Regarding alcohol, for instance, it is not uncommon for young people who drink socially to go through a brief period of time when alcohol is abused for its intoxicating qualities. Sooner or later, however, some type of negative consequence will occur. It might be a bad hangover or an episode of embarrassing behavior. At that point most people will correctly identify the drinking as having caused the negative consequence and will modify their behavior. Some, however, continue to drink despite increasingly negative consequences - and this is addiction.

The prevailing culture is another factor. In a culture where daily social drinking is acceptable, the fact that someone is drinking regularly is less important. On the other hand, in cultures where drinking is highly frowned upon, even occasional alcohol use might be a concern.

Smoking is another example. It has been said that as the prohibitions against smoking have increased, the characteristics of smokers have changed. Those who continue to smoke have a stronger addiction to nicotine, and are less able to use the methods for quitting that have worked for others. So a smoker in the late 1990s in the United States might be much more likely to have severe addiction than a smoker in the early 1950s.

Let’s look at how use of a substance gradually progresses from social use to abuse to dependence (addiction).

Some people never use an addictive substance. Others, who suffer minor consequences such as a hangover or an upset stomach,  limit and control use of the substance. “Social drinkers” or “casual users” use the substance periodically, and some will continue to do so indefinitely if it does not cause much in the way of uncomfortable consequences. They are able to maintain control.

But some people, in continuing to use a substance, will escalate the amount and start to experience more negative consequences. Often this is the point at which the substance begins to be used more for its pharmacological effects - as a sedative or tranquilizer, for example. This “hazardous use” might lead to substantial consequences, and in some cases the person will recognize the problem and begin to abstain from the substance, therefore regaining control. Sometimes people go through a period of abusing substances during stressful periods in their lives. They might experience some fairly severe consequences, such as alcohol-related motor vehicle accidents, other legal charges, or behavioral problems related to intoxication. Some of these people will be able to recognize that using the substance is causing more trouble than it’s worth. Control will be regained, and they will begin to abstain.

But some will continue using regularly despite repeated and increasingly severe consequences, exercising no control over the use of the substance. At this point in the continuum, dependence, not just abuse, is present. This is addiction.

The continued use of the substance becomes the focal point of life. And when that change occurs, even when it is very subtle, all other aspects of life - relationships, jobs, responsibilities, goals - become less important than the addiction.

It is not uncommon for an addict to lose everything before entering treatment. Incarceration or even death may occur before the addict has the chance to enter treatment.

When we think about the continuum from experimentation and casual use on to abuse and dependence, it is important to recognize that some people are probably genetically predisposed to developing dependence and also that the “addictiveness” of a substance will affect the rate at which loss of control and subsequent abuse and dependence occur.

These factors - genetic traits and the addictiveness of the substance - interact with each other in the development of addiction in an individual. People who come from families where there is a great deal of alcoholism and addiction may progress more quickly to dependence and addiction, even with substances that are less highly addictive for others.

For those people, even social drinking may be hazardous.

With highly addictive substances such as heroin and crack cocaine, genetics may be less important, and users may have little opportunity to experience negative consequences and to retreat from casual use before addiction occurs. So, with these substances, even experimentation can be dangerous.

Elizabeth Connell Henderson, M.D.

Glossary

Appendix A: Regulation of Addictive Substances

Appendix B: Sources of Additional Information