might be especially helpful for people with addiction who also have borderline personality disorder.

Psychodynamic therapy

Rooted in Freudian theory, psychodynamic therapy focuses on putting the client in touch with his subconscious and identifying how it influences behavior patterns. During psychodynamic therapy, a person might explore childhood and past experiences to look for clues as to what's driving current behavior. A therapist using this approach might prompt the client to examine unresolved conflicts and failed relationships, in the hopes that resolving those conflicts or understanding those past failures might relieve psychic stress and thus alleviate the need to engage in the addiction.

Through psychodynamic therapy, a person also might examine what benefit the object of addiction offers, and then explore alternative approaches that might be less harmful.

12-step counseling or facilitation

Another approach, known as 12-step counseling, is rooted in the AA philosophy (see “Peer support”). But while AA is a self-help group run by its members, without substance abuse counselors or other health professionals present, 12-step counseling emphasizes working with a therapist for a limited time while attending AA meetings. Like AA, 12-step counseling adheres to the following principles:

  • People with addiction have lost the ability to control their use of the substance or behavior.

  • There is no effective cure for addiction. People with addiction must abstain completely.

  • There's hope for recovery if people accept that they don't have control over their addiction and put their faith in a higher power.

In this approach, the client meets with a clinician for 12 sessions, usually over 12 weeks. A spouse or partner may be included in some of these sessions. During the structured program, the therapist discusses AA — or whichever offshoot of AA is appropriate — with the client, encourages him or her to attend meetings, suggests certain reading materials, and assigns specific recovery tasks, such as making amends for problems resulting from addiction and making a list of one's personal strengths and weaknesses. Once the sessions are done, you continue to draw support by staying involved in 12-step meetings.

The matrix model

Compared with the techniques described so far, the matrix model of psychotherapy takes a more didactic approach. Therapists using this approach play the role of teacher and coach. They inform their clients about the implications of their addiction and — when psychoactive substances are involved — they use urine tests to detect lapses in abstinence. Therapists using the matrix model also might offer education for family members affected by the addiction.

Individualized counseling

Individualized counseling focuses specifically on getting the client to stop or reduce the use of a substance or an addictive behavior. It also helps him or her deal with the adverse repercussions of addiction, which can include joblessness, legal trouble, and family or social conflict. Rather than delve into the psyche of the client, individualized counseling sets discrete short-term practical goals and helps the client develop strategies for coping with craving and for maintaining abstinence.

Contingency management

Contingency management is often used in combination with other techniques. It involves the use of rewards — either monetary or symbolic, in the form of tokens — given when a person completes abstinence milestones. In AA, for example, people receive chips of various colors after they are sober for a month, six months, etc. This form of positive reinforcement seems to promote continued abstinence.

Behavioral therapy for adolescents

Adolescents often need specialized treatment for addiction. Behavioral therapy for adolescents focuses on helping young people develop skills (for instance, developing healthy relationships and good study habits) that might not have had a chance to flourish before they turned to their object of addiction. This form of therapy uses positive reinforcement to guide the acquisition of new skills. Youths participating in this form of therapy may have to complete homework assignments, keep records of their progress, and actively practice their skills. The therapist, in turn, offers praise and privileges when the client meets the mutually established goals. If drugs are the problem, most therapists will also arrange a plan to collect urine samples to monitor drug use.

During treatment, adolescents learn to avoid people or situations that might promote their addiction. They learn instead to spend time doing things that are incompatible with their pattern of addictive behavior. They also learn urge control, meaning that they learn to adjust the way they view and cope with urges and cravings so that they develop restraint over their behavior.

During this form of therapy, parents or others close to the client might be asked to participate in group sessions and to better understand and help steer the adolescent away from harmful behaviors.

Multidimensional family therapy for adolescents

This form of therapy acknowledges that many people, including family members and peers, influence the client's experience with addiction and vice versa. Sessions often include these people and can take place at home, in a clinic, at school, or in other community locations.

During individual sessions, the therapist and adolescent work on ways to develop and improve decision-making, negotiation, and problem-solving skills. Teenagers acquire new skills for communicating their thoughts and feelings, as well as vocational skills. Parallel sessions are held with family members. Parents examine their particular parenting style, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on their child.

Treatment of co-occurring disorders

Many studies have found evidence that addiction and psychiatric disorders, such as depression or anxiety, commonly occur together. Treatment of two or more mental health problems (referred to as co-occurring disorders) can be particularly challenging because the conditions often interact and feed into each other. For example, depression can increase the craving for drugs, which can lead to even more drug use and more severe depression. Researchers have found that using psychotherapeutic techniques to target both the psychiatric disorder and the addiction within a single treatment plan tailored to the individual offers the greatest chance of success.

In cases of mood disorders (such as depression or bipolar disorder), anxiety disorders (such as panic disorder), or schizophrenia or another psychotic thought disorder, treatment usually involves a combination of psychotherapy and medication.

Nicotine

The most popular forms of this drug include cigarettes, cigars, chewing tobacco, and snuff.

If you smoke, you may find yourself in a dwindling minority. What used to be a common and accepted habit is now prohibited in most workplaces, restaurants, and public spaces. You may find yourself hiding your habit from co-workers and family members, standing in the rain to have a smoke outside work, or driving in the car just to have a cigarette. In 2009, about 23% of men and 18% of women smoked — a reduction of nearly 50% since the mid-1960s, when cigarette use peaked in the United States. Most smokers are well aware of the harmful health effects of smoking, which kills an estimated 443,000 people in the United States each year — more than alcohol, cocaine, heroin, homicide, suicide, car accidents, fire, and AIDS combined. Nearly one in five deaths in the United States can be attributed to smoking tobacco. Each year, half of all smokers say they want to quit, but only about 6% who try succeed for more than a month. But if that's been your experience, don't be too hard on yourself: the average person makes five to seven quit attempts before stopping for good.

How nicotine affects you

Nicotine makes you feel alert, energized, and mentally sharp because it triggers a release of adrenaline, which in turn boosts heart rate, blood pressure, and breathing. Unlike other drugs of abuse, nicotine does not cause a feeling of euphoria or pleasure, though people sometimes say they get a mild “buzz.” People who use tobacco say that it calms them, but research indicates that the calming effect is actually relief from the unpleasant symptoms of withdrawal and the result of changes in breathing patterns, rather than a primary effect of the drug itself.

Options for treatment

There are a number of treatments you can choose from to help you stop smoking. Here you'll learn about some of the best studied.

Table 2: Coping with nicotine withdrawal symptoms

Symptom

Cause

Duration

Relief

Craving for cigarette

Body's craving for nicotine

Most intense during first week but can linger for months

Wait out the urge; distract yourself; take a brisk walk.

Irritability, impatience

Body's craving for nicotine

Two to four weeks

Exercise; take hot baths; use relaxation techniques; avoid caffeine.

Insomnia

Body's craving for nicotine temporarily reduces time spent in deep sleep

Two to four weeks

Avoid caffeine after 6 p.m.; use relaxation techniques; exercise; plan activities (such as reading) when sleep is difficult.

Fatigue

Body adjusting to lack of stimulation from nicotine

Two to four weeks

Take naps; do not push yourself.

Lack of concentration

Body adjusting to lack of stimulation from nicotine

A few weeks

Reduce workload; avoid stress.

Hunger

Body adjusting to lack of appetite suppression from nicotine

Several weeks or longer

Drink water or low-calorie drinks; eat low-calorie snacks.

Coughing, dry throat, nasal drip

Body ridding itself of mucus in lungs and airways

Several weeks

Drink plenty of fluids; use cough drops.

Constipation, gas

Intestinal movement decreases with lack of nicotine

One to two weeks

Drink plenty of fluids; add fiber to diet; exercise.

Tips for quitting

The following steps are a variation on the “Five action steps for change.” see Table 2 for ways to cope with specific nicotine withdrawal symptoms.

Get ready. Set a quit date; get rid of all cigarettes and tobacco products from your home, office, and car; don't let people smoke around you; and once you quit, don't smoke — not even a puff!

Find support and encouragement. Tell everyone you are going to quit and ask them not to smoke around you; talk to your health care provider; and get individual, group, or telephone counseling. A study in The New England Journal of Medicine suggests that spouses, friends, co-workers, and other direct contacts have a huge influence on quitting smoking. Once one person stops, others around the quitter have a better chance of quitting, too. Sometimes it helps to quit with a friend or family member so that you can support each other through the process.

Identify and avoid your triggers. Many smokers link having a cigarette with activities like finishing a meal or drinking coffee or alcohol. Breaking these links is an essential part of stopping smoking. Counseling and social support can help you identify and find new ways of dealing with these triggers (see next tip).

Learn new skills and behaviors. When you get a craving, try to distract yourself by taking a walk or getting busy with a hobby or task; reduce your stress by exercising or taking a hot bath; plan something enjoyable to do each day; drink a lot of water and other nonalcoholic fluids.

Time it right (for women only). Nicotine withdrawal symptoms are worse during the premenstrual phase and during menstruation, so plan to quit smoking at the end of your monthly period.

Table 3: Stop-smoking aids

Aid

Advantages

Disadvantages

Cost

*These prescription drugs may be covered by your health insurance plan and therefore require only the cost of your copay.

