But a new book, titled The Addiction Spectrum, is rethinking the idea that addiction is so cut and dry. Author Paul Thomas, MD, an addiction medicine specialist and integrative practitioner, argues that addiction is more of a sliding scale that factors in the severity of the addiction as well as life events, genetic predispositions, and other contributing factors. And, he says, this addiction spectrum is just as applicable to things like food or social media as it is to drugs or alcohol.
This is a little different from the other way experts commonly define addiction: as a disease. The Center of Addiction (CoA), the American Psychiatric Association, the American Medical Association, and the American Society of Addiction Medicine (ASAM) all ascribe to this particular view, which has been mainstream in the medical community for decades. “Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry,” stipulates the ASAM. The CoA compares addiction to diabetes, heart disease, and cancer because “it’s caused by a combination of behavioral, environmental, and biological factors.”
Experts have been thinking about addiction as a disease for a long time. But in his book, Dr. Thomas argues that by classifying addiction as a disease, you’re not getting the full picture of how addiction works—and thus you’re missing out on opportunities to turn around a problematic habit before it gets out of control.
But if addiction is more of a spectrum than a you-are-or-you-aren’t kind of thing, how do you know if you actually have a problem? And what does all this gray area mean for treating substance use disorders? Here, leading addiction experts give all the intel, explaining what you really need to know about addiction—and why you don’t have to hit rock bottom to turn a potentially destructive habit around.
Understanding the spectrum
Sometimes addiction is obvious—like when it starts affecting your relationships and career—and sometimes it’s more hidden, making it harder to identify. “I use [noise] volume as a metaphor to explain it to people,” says Neeraj Gandotra, MD, the chief medical officer at Delphi Behavioral Health, a national addiction treatment network. “Sometimes it’s a disorder that’s very loud and disruptive, and sometimes it’s more quiet.”
That’s where the addiction spectrum comes in. “The way someone can figure out where they fall on the spectrum is based on the number of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria you meet,” says Samantha Arsenault, the director of national treatment quality initiatives for Shatterproof, a non-profit dedicated to ending the destruction addiction causes. There are 11 different factors that specialists use to determine someone’s place on the addiction spectrum, including how much of the substance a person is taking and how long they’ve been taking it, whether they feel cravings for that substance, and whether it’s causing problems in their relationships.
“Technically, a mild substance abuse disorder means they have two or three different factors,” Arsenault says. Someone in the middle of the spectrum would have four of five of these factors, she says, while a person with a much more severe addiction would have six or more of symptoms. While the DSM-5 is currently used for substances like alcohol, stimulants, cannabis, and opioids, Dr. Thomas says the concept of the addiction spectrum could apply to anything that could potentially turn problematic (like exercise and sugar consumption).
“The reason why it’s so important to view addiction as a spectrum is because it means you don’t have to hit rock bottom to turn it around.” —Samantha Arsenault, Shatterproof
Interestingly, this fits in well with the ASAM’s viewpoint on unhealthy substance use. While they do define addiction as a disease, the group also says that there is a whole range of behaviors, from low-risk use (where you’re consuming alcohol or drugs below harmful levels) to hazardous use (where you’re consuming these substances in a way that increases the risk of health consequences) and ultimately addiction. Addiction is less about how much of a substance a person uses or how often they use it, and rather the way in which they respond to those substances, the ASAM says.
To put this thinking in context: “I had a client who was a high-powered executive and he would drink a bottle-and-a-half of wine every night after work to de-stress,” says clinical psychologist Kevin Gilliland, PsyD. “But even though he drank a lot, he would always make it to a 6 a.m. workout. Was he on the severe end of the spectrum? Well, not fully, because he’s holding down a good job and to the outside world he’s not destroying his life in any obvious ways. But he was still putting his health at risk and it actually was greatly harming his relationship with his wife, so it was problematic in those ways.”
A generally non-problematic habit, like a daily glass of wine, can potentially get pushed into more dicey territory. “There are factors that could cause someone to creep up on the addiction spectrum, such as genetic predisposition,” Dr. Thomas says—meaning that if someone in your family is an addict, it could make you more likely to develop an addiction, too. “Or if stressful events in your life occur and you’re turning to that glass to relax, it could increase to two, three, or more a night.” He also adds that it’s pretty common for tolerance to increase, so if you’re drinking a glass of wine to get a little buzz, it could morph into needing more to have the same feeling.
This is not at all to say that everyone who drinks a glass of wine a day will always develop an addiction. But something that seems harmless could potentially transform into a destructive pattern, depending on other factors in your life and your genetic makeup.
The varying degrees of addiction
This might seem overwhelming. But changing how we think about addiction—not as an “on-off” switch, but more as a gradient with levels of seriousness—could be helpful when it comes to prevention, at least according to the experts who tout this way of thinking. “The reason why it’s so important to view addiction as a spectrum is because it means you don’t have to hit rock bottom to turn it around,” Arsenault says. “If you’re on the low or medium end of the spectrum, you can look at that and think about the lifestyle changes you can make before it gets worse.”
Since addiction comes in varying degrees, treatment can vary, too. When Dr. Gandotra is working to treat a patient with an addiction, his first thoughts are on their most basic, primary needs. Do they have a place to live? Are they going to be going through withdrawal? Do they need to be enrolled in a rehab program? “Rehab isn’t always the best answer,” he says. “It really does depend on where they are on the spectrum and factors like if they’re able to hold down a job and have familial support.”
He adds that the substance in question matters, too. “There’s a hierarchy in terms of the consequences. Someone using an illicit substance is at risk of being arrested, or using cocaine puts you at risk for sudden death.” Definitely not the same as being addicted to your phone.
For a person on the lower end of the spectrum, the experts say treatment starts with meeting someone where they are, and what they’re willing to change. “Maybe someone isn’t ready to stop drinking alcohol completely, but they can make the step to limit it to every other night [rather than] every night,” Dr. Gandotra says. “It also allows for the chance to tweak the script a little bit and ask them, ‘Is there any aspect of your drinking you would like to change?’ That can help someone figure out where to start.”
However, in the case of someone with a severe addiction (or a person who is addicted to a life-threatening substance), quitting cold turkey is necessary. “If someone is on the severe end of the spectrum, the physical symptoms need to be addressed first. Then, the lifestyle changes can be addressed,” says Dr. Thomas.
“What I’m really hoping to get across by talking about addiction as a spectrum is, again, you don’t have to hit rock bottom to change,” adds Dr. Thomas. “Maybe your relationship with alcohol, food, screen-time—whatever it is—isn’t as healthy as you would want it to be. You don’t have to reach a tipping point to change it.”
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