It might sound like a stupid question. Surely, someone would know if they have a problem with alcohol or drugs, right?

Not so. In fact, the majority of people (especially young adults) who meet the diagnostic criteria for alcohol or other drug abuse or dependence are honestly unaware of it. They may readily admit that alcohol or drugs causes a few difficulties now and then, but they remain essentially blind to the nature and significance of the problem.

So how do you know for sure? The first step is to take an honest look at your behavior and compare it to the diagnostic criteria. In a way, it works like diagnosing any other illness based on your symptoms.

Diagnosing alcohol and other drug abuse & dependence isn't quite as simple as diagnosing the flu, but the same process applies.

Alcohol & Drug Red Flags: Symptoms of Alcohol & Other Drug Abuse & Dependence

Take a look at the following symptoms and ask yourself honestly, "Do some of these apply to me?" Keep in mind that almost no one has them all.

1. My drinking (drug use) sometimes causes problems.
2. I sometimes set limits on the amount I will drink (use) and then exceed those limits.
3. I sometimes make promises to myself or someone else about drinking (using) and then break those promises.
4. I sometimes lie about or try to hide the frequency and/or amount of my drinking (using).
5. I sometimes forget or deny things that happen when I was intoxicated (high).
6. I sometimes behave very differently when intoxicated (high) than when sober (clean), almost as if I'm a different person.
7. I sometimes tend to avoid social functions at which alcohol (drugs) may not be available.
8. I've embarrassed, angered, or frightened other people when I was drunk (high).
9. I have a very high tolerance - that is, I can drink (use) a lot without acting or feeling highly intoxicated.
10. I sometimes feel guilty, embarrassed, or remorseful about things I said or did while intoxicated (high).
11. I occasionally drink (use) in the morning or early in the day to treat a hangover or to avoid the shakes (withdrawal symptoms).

How many "yes" answers do you need to diagnosis a problem? It depends. If you answered "yes" to one or more, then it may be worth taking a closer look.

The e-CHUG (electronic CHeck-Up to Go)

One simple way to get some honest feedback about alcohol is through e-CHUG, an anonymous online self-assessment.

e-CHUG helps you gain insight into the true nature of your relationship with alcohol with a simple, straightforward format. The information you provide, as well as the feedback you receive, are completely anonymous. It takes most people about 10 minutes.

Speaking of feedback, yours will be personalized and includes interesting, useful, and sometimes surprising information, including:

• Your drinking profile
• The number of calories you drink per month
• Your typical and peak blood alcohol concentration (BAC)
• Your drinking compared to that of other college students, both at UT Austin and in America
• The amount and percent of your disposable income spent on alcohol
• Your tolerance to alcohol's effects
• An estimate of your genetic risk for alcohol dependence
• A full explanation of your feedback
• Local referral information for further information and assistance

e-CHUG is a simple way to find out if a professional consultation with an ADEP counselor might be helpful.

The Use - Abuse - Dependence Continuum

Sometimes the differences between alcohol and/or drug use, abuse, and dependence are obvious, but sometimes they are subtle.

Most people who drink alcohol (use drugs), including college students, do so responsibly and with little risk. Their experience looks something like this:

• They drink (use) simply to enhance enjoyment of normally pleasurable experiences, and that's what happens.
• They don't experience any problems associated with drinking (using).
• They never feel out of control or that they've had too much.
• They don't think about how much or how often they drink (use); it just never comes up.
• No one complains about how much or how often they drink (use) because there is nothing to complain about.

Some people who drink alcohol (use drugs) do so irresponsibly, at least occasionally, and it causes problems. The technical (diagnostic) term is alcohol abuse (drug abuse). Their experience looks like this:

• They know their limits and typically drink (use) within them, unless they consciously decide ahead of time to exceed them.
• When they do drink (use) too much, it's on purpose - a conscious choice.
• They experience negative consequences associated with drinking (using), but are able to alter the way they drink (use) to avoid those problems in the future.
• They often drink (use) to conform to peer pressure or their beliefs about what others expect of them.
• They may use alcohol (drugs) to help change the way they feel about themselves and/or some aspect of their lives.

A small percentage of people who drink alcohol (use drugs) become dependent. Technical terms include dependence, alcoholism, and addiction. Their experience looks like this:

• They experience negative consequences associated with drinking (using), but continue to drink (use) in a way that facilitates a recurrence of those problems.
• They set limits on how much or how often they will drink (use), but sometimes unexpectedly exceed those limits.
• They promise themselves and/or other people that they will drink (use) in moderation, but break those promises.
• They feel guilty, remorseful, and/or uncomfortable about their drinking (using), but fail to permanently change the way they drink (use).
• They get complaints about their drinking (using), but tend to resent, discount, and/or disregard those comments.