Nicotine patch

Provides a stable level of nicotine in the blood for 16 to 24 hours; easy to use

Takes two to four hours to hit peak level; user can't adjust dose to meet cravings

$3 to $4 a day

Nicotine gum

Rapid rise in blood level of nicotine; user can control dose to respond to cravings; oral substitute for a cigarette

Must be chewed properly to get nicotine and avoid upset stomach; can cause mouth soreness or indigestion

$4 to $7 a day

Nicotine inhaler

Rapid rise in nicotine; user controls the dose; hand-to-mouth substitute for smoking

Requires frequent puffs; can irritate the mouth and throat

$7 to $20 a day

Nicotine nasal spray

Offers the quickest increase in blood nicotine levels; user controls the dose

Can irritate the nose and throat; can cause cough

$5 to $21 a day

Nicotine lozenge

User controls the dose; oral substitute for smoking

Can cause sore mouth, indigestion, hiccups

$3 to $5 a day

Bupropion (Wellbutrin, Zyban, generic)

Easy to use; no nicotine involved

Can cause insomnia, dry mouth, agitation; shouldn't be used by anyone with a seizure or eating disorder

$2 to $19 a day*

Varenicline (Chantix)

Easy to use; no nicotine involved

Can cause nausea, headache, insomnia, and abnormal dreams; in rare cases, may cause suicidal thinking

$6 a day*

Medications to help you quit

There are three main classes of quit-smoking medications:

Nicotine replacement

Giving the brain the nicotine it demands without the tar, carbon monoxide, and hundreds of other harmful substances in cigarette smoke was an early breakthrough in stop-smoking aids. Nicotine replacement comes in a patch, gum, lozenge, nasal spray, or inhaler (see Table 3). Although they all do the same thing — deliver nicotine — some people prefer one strategy to another. Gum chewers tend to gravitate to the gum or lozenge, while those who find solace in the act of smoking often choose the inhaler. Some people find combinations, such as the patch plus gum, to be more effective than a single option. A 2009 study in Archives of General Psychiatry involving more than 1,500 smokers compared five different smoking cessation treatments — various combinations of nicotine replacement products and bupropion (see “Zyban”). The most effective combo was the patch plus lozenges.

Zyban.

Another stop-smoking aid is an antidepressant called bupropion. It was first introduced in 1986 under the brand name Wellbutrin. Smokers who used Wellbutrin often reported a lessening in the desire to smoke. After the drug was tested among smokers, the FDA approved it for this use in 1997 under the brand name Zyban. Unlike nicotine patches or gum, Zyban doesn't put nicotine into the body. Instead, it eases nicotine withdrawal symptoms, especially irritability, frustration, anxiety, difficulty concentrating, and depression.

Chantix.

Varenicline (Chantix) is chemically similar to an extract from a medicinal plant that has been used in Europe for many years as a smoking cessation drug. Varenicline takes the “fun” out of smoking by latching onto the brain's nicotine receptors. When nicotine tries to influence these receptors, it can't trigger the flood of dopamine needed to activate the brain's pleasure center. Varenicline doesn't inactivate the receptors. Instead, it stimulates them to slowly but steadily release dopamine, which eases nicotine withdrawal symptoms.

When varenicline was first approved, doctors and smokers were eager to try it. After all, it was significantly more effective than bupropion or nicotine replacement. As is the case for all new drugs, unexpected side effects began to pop up as millions of people tried the drug. Some of the more serious problems are agitation, depression, suicidal thinking, vivid dreams, and drowsiness. The medication has also been linked to a small increase in the risk of heart attacks and related problems among people who have heart disease.

Alcohol

Drinking alcohol is common and widely accepted in America in both social contexts and religious rituals. Most Americans drink, and many do so without suffering any harmful consequences. But nearly one in 13 adults and teens ages 12 and older abuses or is dependent on alcohol. Millions more engage in risky drinking behaviors, such as drunk driving.

Alcohol misuse sharply raises the risk of illness from numerous health problems, including liver disease, heart disease, and some types of cancer. The dangers associated with alcohol abuse tend to vary throughout the lifespan. Compared with older people, young adults are more likely to engage in binge drinking (defined as having five or more drinks on the same occasion), which puts them at risk for injuries and alcohol poisoning. Elderly drinkers, on the other hand, don't metabolize alcohol as efficiently, so they have higher blood alcohol concentrations after drinking than younger people, which leaves them more impaired. Older people are also more likely to use prescription medications, many of which interact with alcohol, causing dangerous side effects.

How alcohol affects you

Alcohol is a depressant, which means it slows down the central nervous system just like other sedatives do (see “Sedatives and hypnotics”). At low doses, this dampening of the nervous system leads to a loss of inhibitions, which is why people under the influence of alcohol are often talkative, more sociable, and perhaps even giddy. Alcohol impairs judgment and coordination, which is why drinking and driving are such a dangerous combination. With increasing amounts of alcohol, people can experience poor decision making, slurred speech, impaired balance, poor coordination, nausea, and disturbed sleep; higher doses can cause vomiting and loss of consciousness.

Treatment options

There are a variety of methods to choose from when attempting to stop or cut back on your drinking. Find explanations of those that have been found to be most effective below.

Tips for cutting down

Most people who drink want to cut down rather than quit altogether, but eventually, they learn they need to stop completely. Deciding how to start the process — gradually or abruptly — is something each person should work out with the help of a clinician.

The National Institute on Alcohol Abuse and Alcoholism suggests the following steps to help people cut back on their drinking:

Put it in writing. Making a list of the reasons to curtail your drinking — such as feeling healthier, sleeping better, or improving your relationships — can motivate you.

Set a drinking goal. Set a limit on how much you will drink. You should keep your drinking below the recommended guidelines: no more than one standard drink per day for women, as well as men ages 65 and older, and no more than two standard drinks per day for men under 65. These limits can be too high for people who have certain medical problems or for some older adults. Your doctor can help you determine what's right for you.

Keep a diary of your drinking. For three to four weeks, keep track of every time you have a drink. Include information about what and how much you drank as well as where you were. Compare this to your goal. If you're having trouble sticking to your goal, discuss it with your doctor or another health professional.

Don't keep alcohol in your house. Having no alcohol at home can help limit your drinking.

Drink slowly. Sip your drink. Take a one-hour break between drinks. Drink soda, water, or juice after having an alcoholic beverage. Never drink on an empty stomach.

Choose alcohol-free days. Decide not to drink a day or two each week. You may want to abstain for a week or a month to see how you feel physically and emotionally without alcohol in your life. Taking a break from alcohol can be a good way to start drinking less.

Watch for peer pressure. Practice ways to say no politely. You do not have to drink just because others are, and you shouldn't feel obligated to accept every drink you're offered. Stay away from people who encourage you to drink.

Keep busy. Take a walk, play sports, go out to eat, or catch a movie. When you're at home, pick up a new hobby or revisit an old one. Painting, board games, playing a musical instrument, woodworking — these and other activities are great alternatives to drinking.

Ask for support. Cutting down on your drinking may not always be easy. Let friends and family members know that you need their support. Your doctor, counselor, or therapist may also be able to offer help; several medications are available to help curb the urge to drink (see “Medications to help you quit”).

Guard against temptation. Steer clear of people and places that make you want to drink. If you associate drinking with certain events, such as holidays or vacations, develop a plan for managing these situations in advance. For example, plan to spend holidays with friends and family who support your sobriety and are willing to have an alcohol-free celebration. Also, some travel agencies specialize in sober vacations. Monitor your feelings. When you're worried, lonely, or angry, you might be tempted to reach for a drink. Try to cultivate new, healthy ways to cope with stress.

Be persistent. Most people who successfully cut down or stop drinking do so only after several attempts. You'll probably have setbacks, but don't let them keep you from reaching your long-term goal.

Some of these strategies — such as watching for peer pressure, keeping busy, asking for support, being aware of temptation, and being persistent — also can be helpful for people who want to give up alcohol completely.

Once you've cut back on your drinking (so you're at or below the recommended guidelines), check regularly to see if you're maintaining this level of drinking. Some people attain their goal only to find that old habits crop up again later. If this happens, revisit your plan to control your drinking, consult your doctor, and recommit to your goals.

Managing withdrawal symptoms

Common withdrawal symptoms for alcohol abuse include shaking, sweating, fatigue and slowed thinking, increased heart rate and blood pressure, flushing, muscle tension and headache, nausea or vomiting, abdominal cramps, and diarrhea. People often feel anxious and restless, as well.

Most alcohol abusers who are having withdrawal symptoms are deficient in several vitamins and minerals and can benefit from nutritional supplements. In particular, alcohol abuse can create shortages of folate, thiamine, vitamin B12, magnesium, zinc, and phosphate. It also can cause low blood sugar. Because sweating, vomiting, and diarrhea might be part of the withdrawal experience, be sure to drink plenty of liquids to avoid dehydration.

For people who drink excessively on a regular basis, quitting without medical supervision can be dangerous. In severe cases of alcohol addiction, stopping alcohol can trigger life-threatening seizures and possible visual or auditory hallucinations (delirium tremens, or DTs). If you are dependent on alcohol, withdrawal is risky and should be done under the supervision of a doctor.

Table 4: FDA-approved medications for treating alcohol abuse

Generic name

Brand name

Common side effects

What it does

acamprosate

Campral

Diarrhea, headache; patient must have normal kidney function tests before using.

Reduces unpleasant effects associated with abstaining from alcohol.

disulfiram

Antabuse

Adverse reaction when taken with alcohol; metallic aftertaste; red, itchy skin. More serious side effects can include disulfiram-induced hepatitis, which in rare cases can be fatal.

Causes unpleasant effects (nausea, vomiting, flushing, and others) from drinking alcohol.

naltrexone

Depade, ReVia, Vivitrol

Nausea, abdominal pain, constipation, dizziness, headache, anxiety, fatigue; increase in liver enzymes, which return to normal when medication is discontinued; blocks effect of narcotic pain relievers.

Reduces pleasurable effects of alcohol; reduces cravings.

