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No one in her right mind would chuck all the good things in life, her job, family, relationships, dignity, health, and maybe ultimately her freedom and her life, chasing down the next high.  No one in her right mind.  Yet people do these things, and they do them because their minds are not right.  What other point of view could possibly make sense?  This is not a problem of character defects and morality, it is a chronic (albeit self-caused) medical condition.  Whether or not you want to call it a "disease" is up to you, but there is no question that chemical dependency in advanced SUD is a problem of abnormal brain chemistry.


How did you score, again?


The DSM-5 self-test, and others like it, are revealing because they show a few of the key characteristics of advanced SUD and chemical dependency. But they can't begin to reveal how hard it is to get out of that hole, and how high the recovery barriers become for anyone venturing too far down it.  It is always much easier to get out early, before things get too bad, but the nature of chemical dependency makes it likely that we will instead keep going towards the abyss, setting ourselves up for an enormous challenge later on at a time when we are least able to take on such a challenge. 


Addiction is sometimes called a progressive disease.  It's certainly often progressive, but we drive it there ourselves by continuing to drink or use and making ourselves ever more dependent.  We can stop the progression, too, and we must stop it, but it's hard.

Drugs taken in a SUD work much the same way, when we take large enough doses regularly enough. The drugs create massive changes in the release and re-uptake of neurotransmitters like dopamine, serotonin, norepinephrine, GABA, and others, in the synapse regions of the brain.  If we keep taking these large regular doses, our brains try to compensate. So, as with psychiatric medications, we develop a tolerance to the drugs, and at constant dose the direct effects diminish. But because we want to get high, we up the dose, and we wind up taking massive quantities that would send most people to the hospital or the psych ward. The hard drinker we see at the bar, pounding shot after shot without getting drunk, has developed a massive tolerance, and if a light drinker tries to keep up he'll be on the floor or perhaps dead.

And soon, not taking the drugs becomes a dreaded physical and psychological disaster, because without the regular high dose our brains swing wildly out of balance in the opposite direction. This is the withdrawal effect also seen in psychiatric medications. Hangovers, and the "hangover jitters", are a mild temporary kind of alcohol withdrawal (stopped, of course, by more alcohol, the "hair of the dog"), but it gets much worse in chemical dependency, and we wake up in the middle of the night shaking and sweating, craving a drink. Eventually, withdrawal results in severe insomnia, delirium, hallucinations, days of nausea, and possible brain seizures that are sometimes fatal. In contrast, cocaine and methamphetamine addicts sleep for days in withdrawal, and can feel profoundly paranoid and depressed. Marijuana addicts feel anxious and can't sleep. Benzo withdrawal is much like alcohol withdrawal, except it can go on for months of hell.

Many people who have gone far down the chemical dependency hole will tell you they don't drink or use to get high anymore, they drink or use to feel normal. And so they do. The "new normal" is an equilibrium homeostasis shifted far from normal by the regular intake of large amounts of drugs, and they adapt to the new state only if the intake is maintained. Stopping the intake feels like the worst thing in the world, and increasingly they will do anything to maintain the new homeostasis. Everything else in life becomes secondary to maintenance of the drug intake.

Psychiatric medications are psychoactive drugs taken under prescription to affect the chemical makeup and function of our brains, for specific purposes and usually to combat deficiencies. They do not themselves make up for deficiencies, instead they induce our brains to change their chemical function, and it is these changes that make up for deficiencies. Typically, their use exhibits both tolerance and withdrawal effects. We ramp up the dose early on, up to some long-term stable level that we wouldn't take at the start, and changing or stopping the dose later can have significant negative consequences if not done gradually following doctor instructions. Over time our brains becomes chemically dependent on the medications, and their (new normal) function is dependent upon regular intake of the meds.

Onwards into chemical dependency...

We can either have or not have a broken bone that needs medical treatment, we can either have or not have cancer, but typical of mental health diagnoses, we can have degrees of a substance use disorder (SUD) based on our (hopefully honest) answers to a quiz in DSM-5. Brains are difficult things to understand. And, as we move from the mild to the severe categorization boxes, we begin to acquire something that changes the game: chemical dependency, a physical transformation of our brains.  The word "addiction" is loaded and carries a certain stigma, but it is a real chronic condition that is rooted in this chemical transformation.  It is a medical problem, and it is often treated as such by health care providers at least in the U.S.  It can be, and frequently is, fatal if it continues too long.  This can be due to the physical effects of dependency, like organ failure or stroke or heart attack, or to indirect effects like overdose, car crashes, or murder.