People in these categories can manage their relationships with alcohol (drugs) using different strategies. Social drinkers (users) are fine. They don't need to do anything, except perhaps drink (use) within the limits of the law.

Social drinkers (users) can get referred for alcohol or drug education or counseling accidentally, usually by being in the wrong place at the wrong time. Nevertheless, they often benefit from the experience because they lack the defensiveness of substance abusers and addicts, so they learn interesting and useful information regarding the use of alcohol (drugs).

Alcohol (drug) abusers may not need to abstain completely from the use of alcohol (drugs), but they do need to change their drinking (using) behavior. That usually means that they must deal with problems and issues that make them want to drink or use to change the way they feel, even if it means getting professional help.

Here are some of the problems, issues, and situations that might encourage someone to abuse alcohol (or drugs, food, sex, gambling, etc.):

• Depression
• Anxiety
• Fear
• Anger
• Low self-esteem
• Immaturity
• Peer pressure
• Habit
• Boredom

Alcohol (drug) abusers are not alcoholics (addicts). They often "outgrow" their abusive use of alcohol (drugs), especially when the circumstances of their lives change in substantial ways.

Alcohol (drug) abusers get referred for alcohol or drug education or counseling for a reason. They usually struggle to benefit from the experience because they are defensive about the true nature of their relationship with alcohol (drugs). They haven't experienced the degree or extent of negative consequences associated with alcoholism (drug addiction), and they typically compare themselves favorably to their peers.

Most adolescents and young adults who get referred for help with alcohol (drug) related problems fit into the abuser category. If they are predisposed to alcoholism or addiction their abuse will almost certainly pave the way. Therefore, alcohol (drug) use patterns and family history are necessary and relevant to assessment and proper care.

Alcoholics (Addicts) need to abstain completely from drinking (using). They will almost always need professional help and/or support to accomplish that goal. Individuals, including adolescents and young adults, who become addicted to alcohol (drugs) and continue to drink (use) will be unable maintain control, at least in the long term.

The following table summarizes the use-abuse-dependence continuum utilizing official DSM-IV diagnostic criteria to the categories of abuse and dependence.

Diagnostic and Statistical Manual of Mental Disorders. (4th ed., text revision). (2000). Washington, DC: American Psychiatric Association.

Addiction is a Disease

Public and professional stigma against addictive diseases is a major social problem when dealing with conditions which have traditionally been dealt with by behavioral and spiritually-based programs. Reducing this stigma is critical, as negative attitudes damage the level and quality of patient care and funding for prevention, education and research.

For far too many years, the "field" of drug addiction treatment and prevention has drifted aimlessly, based on insufficient research evidence that addictions are brain diseases and about the pharmacology of addicting drugs. Much of the confusion is based on an incomplete understanding of the differences between intentional drug abuse and pathological drug dependence - the more accurate and descriptive term for addiction.

There is also a great deal of misinformation about the pharmacology of addicting drugs. This picture is changing rapidly, based on new neuroscience (brain) research which strongly indicates that the pleasure pathway - the medial forebrain bundle - of the brain is affected by all addictions, particularly in the pharmacological qualities of euphoria, craving, and a theoretical concept of "drug need." This is the psychological correlate of behavioral "impaired control." The neuroanatomical and neurochemical bases of drug need have yet to be demonstrated in the laboratory. But the research technology, such as brain scans, is now at hand to test the theories.

Everyone who cares about the victims of addiction must become more scientifically literate about the implications of new research findings, and spread the news that biomedical research is on the threshold of proving what recovering people already know - that drug dependencies are medical diseases which deserve parity in present and future national healthcare programs.

Drug dependence must also be handled differently from drug abuse in terms of responsibility and culpability in law enforcement.

This article covers the latest research on the neurobiology of dependence, including how the brain's pleasure pathway works. It covers the differences between chemical abuse and chemical dependency, the latest therapies for drug dependency, and research methodologies which promise even more exciting breakthroughs in understanding addictions in the future. This information has important implications for prevention and education of the public about the true causes of drug problems, and how society can best deal with such problems.

The Solution

First, get rid of "Spam" - an acronym for stigma, prejudice, anger and misunderstanding. All of these lead to myths, as compared to research-generated facts.