Medications to help you quit

Three medications are FDA-approved for treating alcohol dependence (see Table 4). Each works in a different way to help people reduce drinking, cut down on relapses to heavy drinking, and achieve or maintain abstinence. Generally speaking, disulfiram (Antabuse) creates an aversive physical reaction if the person drinks alcohol, naltrexone (Depade, ReVia, and the injectable form, Vivitrol) reduces cravings and the pleasurable effects of drinking, and acamprosate (Campral) reduces the unpleasant effects of abstaining from alcohol, known as early abstinence syndrome. Other medications not specifically approved for alcohol dependence (anticonvulsants, benzodiazepines, and the muscle relaxant baclofen) have been found to help some people.

Disulfiram (Antabuse). This drug blocks an enzyme called alcohol dehydrogenase, which helps break down acetaldehyde, a chemical produced when alcohol is metabolized. If you drink alcohol while taking disulfiram, acetaldehyde builds up in your bloodstream, causing distressing side effects such as flushing, headache, nausea, and vomiting. Although this medication discourages alcohol use by making you ill if you drink, it doesn't eliminate your desire for alcohol.

Because disulfiram combined with alcohol can cause severe symptoms — including chest pain, increased blood pressure, cardiac arrest, and in rare instances death — it is not recommended for use if you have serious health problems in addition to alcohol dependence, such as heart disease, diabetes, or cirrhosis. Disulfiram can also cause liver inflammation, which can go on to produce hepatitis that, in rare cases, is fatal. Therefore, if you are taking this medication, you should have periodic blood tests to monitor your liver enzymes. Because of the risks, doctors tend not to recommend disulfiram if you have little or no control over your drinking. The drug has few side effects in people who are not drinking, however. Consequently, disulfiram is best used as an added motivational resource for people already committed to abstinence.

Naltrexone (Depade, ReVia, Vivitrol). Known as an opioid antagonist, naltrexone reduces your craving for a drink and, if you go ahead and drink anyway, blunts the pleasurable effects of alcohol. This medication is most effective in conjunction with some form of psychotherapy, according to numerous studies.

Naltrexone is generally recommended if you have stopped drinking and are trying to avoid relapse, but some people who have not been able to stop drinking entirely may use it to control their alcohol consumption.

In many, but not all, studies of this drug, people taking naltrexone achieved longer abstinence and had fewer relapses than those taking a placebo. An analysis of 29 studies done in many countries found that naltrexone reduced the risk of relapse or a return to heavy drinking during the first three months after withdrawal by more than one-third. The effect does not persist, however, when you stop taking the drug.

Naltrexone increases the level of certain liver enzymes, so you should have periodic blood tests to check liver function while taking this medication. Abnormalities typically resolve once the medication is discontinued. Naltrexone also blocks the effects of narcotic pain relievers, including those used during surgery. If you require any type of surgery, talk with your doctor about discontinuing naltrexone before the operation.

Naltrexone is available in pill form (under the trade names Depade and ReVia) as well as in an extended-release formula called Vivitrol, which is given by injection once a month in a doctor's office. The injectable version, which was developed because some people have difficulty sticking to a daily pill regimen, has been shown to increase rates of abstinence after six months and helps lower overall treatment costs for people with alcohol use disorders. If you use this medication, contact your doctor if you develop any pain, swelling, or tenderness at the injection site that doesn't improve, or worsens within two weeks.

Acamprosate (Campral). Researchers are not sure precisely how acamprosate works in an alcohol-dependent person. But they believe it affects two neurotransmitters, which, in turn, reduces the unpleasant symptoms of prolonged abstinence, such as restlessness, anxiety, and insomnia. In theory, this reduces internal triggers (cravings) to relapse.

Acamprosate is approved for people who are abstinent from alcohol and are receiving some form of psychotherapy. Numerous large studies involving thousands of people have shown that acamprosate boosts abstinence rates among those who are alcohol dependent and have recently undergone detoxification. It might not be effective if you are actively drinking or are abusing other substances in addition to alcohol. To take it, you must have normal kidney function, which can be verified with a simple blood test.

Topiramate (Topamax). Topiramate is an antiseizure drug used to treat epilepsy as well as certain psychiatric conditions, including bipolar disorder and schizophrenia. It has been studied as a potential treatment for alcoholism; however, it is not currently FDA-approved for that purpose. Several studies have shown that topiramate helps to promote fewer heavy-drinking days and more abstinent days. One study found the drug can be effective for people who are drinking at the time they start the medication; follow-up research with the same participants linked the drug to improvements in physical health, such as reductions in cholesterol, blood pressure, and weight.

Baclofen (Lioresal). This muscle relaxant might be another choice for treating alcohol dependence in some people. Heavy alcohol intake is a leading cause of liver disease; however, many of the currently available anti-craving medications cannot be used in people with liver disease for fear of further damage. A small study published in The Lancet in 2007 indicated that baclofen reduced alcohol cravings in people with cirrhosis of the liver without harming the liver.

Benzodiazepines. Sometimes called minor tranquilizers or anti-anxiety medications, these drugs produce an effect in the brain similar to that of alcohol; consequently, benzodiazepines can help ease withdrawal symptoms among people who are physically dependent on alcohol. Commonly used examples include chlordiazepoxide (Librium) and diazepam (Valium).

Prescription drugs

Most people use prescription medications responsibly, but a growing number are taking certain classes of these drugs for nonmedical reasons — a phenomenon the National Institute on Drug Abuse (NIDA) refers to as “prescription drug abuse.” In fact, nationwide, about one in five people reports using prescription drugs for nonmedical reasons at some point in his or her lifetime. However, abuse in this context doesn't correspond to the definition that appears in the DSM-IV (see “What is addiction?”). Rather, it means any use that is outside the medically prescribed regimen, such as taking a different dose, getting the drug from a nonmedical source (a relative, friend, or Internet seller), or taking the drug for its psychoactive effects. The three classes of medications that are most often abused are opioids, depressants, and stimulants.

Since the early 2000s, various surveys show that young adults (ages 18 to 25) reported the highest rate and largest increase in prescription drug abuse for each of three use timeframes: the past month, the past year, and during their lifetime. Adults over age 50 also are misusing prescription drugs in record numbers. Although this older demographic constitutes just 13% of the population, they take about one-third of all medications prescribed in the United States, making them more prone to potential prescription drug abuse.

According to NIDA, three factors have fueled this trend:

Misperceptions about safety. People assume drugs that are regulated by the FDA and prescribed by doctors are safe to take under any circumstance, but these medications act on the same brain systems affected by illegal drugs and have a similar potential for abuse.

More widespread availability. Prescriptions for the most commonly abused prescription drugs have increased by six to nine times since the early 2000s.

Varied motivations. Nonmedical use of prescription drugs stems from different underlying reasons — to ease pain or anxiety, to counter sleep problems, to sharpen thinking, or to get high.

Painkillers

The drugs known as opioids are among the most powerful painkilling drugs available (see “What are opioids?” below). Prescribing opioids for chronic pain caused by cancer or experienced at the end of life is considered appropriate and humane. For other chronic conditions, such as arthritis, migraine, or back pain, opioid use has stimulated controversy.

On one hand, some health care providers underprescribe opioids to these people because they overestimate the risk of addiction. In reality, the risk of opioid addiction among people with chronic pain is low — except for those with a personal or family history of drug abuse or mental illness. Short-term use also minimizes the risk of addiction. On the other hand, prescriptions for opioids increased tenfold from 1990 to 2010, and the number of people addicted to painkillers has risen in parallel with this trend. More than five million Americans reported nonmedical use of prescription painkillers and 1.9 million were dependent on or abusing this class of drugs in 2010 — nearly twice as great as the number of people addicted to cocaine. Friends and family are by far the most common source of prescription painkillers (see Figure 4).

Figure 4: Sources of painkillers

Friends and family members are by far the most common source of painkillers used for nonmedical reasons.

Many prescription painkillers come in slow-release versions to optimize pain control, but abusers may crush the pills and inject or snort the contents, increasing the risk of breathing problems or death. Those same heightened risks occur when opioid drugs are taken with other drugs, including alcohol.

In 2011, the FDA approved a new formulation of oxycodone intended to prevent users from tampering with the pills. The pills turn into a gel when dissolved in water and are much harder to crush into a fine powder. These factors might lessen the risk of abuse and overdose. A similar attempt to develop an abuse-proof painkiller led to the development of Embeda, a pill consisting of extended-release morphine surrounding an inner core of naltrexone, an opioid antagonist that blocks the effects of opioids (described further below). Taken as prescribed, little or no naltrexone is absorbed by the body, but crushing or dissolving the pill releases the naltrexone, which counteracts the pain-fighting and pleasure-causing effects of the morphine. However, at this writing, Embeda is unavailable due to a manufacturing issue.

How opioids affect you

In addition to their powerful painkilling effects, opioids can produce a feeling of well-being and euphoria. They also cause drowsiness and, among novice users, can cause nausea and vomiting. With repeated use, these drugs commonly cause constipation.

Tips for quitting

See the tips listed for cutting down on your drinking, as the basic advice is very similar. But unlike stopping heavy alcohol use, quitting these drugs is not particularly risky, unless you have an underlying condition such as cardiovascular disease that is worsened by the withdrawal symptoms.

Managing withdrawal symptoms

Opioids are notorious for producing withdrawal symptoms that include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps, and involuntary leg movements. These symptoms usually subside within a week, but some people continue to experience sleep problems and irritability for months.

Medications to help you quit

Medications for opioid addiction (see Table 5) help prevent or ease withdrawal symptoms and reduce cravings. Although sometimes criticized as “replacing one addiction with another,” these medications can restore normalcy to people's lives and enhance their motivation to change.

