According to the Substance Abuse and Mental Health Services Administration (SAMHSA), well over 20 million people would qualify for a diagnosis of a substance use disorder in the United States. Only a small proportion of these people actually seek treatment. Part of the issue is that many individuals who would qualify for diagnoses of a substance use disorder do not feel they need treatment for their behavior.
The phrase continuum of substance use/abuse refers to a hypothetical outline of how individuals transverse from casual use of drugs and/or alcohol to abuse and addiction. Numerous models outlining how this occurs have been proposed; however, none of them have any significant empirical evidence to support them. This is because there is actually no objective medical test that can be used to determine whether an individual has a drug abuse problem or is just a casual or recreational user. Instead, even the formal diagnostic criteria to diagnose any substance use disorder (the current clinical term that encompasses both the notions of substance abuse and addiction) is based on subjective behavioral observations. Thus, the point at which any individual crosses over from use to abuse is an entirely subjective determination.
Because the notions of addiction, abuse, dependence, etc., are relatively subjective, individuals who are abusing drugs are able to rationalize their drug abuse. Those who want to help a person with the potential substance abuse issue become frustrated because what they see (their subjective viewpoint) is an obvious case of an individual ruining their life, whereas the person with the substance abuse issue is able to constantly find ways to rationalize their use as being “normal” for them.
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The Standard Model Used to Define the Continuum of Use and Abuse
Most formulations of the continuum of use to abuse to addiction theory begin with the notion of casual or recreational drug abuse. Recreational drug use is defined as the use of a drug without medical justification and for its psychoactive effects, with the belief that occasional use of the drug is not addictive or habit-forming.
Similar definitions of casual or recreational use are offered from numerous sources. All of these designations, such as recreational use, abuse, addiction, etc., involve some form of subjective interpretation of an individual’s behavior. Subjective interpretations often vary widely, and individuals who attempt to rationalize their behavior view their actions from a completely different perspective than individuals looking at them from the outside. This results in a rather fuzzy picture of how an individual develops a substance use disorder.
Nonetheless, the standard presentation of the steps in the continuum of drug abuse, such as that in the book Substance Abuse Counseling, involve the following progression:
Nonuse: The individual has not ever used drugs or alcohol, or has never used a specific type of drug or alcohol. This stage is a dichotomous stage; the person has either used drugs or alcohol or has not used them. Only the individual in question knows for sure whether they have ever tried a specific drug.
Experimentation: This is considered to be the least harmful stage of use. An individual begins using drugs in an effort to ascertain what the experience of drug or alcohol use actually feels like. But, where does actual experimentation stop and the next stage begin? Is it just first-time use? Is it two or three times? There is no objective way to ascertain this. Does the definition of experimentation depend on the drug itself? For example, does someone who has only consumed beer “experiment” when they first drink liquor?
Regular, recreational, social, or casual use: After the individual has experimented with drug or alcohol use, they may begin of period of social or casual use. Interestingly, many descriptions of this stage describe signs of distress or dysfunction as a result of an individual’s substance use, such as they may miss work due to a hangover, their grades may drop, etc. These actually represent signs of abuse, and individuals who are considered to be casual users very often demonstrate these issues more than once. The line between social or casual use and abuse is very fine and not objectively delineated.
Risky use: In this stage, individuals begin to have serious issues with distress or dysfunction as a result of their substance use. Unfortunately, it is very difficult to define and separate risky use from social use. According to SAMHSA, over 100 million individuals freely admit to driving an automobile while intoxicated. This is an obvious manifestation of risky use. But, are these individuals simply social users, or are they risky users? How many times does driving an automobile after drinking a significant amount of alcohol fall into the social use category? Where is the line that delineates recreational use from risky use in the context of driving? Does it occur when the individual gets a DUI or has an accident? There is no way to tell.
Dependence: This stage is impossible to empirically or objectively verify. According to descriptions of the stage, while there are no actual chemical or structural changes that occur in an individual’s central nervous system as a result of their substance use, the individual continues to use drugs or alcohol regardless of the negative effects it has on their job, relationships, or health. The problem with this stage is that there is no objective way to measure detrimental changes in one’s brain as a result of drug use because these changes occur with first use. There is no brain scan or other medical test that can be used to determine if an individual has developed a substance use disorder, is a recreational user, will undergo withdrawal, or has developed tolerance.