And there are some dangerous myths in this world. These include the myths that club drugs and marijuana are not addicting... that everyone who uses cocaine or heroin is addicted... that caffeine is highly addicting... that the form of a drug and how it is taken affects its "addiction potentialÓÉ and that alcoholics can stop drinking, since all they have to do is go to AA meetings.

Two Critical Definitions

Professionals carry out assessments to distinguish between chemical abuse and dependence because accurate assessment directly affects what type of treatment is most effective for each client. Therefore, distinguishing between the chemical abuse and dependence is the most humane, most cost-effective, and most professional course of action.

Chemical abuse is intentional overuse of substances in cases of celebration, anxiety, despair or ignorance. It is about people making bad choices about the use of drugs. It typically declines with adverse consequences, supply reduction, or change in drug-use environment.

The criteria for chemical abuse, according to the DSM-IV diagnostic and statistical manual, are:

1. A maladaptive pattern of alcohol or drug use leading to impairment or distress, presenting as one or more of the following over a 12-month period
• recurrent use leading to failure to fulfill obligations
• recurrent use that is physically hazardous
• recurrent alcohol- or drug-related legal problems, and
• continued use despite social/interpersonal problems
2. The symptoms have never met the criteria for chemical dependence

Dependence is impaired control over drug use, probably caused by a dysfunction in the brain's pleasure pathway. This is the disease of addiction, an "I can't stop without help" disease. It requires formal therapy and/or 12 steps and might require anti-craving drug therapy.

The DSM-IV criteria for chemical dependence are:

1. A maladaptive pattern of alcohol or drug use, leading to impairment or distress, presenting as three or more of the following over a 12-month period:
• Tolerance to the substance's actions
• Withdrawal symptoms (generally, physical)
• Substance is used more than intended
• There is an apparent inability to control use
• Effort is expended to obtain the substance
• Important activities are replaced by use
• Alcohol or drug use continues despite negative consequences
2. Two types of dependence can occur, as follows:
3. Physiological dependence, including tolerance and withdrawal
4. Non-physiological dependence, excluding tolerance and withdrawal

The terms "physical addiction" and "psychological addiction" are no longer valid, since the DSM-IV term includes both psychological and physical components.

Does Abuse Lead to Dependence?

A five-year follow-up of 1,300 men and women (Schuckit et al 2001) found that only 3% of abusers met criteria for dependence five years after being diagnosed as abusers. But many people believe that abuse usually leads to dependence. Instead, the two conditions appear to be separate; abuse may be a milder disorder not usually progressing to dependence.

Risk of Dependence

Data from the National Comorbidity Survey of 8,100 men and women aged 15-24 years old (Wagner & Anthony 2002) showed that different drugs are associated with different rates of dependence. In the 10 year study, 15-16% of cocaine users, 12-13% of alcohol users, and 8% of marijuana users become dependent. Of those who became dependent on cocaine, 5-6% became dependent in the first year of use. Fully 80% of people who became dependent on cocaine over the 10 years had become dependent in the first three years.

These are only single studies which deserve more replication, but they are interesting in that they begin to break down some myths that people have about the onset of dependence in users and abusers.

Early vs. Late Onset

Although it "looks" as if most people evolve from abuse to dependence, people can become dependent during their first year of using drugs, including alcohol. People in recovery seem to understand that some people become "instantly" dependent with the very first use of the drug; most reports concern early onset with the use of alcohol and cocaine. There is only one explanation, and it lies in the physiology of the medial forebrain bundle, or MFB, also known as the mesolimbic dopamine system.

The Neurobiological Model of "Impaired Control" Characteristics

A key point is that the "dependence" brain areas are in the part of the brain that governs unconscious thought. Dependence is not a "lack of will power" because:

• The main problem with dependence lies in the MFB
• Problems with the frontal cortex portion of the MFB produce a pathological impairment of decision-making

Therefore, dependence is not mainly under conscious control.

Basic Neurobiology: Neurotransmitters Involved in Dependence

Dependence is probably due to a functional dysregulation (meaning they aren't working right) of one or more neurotransmitter chemicals in the MFB. These include dopamine (which is affected by cocaine, amphetamines or alcohol), serotonin (alcohol or LSD), endorphins (alcohol or opioids such as heroin), gamma-aminobutyric acid (alcohol or benzodiazepines), glutamate (alcohol), and acetylcholine (nicotine or alcohol).

The dysregulation could be related to too much or too little neurotransmission, abnormal breakdown of neurotransmitters, or abnormal receptor function. How does it come about? Is it due to genetic malfunctions, to drug-induced changes, or to other aspects of the environment? Neurobiological research points to genetics and drug-induced changes as being primary causes of dependence, whereas the environment is a major, though secondary, contributor to drug abuse and thus dependence.