Methadone (Diskets, Dolophine, Methadose).

Methadone is the best-known and most frequently used medication for treating opioid dependence. Methadone binds to the same opioid brain receptors to which heroin, morphine, and prescription (synthetic) opioids bind. Compared with opioids of abuse, methadone remains attached to the receptor and continues to exert its effects for much longer. A single dose of methadone can ease or prevent opioid withdrawal symptoms and alleviate cravings for 24 to 36 hours.

Doctors use methadone to ease withdrawal symptoms among patients who are detoxifying (clearing their system of drugs). Some people opt to continue methadone indefinitely as a way to help them remain abstinent, a practice known as methadone maintenance therapy. The blood pressure–lowering drug clonidine (Catapres, Duraclon) and naltrexone are other medications sometimes used to help people detoxify from opioids.

When taken at appropriate doses, methadone does not produce a high. However, if you take a dose that exceeds your tolerance level, it can cause intoxication that ranges from a mild to a more intense high. As a result, methadone has street value and the potential for misuse. For these reasons, methadone is available only through specialized clinics that follow strict federal, state, and local regulations. These clinics typically couple methadone treatment with counseling and other types of support for people with opioid addiction. People report to the clinic daily to get their treatment. They also must regularly provide urine samples, so their clinicians can monitor them for any illicit drug use. Blood samples allow doctors to check if the person is getting the correct dose of methadone. Some clinics occasionally permit people who successfully abstain from illicit drug use and who do well in treatment to take multiple doses home, so they can cut back on the number of trips to the clinic.

Buprenorphine (Suboxone, Subutex).

Buprenorphine is similar to methadone, but it can both stimulate and block opioid receptors, depending on the dose you take. Buprenorphine comes as a tablet or film that dissolves under the tongue. At lower doses, buprenorphine works mostly to stimulate the receptors; at higher doses, it does the opposite. Because of these properties, buprenorphine is less likely than methadone to lead to misuse.

Unlike people on methadone, people on buprenorphine need not attend a clinic to use the drug. Doctors in private practice can prescribe buprenorphine if they have the appropriate licensing and they also refer patients for drug counseling. Usually, a person starts by taking Subutex (which contains only buprenorphine) for two days and then switches to Suboxone, which contains buprenorphine and naloxone. The naloxone is added to discourage people from dissolving the tablet and injecting it in an attempt to get high. If a person injects Suboxone, the naloxone in the drug may cause them to develop withdrawal symptoms. But when the drug is dissolved under the tongue as directed, very little naloxone enters the bloodstream, so the patient feels only the effects of the buprenorphine.

Buprenorphine offers certain advantages over methadone: it is safer and its withdrawal symptoms are briefer. More importantly, it offers an alternative for people who are concerned about keeping their recovery treatment private. Some doctors propose that buprenorphine is most appropriate for people who are extremely motivated to abstain or who have mild dependence.

People taking buprenorphine should beware of two uncommon side effects: respiratory problems or impaired thinking. Driving or operating machinery may be unsafe, especially when first starting the medication.

Naltrexone (Depade, ReVia, Vivitrol).

Although FDA-approved for use with people struggling with opioid addiction, naltrexone does not have a good track record of helping people stay opioid-free. The reason might be because naltrexone triggers withdrawal, so people often are unwilling to take it as directed. Long-acting naltrexone (Vivitrol), which is given by injection at the doctor's office and lasts for a month, might prove better at keeping people off opioids, but one review article concluded that there is not enough evidence to make that claim.

Naloxone (Narcan).

Doctors sometimes use naloxone, another opioid antagonist, in two controversial forms of detoxification called rapid and ultra-rapid detoxification. Both techniques attempt to shorten the duration of withdrawal, which normally lasts five to 10 days, by displacing opioids still in the system and speeding the process. During ultra-rapid detoxification, people are anesthetized for 24 hours and are thus spared the worst aspects of opioid withdrawal. But some experts maintain that rapid detoxification is dangerous and not effective for treating addiction, in part because the process doesn't address the variety of other problems associated with addiction.

Table 5: FDA-approved medications for treating opioid addiction

Generic name

Brand name

How it works

Common side effects

Comments

buprenorphine

Subutex

Eases withdrawal symptoms by binding to opioid receptors.

Headache, pain, insomnia, excessive sweating, constipation, nausea. Can trigger withdrawal symptoms if taken while opiate drugs are still in the system. Stopping medication abruptly can trigger withdrawal symptoms.

Taken in tablets or film dissolved under the tongue. Should not be taken until at least 24 hours after using other opiate drugs.

buprenorphine and naloxone

Suboxone

Eases withdrawal symptoms and blocks euphoria from opiates.

Similar to buprenorphine.

Taken in tablets dissolved under the tongue. May be prescribed for use outside a substance abuse clinic.

methadone

Diskets, Dolophine, Methadose

Eases withdrawal symptoms in a manner similar to buprenorphine.

Severely slowed breathing; irregular heart rate. Most dangerous at the onset of treatment. Large doses can produce a high similar to heroin. Can be habit-forming.

Taken as a pill, a tablet dissolved in juice, a liquid, or a concentrated liquid solution that must first be diluted. Also used to treat chronic pain. Must be taken at a substance abuse clinic.

naloxone

Narcan

Prevents an opioid high.

Very slow, very fast, or irregular heartbeat. May cause heightened pain sensitivity.

Taken by injection or intravenously. Taken as a pill when combined with buprenorphine (Suboxone).

naltrexone

Depade, ReVia, Vivitrol

Helps people stay off opiates by preventing opiate high in a way similar to naloxone.

Nausea, vomiting, and dizziness. Liver damage has been associated with large doses. Causes withdrawal symptoms if opiates are still in the body.

Taken orally or by injection. Works much longer than naloxone. Take seven to 10 days after last exposure to opiate drugs.

Sedatives and hypnotics

These drugs include tranquilizer medications, which are used to treat anxiety, and sedatives (sleeping pills), which are used for insomnia. Some examples are benzodiazepines, such as diazepam (Valium), alprazolam (Xanax), and clonazepam (Klonopin), as well as barbiturates, such as phenobarbital (Luminal), pentobarbital (Nembutal), and amobarbital (Amytal).

Barbiturates were popular in the first half of the 20th century, but these drugs have now largely been replaced by benzodiazepines, which were first marketed in the 1960s and are now among the most commonly prescribed medications in the United States. In 2010, 2.5 million people reported nonmedical use of prescription tranquilizers and sedatives. Older people, especially older women, may be at higher risk for abusing these drugs, in part because they are more likely to receive prescriptions for these medications.

How sedatives and hypnotics affect you

These drugs reduce anxiety, create a feeling of well-being, and lower your inhibitions. They also slow the pulse, breathing rate, and blood pressure. At higher doses, these drugs can cause poor concentration, fatigue, confusion, impaired coordination, and memory and judgment problems.

Tips for quitting

Do not attempt to stop taking sedatives on your own. Like withdrawal from alcohol, withdrawal from these medications can lead to seizures that, in some cases, are life-threatening. You must gradually taper back your dose under the close supervision of a health care provider.

Managing withdrawal symptoms

Withdrawal symptoms often mimic the symptoms of anxiety, such as worry, tension, fear, and restlessness. Disturbing dreams, frequent awakening, and feelings of tension in the early morning can also occur. According to some reports, the withdrawal process is more difficult than withdrawing from heroin. Some people find that relaxation techniques such as deep breathing, meditation, or yoga help ease the symptoms.

Medications to help you quit

In some cases, doctors prescribe a milder sedative for people who are addicted to more powerful sedatives to help wean them off these medications. For example, people dependent on alprazolam (Xanax) may be prescribed chlordiazepoxide (Librium).

Stimulants

Prescription stimulants, which include methylphenidate (Ritalin, Concerta) and dextroamphetamine (Dexedrine, Adderall), are used to treat attention deficit hyperactivity disorder (ADHD) and narcolepsy. However, these medications also are abused for performance enhancement (that is, to boost focus and attention) or for weight loss. Stimulant prescriptions soared from around five million in 1991 to 45 million in 2010. In 2010, about 1.1 million people reported using prescription stimulants for nonmedical uses. A 2009 report in the journal Pediatrics documented a 76% increase in calls to poison control centers about teens abusing ADHD drugs during an eight-year period. This sharp rise, which far outpaced other poison control center calls, paralleled the 86% increase in ADHD prescriptions for youths ages 10 to 19 during the same time period.

How stimulants affect you

Stimulants boost alertness, attention, and energy. They also ward off sleep and suppress appetite. Misuse of these drugs, which typically involves crushing and snorting the pills, can produce a buzz or sense of power and euphoria. Stimulants can also lead to agitation and paranoia; in rare cases, stimulants can cause life-threatening rises in heart rate and blood pressure.

Tips for quitting

See the tips for quitting nicotine, as the basic advice is similar. Weight gain is often a problem when people stop taking stimulants. If you're overweight or have a tendency to gain weight, watching your diet and exercising regularly are important when quitting stimulants.

Managing withdrawal symptoms

People often experience depression after quitting stimulants. Sometimes the depression occurs quickly and powerfully, so quitting stimulant use on your own is risky. It is best to seek the help and guidance of a doctor.

Illegal drugs: Marijuana, cocaine, and heroin

Marijuana, cocaine, and heroin are perhaps the most recognized illegal drugs in the United States. Yet all three have bona fide medical applications similar to prescription drugs, as their history and current use reveal.

Marijuana, which wasn't widely used in the United States until the 1960s, has been considered capable of leading to addiction. Its known medicinal benefits include treating nerve pain, stimulating the appetites of people with AIDS wasting syndrome, and controlling chemotherapy-related nausea and vomiting.