Addiction/compulsive use: In the final stage, the individual has developed a serious physiological adaptation in their brain as a result of the use of drugs, and no matter how hard they try, they cannot stop using drugs or alcohol. The notion of choice is gone, and individuals are slaves to their cravings. The problem with the definition of this stage is that there is no such situation where an individual cannot choose to use drugs or alcohol. Even individuals who develop severe physical dependence on drugs can often choose to forestall their use of drugs. The description of this stage is dependent on subjective interpretations by individuals with severe substance use disorders or outsiders observing them (including clinicians) and concluding that these individuals no longer choose but are driven to use drugs.
When one views the types of criteria that are alleged to separate recreational users from abusers or individuals with formal addictions, the picture becomes even fuzzier.
Can say “no”: Recreational or social users can easily say “no” to drugs or alcohol, whereas individuals who are addicted cannot. In reality, this is a false dichotomy. Even individuals with very severe substance use disorders can sometimes say “no,” whereas individuals who would be classified as social users sometimes cannot and do not say “no” when they should.
No compulsion: Recreational or social users rarely think about drugs and getting high, whereas drug addicts think about this quite a bit. How do we know this? This is an assumption based on a biologically based model of addiction that cannot be empirically verified.
Stable relationships: Recreational or social users typically have good relationships with family, friends, and coworkers, whereas addicts have strained relationships as a result of their drug use. Again, this is a false dichotomy. Many people who have significant substance use disorders may have good relationships with others. Individuals who are recreational users often have strained relationships with others that are in part due to their recreational use of drugs or alcohol.
Reason for using: Recreational or social users do not depend on drug or alcohol use to empower themselves, whereas drug addicts use drugs or alcohol to gain confidence, empower themselves, etc. Again, this is a false dichotomy.
No financial problems: Recreational or social users are frugal when it comes to spending money on drugs or alcohol, whereas drug addicts are not. Recreational users do not spend their money on drugs or alcohol, such that it depletes their financial resources, whereas addicts do. However, there is no evidence that recreational users do not at times overspend or strain their finances to use drugs or alcohol, and that addicts cannot forestall using drugs or alcohol to pay important bills or satisfy financial obligations.
The Use/Misuse/Abuse Distinction
A different way of viewing the continuum involves the use/misuse/abuse distinction. Organizations such as SAMHSA often employ the use/misuse distinction. The problem with this distinction is that it is really only relevant when it is applied to over-the-counter medications or prescription medications. It would be wrong to say that a drug like heroin, a drug that is not used for medicinal purposes in the United States, can be misused. According to this idea, any use of a medication that is not within the prescribed instructions of the medication, or the instructions on the label of the medication, is deemed as misuse, whereas any use of the medication that is in compliance with the prescription or instructions on the medication (or used according to the instructions of one’s physician) is considered to be normal use.
Misuse of a drug does not necessarily imply abuse. Abuse occurs when an individual’s misuse becomes repetitive and results in negative ramifications in functioning. The use/misuse dichotomy is relatively well defined for drugs that can be used for medicinal reasons; however, the transition from misuse to abuse is much more subjective in nature.
Identifying a Substance Abuse Issue
The American Psychiatric Association (APA) presents the formal diagnostic criteria for substance use disorders (the current clinical term that combines older notions of abuse and addiction or dependence). The formal diagnosis of any substance use disorder can only be made by a trained mental health clinician. The diagnostic criteria are based on behavioral signs and ramifications of the individual’s behavior.
As mentioned several times, there are no objective medical tests that can be used to diagnose a substance use disorder. Instead, clinicians interview the individual in question, may interview family members, and may have access to objective data, such as the individual’s legal history, performance at work, etc. Some clinicians may also give psychometric tests, which are often question-and-answer tests, to the person with a suspected substance use disorder and/or that person’s family members. The results of psychometric tests alone should not be used to formally diagnose any type of mental health disorder, but they can provide useful information in helping to diagnosis a potential substance use disorder according to the diagnostic criteria presented in APA’s current diagnostic manual, the DSM-5.
Most often, there are several diagnostic criteria or symptoms to determine different types of substance use disorders, and the individual must satisfy at least two of these criteria within a 12-month period in order to be diagnosed with a substance use disorder. In addition, the individual’s substance use must result in either severe distress for them or significant dysfunction in two or more areas of their life. This determination is made by the clinician based on the reports of the client and/or family members, friends, coworkers, etc.