The Rationale Based on Genetics

Abnormal genes lead to abnormal proteins. This results in abnormal transmitter-synthesizing enzymes, abnormal transmitter-breakdown enzymes, or abnormal receptors. This is the cause of neurotransmitter dysregulation in the pleasure pathway. Impaired control appears to be due to this brain-chemistry disruption. It is the reason that scientists and clinicians now believe that dependence is a chronic medical brain disease.

Summary

Addicting drugs seem to "match" the transmitter system that is not normal. To treat such individuals, detoxification - weaning people off the drug of choiceÑis the first step. Then, ideally, abstinence-based treatments are attempted, which traditionally have the greatest chance of success. But abstinence is not for everyone, so more treatment choices are becoming available through scientific research.

For some, continued use of a similar drug (such as methadone for heroin dependent people) or the initial drug (nicotine patches for people who stop smoking) is the choice, because some people report that they "need" a chemical to "feel normal," in other words, to overcome the non-normal transmitter system.

Today's Treatment Options

More options create greater chances for helping people. Today's options include some or all of the following:

• Traditional
• Inpatient, outpatient, & aftercare treatment
• 12-step programs, with abstinence
• Misunderstood but useful
• Harm reduction
• Moderation management
• New and promising
• Brief motivational counseling
• Cognitive behavioral therapy
• Motivational enhancement therapy
• Medications to enhance abstinence
• Anti-craving medications
• Methadone
• Buprenorphine
• Vaccines
• Drugs to alleviate withdrawal

A final note: If addictions are a medical disease, why do we typically treat them behaviorally? What is the similarity between behavioral or talk therapies and pharmacotherapies in the way they work? The answer is simple. Behavioral therapies probably change brain chemistry. If this is a brain disease, and people get better in behaviorally-based therapies, then brain chemistry has to change. Recent brain-scan research is confirming this rational conclusion.

Carlton Erickson PhD is a research scientist who has been studying the effects of alcohol on the brain for over 30 years. He is the Pfizer Centennial Professor of Pharmacology and director of the Addiction Science Research and Education Center, College of Pharmacy, University of Texas. He has published over 150 scientific and professional articles, has co-edited and co-authored books, and is associate editor of the scientific journal Alcoholism: Clinical and Experimental Research. In 2000, he received the Betty Ford Center Visionary Award 2000. Since 1978, he has addressed more than 70,000 professionals and people in recovery.

The Genetics of Alcohol Addiction

Research Summary on the Genetics of Alcohol Addiction
By: Charles N. Roper, PhD

Research has shown conclusively that the risk of alcoholism is, at least in part, genetic (inherited from one or both parents), and not just the result of family environment (upbringing).

Family Studies: Findings

1. Sons and daughters of an alcoholic parent are four times more likely to develop alcoholism than those of non-alcoholic parents.
2. Alcoholics with a family history of alcoholism have some predictable characteristics.
• They show the first signs of alcohol dependence at an earlier age.
• They develop a more severe form of alcoholism, with a more rapid and explosive course.
• They are less likely to have other psychiatric illnesses. However, they may have an increased risk of antisocial personality disorder and may have had childhood hyperactivity or conduct disorders.
3. Alcoholics with no family history have less predictable characteristics.
• They generally show signs of alcoholism at a later age.
• They typically develop a less severe form of alcoholism, at least in its earlier stage.
• They are more likely to have an accompanying or predisposing psychiatric disorder, such as depression.

Twin Studies: Findings

1. Fraternal twins - those who share 50% of their genes - who have an alcoholic parent are four times more likely to develop alcoholism, and alcoholism in one twin does not predict alcoholism in the other twin.
2. Identical twins - those who share 100% of their genes - who have an alcoholic parent are four times more likely to develop alcoholism, and alcoholism in one twin does predict alcoholism in the other twin at a statistically significant rate.

Adoption Studies: Findings

1. In children of alcoholic birth parents who were adopted out, the risk of alcoholism is the same as if they had remained in the alcoholic family. In other words, they are also four times more likely to develop alcoholism than children of non-alcoholic birth parents. This is true regardless of who raises them.
2. These adoption studies control for environmental factors in order to demonstrate the prevalence of genetic predisposition.

Taken as a whole, these studies indicate a very high probability that alcohol addiction is genetically influenced.

For more information on the genetics of alcoholism, read the article: The Genetics of Alcoholism, from The National Institute on Alcohol Abuse and Alcoholism (NIAAA):