On the other hand, both cocaine and morphine (a heroin relative; see “What are opioids?”) were used legally during the 19th century for medicinal purposes in their natural forms — coca leaves and poppy plants. In 1898, Bayer coined the name “heroin” and used it in cough syrup; a year later, the company introduced aspirin.

Today, people face stiff penalties for possessing cocaine or heroin, yet data suggest that opioids obtained by legal prescription actually are a much larger problem, leading to more unintentional deaths from drug overdoses than cocaine and heroin combined (see Figure 5).

Figure 5: Unintentional drug overdose deaths, 1999–2007

Unintentional or accidental drug overdoses include those caused by drug abuse, as well as taking too much of a drug for medical reasons. In 2007, the death toll from prescription opioids was higher than that from cocaine and heroin combined.

Marijuana

Marijuana (also called pot, dope, and weed) and hashish (a concentrated, resinous form of marijuana) have mild stimulating and euphoric effects. They also can cause sensory changes, and slow reaction time and thinking.

Marijuana is the most commonly used illicit drug in the United States (see Figure 6). But the number of people who abuse the drug isn't known. For years, researchers thought marijuana was unlike the other drugs of abuse, because quitting it didn't appear to cause withdrawal symptoms in people or in animals, and because laboratory animals did not self-administer the drug as they do other drugs of abuse. However, researchers have begun to realize that many regular marijuana users fit the DSM-IV criteria for substance abuse or dependence. Also, studies suggest that some people do experience withdrawal symptoms when stopping marijuana. These symptom patterns include craving for marijuana, reduced appetite, sleep difficulty, weight loss, and — in some cases — even anger, aggression, irritability, and restlessness.

Researchers have yet to discover any medications that help specifically with marijuana addiction. Still, people can recover successfully from marijuana addiction with behavioral and other nondrug strategies.

Cocaine

Cocaine, also known as coke, snow, flake, and blow, became popular in the United States during the 1980s and 1990s. In 2010, 1.5 million people reported current cocaine use, a drop from the 2.4 million users reported in 2006.

The drug is either snorted, injected, or smoked. Like other stimulant drugs, cocaine makes people feel happy, energetic, and mentally alert. It also constricts blood vessels and boosts body temperature, heart rate, and blood pressure. Chronic use can lead to paranoia and psychosis. Withdrawal symptoms include fatigue, anxiety, irritability, depression, and sleepiness.

There are no FDA-approved medications to help people quit cocaine addiction, but a number of studies suggest that disulfiram (Antabuse), which is approved for treating alcohol abuse, also can help reduce cocaine use. People who use cocaine while taking disulfiram report anxiety, paranoia, and lack of euphoria, which may discourage them from using cocaine. Other drugs that help people abstain from cocaine include topiramate (Topamax), baclofen (Lioresal), and modafinil (Provigil), which is used to treat narcolepsy.

Figure 6: Commonly abused illicit drugs

Marijuana was the drug of choice for nearly two-thirds of the 7.1 million people ages 12 or older who were dependent on, or abused, illicit drugs during 2010. Prescription pain relievers were the second most commonly abused drug. Two other classes of prescription medications, tranquilizers and stimulants, ranked fourth and seventh.

Source: 2010 National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration.

Heroin

Also known as dope, smack, and junk, heroin can be injected, smoked, or snorted. Although for many people the term “drug abuser” or “drug addict” conjures up a vision of a person “shooting” heroin intravenously, this drug is one of the least common expressions of addiction (see Figure 6). Prescription opioid abuse (see “Painkillers”) is not only far more common, in 2007 it killed five times as many people as heroin, according to the Centers for Disease Control and Prevention. Heroin use is more prevalent in the northeastern United States than other parts of the country.

Information about how heroin affects you, tips for quitting, coping with withdrawal, and medications to help you quit are the same as those described for opioid painkillers. Treatment with methadone is among the best studied of all drug treatment strategies. For example, the Drug Abuse Treatment Outcome Study tracked 10,010 people dependent on opiates and other drugs, including heroin, who entered nearly 100 treatment programs between 1991 and 1993. Among people taking methadone, weekly heroin use decreased 69%, cocaine use decreased by 48%, illegal activity decreased by 52%, and full-time work increased by 24%. Methadone treatment also reduces HIV transmission and hepatitis B and C infections, presumably by reducing intravenous drug use and needle sharing.

People who abuse heroin should consider seeking treatment at a methadone clinic. However, because treatment typically lasts at least a year, shorter-term options could also be explored (see “Naloxone”).

Gambling and other behavioral expressions of addiction

Even though behavioral expressions of addiction don't require the use of psychoactive substances, certain behaviors cause the brain to generate the same chemicals (most notably dopamine) that are released in response to using certain substances. This creates a desirable experience, which, for some people, can lead to addiction (see “How behavioral addiction affects you,” below). Other behavioral expressions of addiction include computer or Internet use, shopping, sexual activity, and eating.

About 0.6% of people in the United States are thought to be pathological gamblers, and an additional 2% to 3% experience adverse symptoms because of their gambling. Despite the dramatic expansion of opportunities and access to gambling, surprisingly, these estimates are similar to those obtained during the middle 1970s.

In general, behavioral expressions of addiction, such as gambling, are less prevalent than addiction to substances. It is likely that this is the case because behaviors don't alter your state of mind as powerfully or consistently as drugs. However, the less-common behaviors haven't been as well studied. In 2011, researchers from the University of Southern California published a review of 83 studies, each involving at least 500 subjects, looking at the prevalence of 11 different expressions of addiction (tobacco, alcohol, illegal drugs, eating, gambling, Internet use, love, sex, exercise, work, and shopping). They found that most of the forms of behavioral addiction studied — eating, gambling, Internet use, love, sex, and exercise — each occurred in about 2% to 3% of the population. Addiction to substances (alcohol, cigarettes, and illicit drugs) had prevalence rates between 5% and 15%, as did two behavioral expressions of addiction (work and shopping). However, other research suggests that the rate of shopping addiction is closer to 2% to 3%.

It's hard to know how reliable such data are, considering the numerous confounding factors. For example, the Internet likely serves as a conduit to other behavioral expressions of addiction, namely, sex and shopping. In fact, sexual content has been a leading driver of Internet expansion, according to some technology experts. Also, people with sexual addiction tend to be secretive about their problem.

How behavioral addiction affects you

Just as certain drugs produce a surge of dopamine in the brain, the above-mentioned behaviors can elicit a similar response, as evidenced by modern brain-imaging techniques. For example, scientists scanned the brains of nonaddicted men, with an average age of 27, while they participated in a game of chance similar to roulette. When the subjects were anticipating winning the game, and therefore getting a monetary reward, their brain reward centers became activated in much the same way as these areas do among people with cocaine addiction who are given cocaine.

In addition, a growing body of research supports the idea that food or eating addiction leads to the same neural phenomena that occur with addiction to substances (see “Dopamine differences”). Obese people tend to have fewer dopamine D2 receptors in the part of the brain called the striatum than people of normal weight, and the reduction in receptor number is similar to that seen with people struggling with drug addiction. Also, research shows that people who are mildly obese have more D2 receptors compared with people who are more severely obese, which suggests that in people addicted to food, the severity of addiction might be influenced by the number of D2 receptors.

Tips for quitting

See the tips for quitting nicotine, as the basic advice is similar, since behavioral addictions tend to be stimulating.

The Substance Abuse and Mental Health Services Administration (see “Resources”) offers a Problem Gambling Toolkit, which offers the following advice for family members of problem gamblers:

  • Take the gambler's name off all credit cards.

  • Deposit the gambler's paycheck into an account in your name only, and agree to a weekly cash budget.

  • Call creditors, explain the gambler's problem, and promise to provide a restitution plan within 45 days.

If gambling continues:

  • Take your name off any joint credit cards and bank accounts.

  • Alert all creditors and ask them not to extend any more credit to the gambler.

  • Assume payment of household bills, if possible.

  • Open a separate safe-deposit box to store valuables that the gambler might sell for cash.

  • Identify income and assets, establish a spending plan, and shift control of the finances to a nongambler.

Managing withdrawal symptoms

See the advice in Table 2, as withdrawal symptoms for most behavioral addictions can be similar to those caused by nicotine and other stimulants.

Medications to help you quit

Several medications show promise for treating pathological gambling, but none is currently FDA-approved. One study found that low doses of nalmefene, a drug that works similarly to naltrexone, improved pathological gambling symptoms, but the drug is not currently available in pill form, except for research purposes. A handful of studies indicate that naltrexone also improves the symptoms of pathological gambling, and one case study reported the drug's benefits for treating sexual addiction. Other medications that have shown promise for gambling addiction include topiramate and the antidepressants fluvoxamine (Luvox) and bupropion (Wellbutrin).

The literature on successful treatment of sexual addiction is even more sparse. However, two case studies showed a “dramatic” reduction in symptoms in people treated with naltrexone. Other people in case studies experienced benefits with antidepressants, anticonvulsants, and even hormonal agents.

Special section: Gender and age differences in addiction

To some degree, two familiar adages — biology is destiny, and timing is everything — hold true when it comes to addiction. Both your gender and age influence whether you will develop an addiction. Men are about twice as likely as women to develop problems with addiction, and adults younger than 25 have about three times the risk as their older counterparts. Gender and age differences also influence the object you select, how it affects your health, and your treatment path.

Gender differences

Each year, the Substance Abuse and Mental Health Services Administration conducts the National Survey on Drug Use and Health (NSDUH). The survey released in 2010 confirmed that men are more likely than women to use both illicit and legal drugs, including alcohol and tobacco.