According to the diagnostic criteria for substance use disorders, individuals can be diagnosed with mild-level substance use disorders (relatively few symptoms; this level of a substance use disorder would qualify for older definitions of substance abuse), moderate-level substance use disorders, or severe substance use disorders (typically displaying 5-6 symptoms within the same 12-month period). The development of tolerance and/or withdrawal syndromes is often part of the diagnostic criteria for substance use disorders; however, it is neither necessary, nor is it sufficient, to receive a diagnosis of a substance use disorder (even a diagnosis of a severe substance use disorder).
Even though the diagnostic process for a substance use disorder is based on the judgment of the clinician, it is a basic dichotomy: One either has a substance use disorder or one does not have one. The reliability of this diagnostic process is surprisingly consistent from clinician to clinician, evaluating the same person, although there may be some instances that are fuzzy.
The diagnosis of a substance use disorder does not consider the continuum model/theory but instead is simply used to determine whether an individual needs to receive formal treatment for their substance use. Individuals who wish to engage in treatment for their substance use and do not meet the diagnostic criteria for a substance use disorder would not be denied treatment.
Conclusions about the Continuum of Substance Abuse
In the final analysis, there is most likely some transition from early experimental use to social use to potential abuse of drugs or alcohol, but theories attempting to delineate specific stages that are mutually exclusive from one another fail miserably because of significant variability in this process from person to person.
There is no empirical evidence that indicates that individuals go through the stages in a specific order and that one can delineate social use from abuse in an objective manner. Clinically, one either has a substance use disorder or one does not have a substance use disorder. The use of formal diagnostic criteria based on behavioral observations, expertly trained clinicians that can consistently use these criteria, and continued research targeted at refining the diagnostic criteria is the best viable alternative at this time to determine whether or not one’s use of drugs or alcohol represents a formal mental health disorder. Other designations, such as experimentation, social use, etc., have very little clinical utility. For clinicians, an individual either has a substance use disorder, or they do not have one.
When any individual is concerned that they may be abusing drugs or alcohol, this represents a sign that they should seek help to stop using drugs or alcohol. However, the more common scenario occurs when an individual’s use of drugs or alcohol appears clearly dysfunctional to others, but the individual continues to rationalize their behavior.
Individuals with substance use disorders often attempt to rationalize their behavior, even in instances where it is clear that their use of drugs or alcohol is dysfunctional and creating significant distress for them and the individuals who care about them. Some of the most common rationalizations include:
I don’t drink or use drugs every day, so I am not an addict. Many individuals are under the mistaken impression that having a substance use disorder requires that the person uses drugs or alcohol daily. The diagnostic criteria for any substance use disorder does not specify a minimum or maximum number of times per week an individual must use drugs or alcohol to qualify for a substance use disorder. This is never been a criteria for substance abuse of any type. This is a manifestation of the frequently used line, “I can stop anytime I want to.” Individuals can often specifically point out times when they did not use their drug of choice for days or even several weeks. This allows them to rationalize their dysfunctional behaviors.
I don’t need to use drugs or alcohol. This rationalization is an excellent example of the subjective nature of the interpretation of a substance use disorder. Individuals often believe that the defining factor of abuse is a compulsion to use drugs or alcohol that is so strong that an individual cannot resist it. Even individuals with severe substance use disorders can recall a time when they chose not to use their substance of choice. There is no way to determine whether one actually needs to use their substance of choice, but trained clinicians can determine that an individual is having difficulties controlling their use of drugs or alcohol.
I don’t have withdrawal symptoms. This is another mistaken impression, probably fostered by the media. The presence of withdrawal symptoms is neither necessary nor sufficient to be diagnosed with even a severe substance use disorder of any type.
My use of drugs or alcohol is “normal” for me. This rationalization allows individuals to assume that they are “special” compared to other individuals who are weak and develop substance use disorders. Individuals who use this type of rationalization often point out the positive effects of their substance abuse, such as how substance abuse relieves their stress, reduces physical pain, helps them cope with work or with others, etc. It simply represents individuals lying to themselves about the consequences of their behavior.
The bottom line is that individuals who develop substance use disorders certainly start from a point where they did not use their substance of choice to a point where their use of drugs or alcohol became dysfunctional for them. Somewhere in between these two poles, some individuals may have been able to casually engage in drug or alcohol use, and some individuals began using drugs for stress control, to escape, etc., from the start.
Attempts to define a formal continuum of a substance use/abuse model fail because the process that occurs from individual to individual is quite variable, and there are no objective ways to delineate the stages in these models. The actual determination of whether or not one has a formal substance use disorder can only be conducted by a licensed mental health professional who has experience in diagnosing these conditions.