Age affects these gender differences. The gender divide doesn't become apparent until after age 17. Experts don't know why gender differences do not emerge until people reach adulthood. It's possible that something happens to the brains of boys as they mature, perhaps making them more vulnerable to addiction. Alternatively, use trends might be changing such that, among the younger generation, both genders use drugs at more similar rates. In fact, historical data suggest that the gender gap in addiction is closing.

Following are brief summaries of what current research shows about gender differences with different expressions of addiction:

Alcohol. About 7% to 12% of women abuse alcohol, compared with 20% of men. Yet women who abuse alcohol are more likely than men to damage their health and well-being and to die as a result of their drinking. For example, women who abuse or are dependent on alcohol are more vulnerable than men to developing alcoholic liver disease, such as hepatitis, and more likely to die from liver cirrhosis. Women are more likely than men to suffer alcohol-induced brain damage, such as loss of mental function and reduced brain size. In addition, a woman's lifetime risk of breast cancer increases in parallel with the amount of alcohol she drinks, from almost nine in 100 for nondrinkers to just over 13 in 100 for heavy drinkers (six drinks per day).

Women are more sensitive than men to the effects of alcohol for two main reasons. First, women tend to weigh less than men and — pound for pound — a woman's body contains less water and more fatty tissue than a man's. Because fat retains alcohol while water dilutes it, a woman's brain and other organs are exposed to alcohol for longer time periods.

Second, women have lower levels of two enzymes — alcohol dehydrogenase and aldehyde dehydrogenase — that break alcohol down in the stomach and liver. As a result, women absorb more alcohol into the bloodstream, which is why one drink for a woman has about twice the effect of one for a man. Together, these two factors explain why women become intoxicated after drinking less and are more likely to suffer adverse consequences after drinking less and for fewer years than men.

Nicotine. About 24% of men and 18% of women said they smoked tobacco (usually cigarettes) in 2010. Like female alcoholics, female smokers face more health risks than male smokers; they might be more likely to develop lung cancer, for example, and are twice as likely to have a heart attack. The research also suggests that women find it more difficult than men to quit smoking, and are more likely to start smoking again even if they do quit. The reasons for this are not clear, although studies have found that female smokers are more responsive to environmental cues and triggers (such as wanting to light up a cigarette when drinking alcohol); alternatively, male smokers are more responsive to the biological effects of nicotine. This suggests — and preliminary research confirms — that nicotine replacement therapy might not work as well for women as it does for men. A report that combined results from 14 studies found that about 20% of men quit for six months using a nicotine patch, compared with nearly 15% of women. With a placebo patch, roughly 10% of both genders quit.

About half of female smokers say they are afraid they will gain weight if they stop smoking. Although the usual advice is to exercise or count calories while kicking the habit, this may be impractical because both are emotionally draining tasks, and concentrating on dieting may mean that the effort to stop smoking will fail. A preliminary study suggests that it might be more productive to help women learn to accept any weight gain as a reasonable trade-off for the improved health that comes from kicking the habit. If you're worried about weight gain, you can always give yourself a break while you're quitting and then go on a diet after you've successfully stopped smoking.

Stimulants. Men and women are about equally likely to use and abuse stimulants, such as cocaine and methamphetamine. However, women report first using cocaine at younger ages than men. Some initial evidence in people and in animals also suggests that women more quickly develop dependence on stimulants, and are more prone to relapse after quitting the habit.

Opioids. Women are more likely than men to receive prescriptions for opioids, perhaps because they are more likely to suffer from chronic pain conditions such as fibromyalgia. Women are more likely than men to visit emergency rooms because they abused opioids, suggesting (although not proving) that they suffer more medical consequences.

Marijuana. Men are nearly three times as likely as women to report smoking marijuana on a daily basis. Although preliminary research suggests that women might suffer more adverse effects (such as panic attack and memory problems), and progress more quickly to dependence, the only consensus so far is that more research is needed about gender differences in marijuana use.

Gambling. Although the research about pathological gambling is not as extensive as studies assessing substance use and misuse, patterns of pathological gambling appear to resemble those for substance abuse. According to the National Epidemiologic Survey on Alcoholism and Related Conditions (NESARC), a huge study involving 43,000 Americans, pathological gambling is more common among men than among women, and they tend to prefer different forms of gambling (see Figure 7).

Figure 7: Preferred gambling activities: Men vs. women

In the United States, men are about three times as likely to become pathological gamblers compared with women during their lives (0.64% vs. 0.23%); see “Are you addicted to gambling?” in the previous chapter. They're also about twice as likely to develop “subclinical” pathological gambling, a less severe form of the problem, which is estimated at about 7% for men and 3% for women. Men and women also tend to gravitate toward different forms of gambling: women are more likely to play bingo, slots, and keno; men seem to prefer gambling on the stock market, table casino games, and roulette.

Source:

  • Blanco, C, et al. “Sex Differences in Subclinical and DSM-IV Pathological Gambling: Results from the National Epidemiologic Survey on Alcohol and Related Conditions,” Psychological Medicine, 2006.
Implications of gender differences

Although women have been less likely than men to use illicit drugs, gamble, or drink to excess, women tend to have more severe consequences of addiction, and they can find addiction more difficult to overcome. Women also seem to take a different path toward addiction. Compared with men, women start their relationships with their objects of addiction at a different stage in life. For example, women typically start using cocaine and amphetamines at a younger age than men, but they begin gambling at an older age. Once women do start, however, they progress to problematic levels more quickly. This “telescoping effect,” as the phenomenon is known, happens with most substances of abuse as well as with pathological gambling.

Why gender differences exist is a matter of intense debate. Some argue that different rates of addiction for men and women reflect social mores that set different standards for men and women. Indeed, studies show that women have less access to objects of addiction than men, but that when presented with the opportunity, women are no less likely than men to engage those objects. What might be different is why they do so.

In 2000, the National Institute on Drug Abuse and the Society for Women's Health Research cosponsored a national symposium where addiction experts shared their understanding of gender differences in addiction and recovery. According to a synopsis of the symposium published in TheJournal of Women's Health and Gender-based Medicine, men tend to seek out psychoactive drugs as a form of adventure, but women tend to seek them out to self-medicate. Women with drug dependency, says the report, are more likely to have mood disorders and more likely to have attempted suicide. Men with drug dependency, by contrast, are more likely to have sociopathic and antisocial personality disorders.

Findings from NESARC indicate that similar forces are at work in the context of pathological gambling. Women with gambling disorders are significantly more likely than men to have mood and anxiety disorders, and to use gambling to relieve depression.

Ironically, women who develop problems with an object of addiction are often introduced to it by the men in their lives. Women who gamble, for example, often say their first experience gambling was with a man; female heroin users often report that a man introduced them to the drug and to intravenous use. In light of this, for women, addiction recovery must often start with a change in the relationships they forge with men. When harmful relationships with men contribute to the addiction, clinicians sometimes recommend that women disengage from those relationships, at least for a time. Later during the recovery process, however, women must relearn how to negotiate relationships with men so as to avoid similar pitfalls in the future.

Biology of gender differences

While no one negates the importance of societal constructs in dictating differences in behavior between the genders, biological forces are also at play.

Studies with rats and mice show that females self-administer psychoactive drugs more readily than do males, and they escalate their use more quickly. Female rodents also seem more willing to work for drugs than are males. Plus, when their access to drugs is restricted, females spend more time bingeing than do males. What's more, females are more likely to relapse after periods of abstinence.

These gender differences in behavior might reflect differences in the brains of males and females. Studies with rodents and with humans have found gender differences in the way dopamine receptors bind to the neurotransmitter and in the levels of dopamine itself.

In women, timing a quit date to their period may help them succeed. Studies find that kicking the smoking habit is especially tough for women during the menstrual cycle's luteal phase, which begins midcycle, just after ovulation. There's some evidence that women who time their quit date to occur during the follicular phase, which begins after menstruation and ends at ovulation, are more likely to abstain from cigarettes for a longer period than women who quit during the luteal phase.

Women also appear to respond differently to amphetamine use depending on where they are in their menstrual cycle. If they take amphetamines during the follicular phase of the cycle, they find it more pleasant and crave the drug more than they do if they take amphetamines during other times of the cycle. In part, this might be because the characteristics of dopamine receptors in the brain change with the menstrual cycle. Unfortunately, scientists know rather little about gender-based differences in the human brain, in part because neuroimaging studies in addiction have focused almost exclusively on men.

Age differences

As Figure 8 shows, recent use of illicit substances is most common among people in their mid-teens to mid-20s. Given the age distribution of substance use, it's not surprising that the rates of substance abuse and dependence were highest among people ages 18 to 25. Roughly 23% of people in that age group had problems with abuse and dependence, compared with just under 9% of the general population.

Age trends for pathological gambling are similar to those for substance abuse. The disorder is most common among those ages 18 to 24 and least common among those ages 65 and older.

Figure 8: Illicit drug use at different ages

During 2010, about one in five people ages 18 to 20 admitted using illicit drugs during the past month. This rate declines as people grow older.

Source: 2010 National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration.

Youthful experimentation

Compared with gender differences, age differences in addiction are perhaps easier to understand. Adolescence and young adulthood is a time for experimentation and growth, so it's not surprising that young people are more apt to sample psychoactive substances and activities. Older people, though less prone to addiction than younger adults, are more likely to have problems with pharmaceutical drugs and alcohol than with illicit drugs.

Unfortunately for young people, experimentation with objects of addiction early in life is more likely to lead to addiction than is experimentation at later stages. For example, results from the 2010 NSDUH reveal that youths who begin drinking at age 14 or younger are far more likely to become alcohol dependent or to abuse alcohol compared with people who first used alcohol when they were 21 or older (see Figure 9). What's more, a significant proportion of young people are drinking. A 2010 survey looking at adolescent drug use found that 14% of eighth graders, 29% of 10th graders, and 41% of 12th graders admitted to drinking alcohol within 30 days of the survey.

Early experimentation with marijuana also increases the risk of subsequent substance dependence. Adults who used marijuana before age 15 were six times more likely to become dependent on an illicit drug than adults who first used marijuana at age 21 or older. In addition, of adults who first used marijuana before age 15, 62% reported cocaine use, 9% reported heroin use, and 54% reported using prescription drugs for nonmedical reasons at some point during their lives. By comparison, among marijuana users who reported first smoking the drug after age 20, about 16% used cocaine, 1% used heroin, and 21% used prescription drugs for nonmedical reasons during their lives. Among those who had never used marijuana, 0.6% reported lifetime cocaine use, 0.1% reported lifetime heroin use, and 5.1% reported lifetime nonmedical prescription drug use.

Nine out of 10 Americans who meet the DSM-IV criteria for substance abuse or dependence started smoking, drinking, or using other substances before age 18, according to a study released in 2011 by the National Center on Addiction and Substance Abuse at Columbia University. The report also found that starting to use an object of addiction earlier in life made addiction more likely. For example, one in four people who first used an addictive substance before age 18 is addicted, compared with one in 25 who started using after they turned 21.

Experimenting with drugs early in life might be more likely to lead to addiction than later experimentation because the adolescent brain is still developing. Research reveals that our brains aren't fully developed until about age 25. The immature adolescent brain has less ability to manage risky behaviors and impulses by putting the brakes on; restraint comes with both biological and behavioral maturity.

Some researchers speculate that adolescents are more vulnerable to addiction because the nucleus accumbens — the pleasure center of the brain — matures before the frontal cortex, the part of the brain responsible for impulse control and executive decision making. In other words, teenagers' capacity for pleasure reaches adult proportions well before their capacity for sound decision making does.

The same incomplete neural development that puts adolescents at increased risk for using psychoactive substances also makes them more vulnerable to their damaging effects. That's because the psychoactive substances can themselves impede or redirect the changes that normally transform the adolescent brain to that of a mature adult. Binge drinking during adolescence, for example, can permanently damage the prefrontal cortex — the executive center of the brain. And having a faulty executive center can, in turn, promote addiction. This might explain why adolescents who begin drinking very young are so much more likely to become dependent on alcohol and other drugs.

Figure 9: Early drinking increases the risk of alcohol problems in adults

People who have their first drink at age 14 or younger are nearly six times more likely to develop alcohol problems than those who don't try alcohol until the legal drinking age of 21, as this graph illustrates. Just 2.7% of adults who had their first drink at age 21 or older had serious alcohol problems, compared with 15.1% of adults who had their first drink when they were 14 or younger. What makes this even more worrisome is that teenagers are starting to drink at younger ages. In 1965, the average age at which adolescents first tried alcohol was 17. Today, the average age for American girls' first drink is 13; for boys, it's 11.

Source: 2010 National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration.

Older adults

Addiction trends among older adults might be shifting, both in the numbers of people with addiction and the addictions they have. As the number of baby boomers (people born between 1946 and 1964) in their 50s has grown, so has the number of people in that age group who use illicit drugs.

One study that used mathematical models to project future changes in substance abuse prevalence among people older than 50 concluded that the number of older adults needing substance abuse treatment will likely increase from 1.7 million in 2000 and 2001 to 4.4 million in 2020.

Older people with addiction usually have had the disorder for many years. Rarely does addiction emerge among older people. When it does, it usually starts with the medical use of a prescribed drug. For example, older people may begin taking opioids for pain control or benzodiazepines as sleep aids, and then find themselves increasingly drawn to them for reasons unrelated to the original medical complaint.

Neuroscientists speculate that changes in brain chemistry and function that come with aging alter the effects of drugs of abuse, but they do not yet know how. They do know, however, that older people metabolize drugs less efficiently than their younger counterparts, so it is easier for older people to overdose (see “Alcohol and older adults”). In addition, older people often have medical conditions that make them more vulnerable to the harmful effects of drugs of abuse, and they often take medications that can interact with drugs of abuse. For example, stimulants can speed up your heart, an effect that might be magnified in an older person with high blood pressure.

Tailoring treatment based on age

Treatment for adolescents involves a different focus than treatment aimed at older people. Young people need to be taught that impulses pass and that not every urge must be acted upon. Perhaps because their brains are not yet wired for impulse control, young people need more help with this than adults. In fact, adolescents do best when they have a role model who is available to them, especially during times of crisis or temptation.

Treatment for children and adolescents often focuses on those with addiction, their families, and possibly their teachers and classmates (see “Working with a therapist”). That's partly because close familial bonds have been shown to protect young people from addiction. Research shows that children who do not have substance abuse problems often also lack certain risk factors, such as inadequate parenting or susceptible temperaments. But other protective factors are particularly important as well.

One study reported that adolescents from families with alcohol problems were less likely to use alcohol or drugs if they felt a sense of control over their environments, had good coping skills, and had highly organized families. Other researchers have found that preserving family rituals, such as keeping established daily routines and celebrating holidays, also can make a difference.

Although addiction is more common among young people, it actually might be more difficult to treat in older people. In part, that's because older people often have become more entrenched in their behaviors than younger people. Old habits, as they say, are hard to break. The bigger issue, however, is that older people must often cope with loss — the loss of health, of loved ones, and of purpose.

Cultures that value older people and that see them as a source of guidance and wisdom don't have the same rate of problems with substance and alcohol abuse in the older population as societies that discard the elderly. Indeed, cultures that have less subdivision between generations and between genders generally are much less prone to problems with addiction. Perhaps for these reasons, the Office of Drug Control Policy and the Partnership for a Drug-Free America emphasize the importance of family unity in protecting people from addiction.

When a loved one has addiction

The most important thing to keep in mind if someone you love has a problem with addiction is that you need to take care of yourself before you can take care of anybody else. Think about the instructions you get on an airplane: “If the cabin pressure drops, secure your own oxygen mask first, then help others with theirs.” That philosophy applies here, too.

You may get the information and support you need from groups like Al-Anon (an AA spin-off for the family and friends of alcoholics) or Alateen (an offshoot of Al-Anon geared toward teenagers and preteens who are affected by the drinking of a parent or other close relative). These groups are free and open to the public, and they have frequent meetings in most towns.

These fellowship groups can help you better understand your loved one's problem with addiction. In particular, you can learn that you aren't responsible for it and that you can't force the person to stop using the object of addiction. These groups also can teach you effective ways to cope as your friend or family member faces the consequences of addiction and, if all goes well, finds his or her way to recovery.

Although some groups advocate “tough love” — confronting people with addiction and trying to force them to seek help — others recommend the exact opposite approach. For example, the CRAFT (Community Reinforcement Approach and Family Training) intervention encourages family members to avoid confrontation and instead use encouragement and other positive motivational strategies when trying to convince a loved one to seek help for addiction.

You also may want to seek advice and support from a therapist, clergy member, doctor, or social worker who is knowledgeable about addiction.

If someone you love has a problem with addiction, there are some things you can do to help:

Take care of yourself. Seek out the people and resources that can support you. Keep in mind that you are not alone, and try to remain hopeful. Practical help is available in your community.

Speak up. Express your concerns about your loved one's problem in a caring way.

Don't make excuses. Don't make it easier for your loved one to use the object of addiction by lying to protect him or her from the consequences of that use.

Don't blame yourself. Remember that you aren't to blame for this problem and you can't control it. Allow the person with the problem to take responsibility.

Be safe. Don't put yourself in dangerous situations. Find a friend you can call for assistance.

Step back. Don't argue, lecture, accuse, or threaten. Try to remain neutral.

Be positive. Remember that addiction is treatable. You may want to learn about what kinds of treatment are available and discuss these options with your loved one.

Take action. Consider staging a family meeting or an intervention (see “Planning an intervention”).

Focus your energies. Encourage your friend or family member to get help, but try not to push. Remember that the only person you can change is yourself. Don't hesitate to use available resources to help yourself.

Resources
Organizations

Al-Anon/Alateen

1600 Corporate Landing Parkway

Virginia Beach, VA 23454

888-425-2666

www.al-anon.alateen.org

Al-Anon offers support groups for relatives and friends of individuals with an alcohol problem. Alateen is primarily for teenagers and may include preteens.

Alcoholics Anonymous (AA)

P.O. Box 459

New York, NY 10163

212-870-3400

www.aa.org

AA is the first, best known, and most widely successful of the self-help fellowships. Its 12 steps — and the philosophy of going through the recovery process “one day at a time” — have become familiar to many. The steps begin with the problem drinker's acknowledgment of powerlessness in the face of alcohol, and take him or her through a healing process that depends on trusting in a higher power.

American Lung Association

1301 Pennsylvania Ave. NW, Suite 800

Washington, DC 20004

202-785-3355

www.lungusa.org

This national organization offers a variety of stop-smoking resources.

Center on Addiction and the Family

50 Jay St.

Brooklyn, NY 11201

646-505-2061

www.coaf.org

This organization's mission is to help children from alcoholic and substance-abusing families, to educate the public and professionals, and to disseminate research on the effects of alcohol and substance abuse on children through a variety of educational materials.

Gam-Anon

P.O. Box 157

Whitestone, NY 11357

718-352-1671

www.gam-anon.org

This organization offers support to family and close friends of problem gamblers, by teaching “acceptance and understanding of the gambling illness,” as well as offering problem-solving suggestions, such as refusing to be responsible for the gambler's behavior.

Gamblers Anonymous

P.O. Box 17173

Los Angeles, CA 90017

213-386-8789

www.gamblersanonymous.org

Like AA, this organization uses a 12-step recovery program and has no dues or fees; membership is open to anyone with a desire to stop gambling and relies on sharing experiences, strength, and hope to help people recover from compulsive gambling.

Narcotics Anonymous (NA)

P.O. Box 9999

Van Nuys, CA 91409

818-773-9999

www.na.org

Modeled after AA, this nonprofit fellowship is geared to people “for whom drugs have become a major problem.” It is open to people who abuse any type of drug or combination of drugs. When adapting AA's first step in the 12 steps ("We admitted we were powerless over alcohol — that our lives had become unmanageable"), the word “addiction” was substituted for “alcohol,” thus removing drug-specific language and reflecting the ”disease concept” of addiction.

National Cancer Institute (NCI)

6116 Executive Blvd.

Suite 300

Bethesda, MD 20892

800-422-6237

https://cissecure-nci-nih-gov.lib.kaplan.edu/livehelp/welcome.asp

The NCI provides free, individualized counseling and referrals to resources and informational materials. In collaboration with the Centers for Disease Control and Prevention and other experts, the NCI developed an online guide to quitting smoking, available at www.smokefree.gov.

National Clearinghouse for Alcohol and Drug Information

1 Choke Cherry Road

Rockville, MD 20857

877-726-4727 (toll-free)

store.samhsa.gov

This nonprofit government clearinghouse offers a wide range of information about preventing substance abuse, including publications, videos, research information, and curriculum materials — many of which are provided free of charge.

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

5635 Fishers Lane, MSC 9304

Bethesda, MD 20892

301-443-3860

www.niaaa.nih.gov

This government agency supports and conducts biomedical and behavioral research on the causes, consequences, treatment, and prevention of alcoholism and alcohol-related problems. It also provides fact sheets and pamphlets on these topics.

National Institute on Drug Abuse (NIDA)

6001 Executive Blvd., Room 5213

Bethesda, MD 20892

301-443-1124

www.nida.nih.gov

This government agency supports and conducts research on drug abuse, with a focus on prevention, treatment, and policy related to drug abuse and addiction. NIDA also provides educational resources and material on drugs of abuse.

Overeaters Anonymous

P.O. Box 44020

Rio Rancho, NM 87174

505-891-2664

www.oa.org

This program of recovery from compulsive overeating is based on the 12-step program from AA.

Secular Organizations for Sobriety (SOS)

SOS Clearinghouse

4773 Hollywood Blvd.

Hollywood, CA 90027

323-666-4295

www.cfiwest.org/sos

Founded in the 1980s, SOS encourages participants to rely on themselves rather than a higher power when trying to overcome addiction. SOS does not offer a standardized program, but rather suggests making sobriety a priority, and then finding an individual strategy to achieve it.

Sex Addicts Anonymous

International Service Organization of SAA

P.O. Box 70949

Houston, TX 77270

www.sexaa.org

This fellowship seeks to enable men and women to share their experience, strength, and hope with one another so they may overcome their sexual addiction and help others recover from sexual addiction or dependency.

Shopaholics Anonymous

The Shulman Center

P.O. Box 250008

Franklin, MI 48025

248-358-8508

www.shopaholicsanonymous.org

This program features paid phone or video conference counseling to address compulsive shopping.

SMART Recovery

7304 Mentor Ave., Suite F

Mentor, OH 44060

866-951-5357 (toll-free)

www.smartrecovery.org

The Self Management and Recovery Training (SMART) program, launched in the 1990s, emphasizes cognitive behavioral change, helping participants to recognize and modify the emotional and environmental triggers for their drinking or drug use.

Substance Abuse and Mental Health Services Administration (SAMHSA)

1 Choke Cherry Road

Rockville, MD 20857

877-726-4727

www.samhsa.gov

A division of the U.S. Department of Health and Human Services, SAMHSA awards grants and operates prevention and treatment programs for alcohol dependence and abuse. The organization provides information on various forms of substance abuse, including alcohol dependence.

Women for Sobriety

P.O. Box 618

Quakertown, PA 18951

215-536-8026

www.womenforsobriety.org

Founded in the 1970s, this program seeks to improve participants' self-esteem and confidence and counter the feelings of stress, depression, and loneliness that often trigger a relapse episode. The program offers 13 positive affirmations rather than AA's 12-step approach.

Special Health Report

Alcohol Use and Abuse

Hillary Smith Connery, M.D., Ph.D., Medical Editor

Harvard Health Publications

This report describes who is at risk for developing an alcohol use disorder, as well as the many health problems associated with alcohol misuse. It also includes information about treatments, including support groups, therapy, and medications, that can help people recover from alcohol addiction.

Glossary
addiction:

A condition characterized by the loss of control over the use of a psychoactive drug or the participation in an activity, such as gambling. People with addiction also crave their activity and continue to pursue it even though they experience adverse consequences as a result of doing so.

alcohol dehydrogenase (ADH):

A liver enzyme that metabolizes alcohol into a substance called acetaldehyde, which is toxic.

binge drinking:

Heavy bouts of drinking interspersed with periods of abstinence; often refers to the consumption of five or more alcoholic beverages within one day.

D2 receptor:

A type of dopamine receptor (see neurotransmitter receptors, below) that seems to be particularly important in addiction.

denial:

A defense mechanism characterized by the inability to recognize or admit that addiction is the cause of problems, rather than a solution or mere byproduct.

dopamine:

A neurotransmitter that seems to be especially important in the development and maintenance of addiction.

expression hopping:

A common phenomenon whereby people jump to a different expression of addiction. For example, people with heroin addiction might transition to alcohol addiction. Hopping is especially common during the recovery process.

expression of addiction:

The specific way in which a person manifests addiction, for example, through the use of cocaine, or compulsive gambling.

harm reduction therapy:

A treatment strategy aimed at minimizing the harm associated with an object of addiction. This strategic approach helps people learn how to limit the degree to which they use their object of addiction, or limit the risks associated with their use, but they do not necessarily stop altogether.

intervention:

A planned, often group, meeting with a person with addiction, with the aim of overcoming denial and inducing the individual to seek treatment.

natural recoverers:

People who overcome addiction without treatment or formal self-help programs.

neurotransmitter receptors:

Cell structures (usually proteins) that recognize specific neurotransmitters and bind to them. Once bound, a receptor often changes shape, causing a cascade of chemical events within the cell. These events can alter which genes are turned on or off and can make the cell more or less likely to release its neurotransmitters.

nucleus accumbens:

The part of the brain's reward pathway that is most tightly and consistently responsive to pleasure. Also known as the pleasure center.

object of addiction:

The psychoactive drug or rewarding behavior with which a person with addiction has a pathological relationship.

physical dependence:

The process through which the body becomes accustomed to a psychoactive drug or rewarding behavior and “misses it” if it's taken away. People with physical dependence who stop or cut down on their substance or activity of choice might develop uncomfortable withdrawal symptoms.

recovery:

A process of overcoming addiction. Often this involves a commitment to abstinence, but sometimes it involves reduced use rather than complete abstinence.

reward insufficiency theory:

The theory that some people turn to addiction to compensate for an inability to sufficiently experience pleasure.

reward pathway:

An interrelated set of brain regions that are all involved in recognizing, experiencing, and remembering rewarding events.

self-help group:

A group of people who meet to discuss and offer assistance to one another with the goal of providing social support for changing troubling behavior patterns.

stages of change:

A model for addressing change in general and problematic health behaviors in particular that is widely applied in addiction treatment programs. According to this model, people change their behavior gradually and in relatively distinct stages.

substance abuse:

Continued substance use despite substance-related social or interpersonal problems.

substance dependence:

A condition characterized by excessive and often compulsive substance use, impaired control over substance use, continued use of substances despite adverse consequences, and withdrawal symptoms that emerge when the substance use is discontinued.

tolerance:

The process through which the body becomes less responsive to a psychoactive drug or rewarding behavior. Over time, people who develop tolerance need larger doses to get the same effect they first got with smaller doses.

withdrawal:

A range of symptoms that may occur when a person cuts down or discontinues a substance or activity involved in an addiction. The specific symptoms, how long they last, and how severe they are depend on which substance (or activity) a person uses, at what dose, and for how long.

Credits

Medical Editor

Howard J. Shaffer, Ph.D., C.A.S.

Director, Divisions of Addictions Cambridge Health Alliance Associate Professor of Psychology Department of Psychiatry, Harvard Medical School

Editor

Christine Junge

Writer

Julie Corliss

Editor, Special Health Reports

Kathleen Cahill Allison

Art Director

Heather Derocher

Production Editors

Mary Kenda Allen

Melissa Rico

Illustrators

Alex Gonzalez

Scott Leighton

Published by Harvard Medical School

Anthony L. Komaroff, M.D., Editor in Chief

Edward Coburn, Publishing Director

In association with Belvoir Media Group, LLC

Robert Englander, Chairman and CEO

Timothy H. Cole, Executive Vice President and Editorial Director

Permissions requests

Natalie Ramm

natalie_ramm@hms.harvard.edu

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For the latest information and most up-to-date publication list, visit us online at www.health.harvard.edu

See Also

A Guide to Alzheimer's Disease; Alcohol Use and Abuse; Headaches: Relieving and preventing migraine and other headaches; Hypertension: Controlling the ‘silent killer’; Improving Memory: Understanding age-related memory loss; Living Better, Living Longer: The secrets of healthy aging; Positive Psychology: Harnessing the power of happiness, mindfulness, and inner strength; Stress Management: Approaches for preventing and reducing stress; Stroke: Preventing and treating “brain attack”

11/1/2011