Stinkin’ Thinkin’ Addiction

© Gennadiy Kravchenko | 123RF.com

© Gennadiy Kravchenko | 123RF.com

“Most Substance-addicted people are also addicted to thinking, meaning they have a compulsive and unhealthy relationship with their own thinking.” (David Foster Wallace, Infinite Jest)

Once a person becomes dependent upon a drug there is a tendency to transfer that addiction to other mood-altering substances. This is what is meant by cross addiction. If an individual becomes addicted to one drug, they can rapidly develop an addiction to another drug in that class of drugs. The reason is mostly physical. The body becomes accustomed to the effects of one kind of drug and will have an affinity to drugs that are similar. “Cross addiction occurs because all addictions work in the same part of the brain.” For an in-depth examination of the neurobiological factors underlying drug addiction and relapse, read “Neuroplasticity in Drug Addiction” on “Terry Gorski’s Blog.”

A chemically dependent person who comes to rely on a particular drug may, for various reasons, decide to abstain from that drug. If they substitute something else, it may not be as effective as the original drug of choice was for them. This can lead to thinking about or craving the original drug. Intoxication with the substitute drug that results in impaired thinking could lead them to use their primary drug again. You don’t have to be incredibly intoxicated either. You just have to be high enough to want your drug of choice and be willing to act on the impulse.

Alisha celebrated a years worth of clean time since she stopped using cocaine. She went out to dinner with a guy on a first date. He must have wanted to impress her, because he’d taken her to a very nice restaurant. He didn’t know about her history and ordered a bottle of wine. Alisha didn’t see the harm in having a glass or two of wine; alcohol had never been her thing. In the middle of the dinner she excused herself and called her cocaine dealer from the bathroom.

In The Science of Addiction, Carleton Erickson said that cross-dependence or cross-tolerance occurs between drugs within the same class. So when a person becomes dependent upon one benzodiazepine, they are dependent upon other benzodiazepines. “It is also possible for a person to be cross-tolerant to drugs of different classes.” One example could be benzodiazepines and alcohol.

Cross-dependence between classes occurs as well. “Reports suggest that such cross-dependence occurs between alcohol and cocaine, alcohol and nicotine, alcohol and benzodiazepines, and heroin and cocaine.” Terence Gorski suggested that this cross-dependency is likely to develop gradually. Early in my professional career I referred a heroin addict to an inpatient detox and rehab program, expecting that the individual would be referred back once the inpatient treatment was completed. In their infinite wisdom, the treatment staff referred the man to a methadone clinic. Two or three years later, he came back to my outpatient program, but not for heroin. He never resumed using heroin. Now he had a serious alcohol problem. What started out as a few drinks to take the edge off became a full-blown alcohol dependency problem.

Substance use disorders cannot be effectively treated as if each one is a discrete disease entity. Stable, long term sobriety is only possible if the person lays a foundation of abstinence from all addictive drugs and then works through the personal and social dysfunction that inhabited their life concurrently with their substance use. Sobriety is not simply whether or not you are drinking or using drugs. A relapse begins sometime before the individual resumes active drinking or drug use. Terence Gorski has said:

Sobriety is abstinence from addictive drugs plus abstinence from compulsive behaviors plus improvements in bio-psycho-social health. Sobriety includes all three things. To the extent that you have accomplished those three things you are sober; to the extent that you have not accomplished those three things you are not sober.

The grey area between initial abstinence and sobriety is where cross-addictions develop. These substitutes can be other chemicals or compulsive behaviors—what Gorski referred to as “process addictions.” These compulsive behaviors/process addictions will typically fall into eight types: 1) eating/dieting; 2) gambling; 3) working/achieving; 4) exercising; 5) sex; 6) thrill seeking; 7) escape; 8) spending.

Compulsive behaviors are actions that can produce excitement or emotional release, what Gorski called an addictive brain response. “This means that the brain is flooded with pleasure chemicals that create a unique sense of euphoria while being inhibiting from producing warning chemicals which cause the feelings of stress, anxiety, fear, and panic.” So these triggers initiate a neurochemical reaction that reinforces the person to keep pulling the addictive trigger.

Evidence supportive of this view is found in the treatment of pathological gambling with the opiate antagonist, naltrexone (here). Piz et al. published a case report where a patient with a compulsive gambling problem avoided a resumption of gambling for three years while taking naltrexone.

Many people begin with a chemical addiction and in sobriety “crossover” or “migrate” into a process addiction. In his book, Staying Sober, Terence Gorski noted how the same behaviors could be compulsive, process addictions or positive outlets. “Every behavior that can be used compulsively, can be productive if used in a way that does not result in long-term pain or dysfunction.” A behavior that is used compulsively is used as some people use drugs—to alter mood, turn off mind and evade reality. Behaviors are positive outlets when they enhance reality and help a person to cope more effectively with reality.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.


Growing Out of Alcoholism

While driving home, I caught the end of an NPR program, “This American Life,” with Ira Glass. I later learned the feature I was listening to was the third segment of a program they titled “The Leap.” The interview was of a woman, Tina, who came into Alcoholics Anonymous (A.A.) at the age of 13. As an adult, she began to question whether or not she was truly an alcoholic, decided she wasn’t, and now drinks socially. Still not really intrigued? Her story of getting sober at 13 is in the A.A. pamphlet, “Young People and A.A.”

So what about Tina? How did she grow out of alcoholism; or are we waiting for the “yet”—the inevitable slide back into drinking alcoholically? The above link for “The Leap” will take you to a page to either listen to the broadcast or read a transcript of the program. Tina’s segment, “The Wisdom to Know the Difference,” is the third of three in the broadcast and transcript.

For twenty years of her life she didn’t question that she was an “alcoholic.” Then she began to wonder what would happen if she drank. “Asking herself, should I take a drink, was basically asking, should I turn my back on what I believed about myself for 20 years?”

As a child, Tina’s parents had been part of The Children of God, a cult or “new religious movement.” In what seems to have been normal for members at the time, they moved around a lot—four different countries before she was three years old. Her life with The Children of God would have been full of dysfunction, abuse and trauma. This is speculation on my part from easily obtained information on The Children of God, especially the stories of former cult members.  She would have been primed to become a preteen who turned to alcohol and drugs.

She was eventually sent to a girl’s group home, where she lived until she graduated from high school. It was while she was there that she began attending A.A. meetings. She became a popular A.A. speaker—“the girl who got sober when she was 13, and could tell the hell out of her story.” By the time she was 33, Tina had been married for several years. She was a columnist and political commentator, “a long way from the miserable, angry girl she’d been who dropped out of school and spent her time drinking and smoking pot with the older kids.”

So when she began to wonder if she could drink alcohol socially, she talked it over with her husband, who was supportive of whatever she decided. She discovered that she could drink socially, and now believes that: “I’m not an alcoholic. Not by any measure.”  No personality changes from drinking; no gradual increase in how much she drinks.

So how does a non-alcoholic child come to believe that she’s an alcoholic? Tina makes sense of what happened to her this way. She went to her first A.A. meeting for something to do. While she was there, she found she could relate to what other people at the meeting said. They had been rejected by family too. They had felt trapped and furious and desperate too. People told her they used to be exactly like her.

There was no other way of explaining at the time. And it wasn’t until, I mean, this is very recently, there was no way for me to figure out why I kept on getting locked up. Why I kept on being sent away. Why my mother was fuming at me.

If she was an alcoholic, she could make sense of her life—and she could fix the problem. A.A. gave her a new life, with goals, discipline, a belief system. And most importantly, people to relate to when things were bad or when they were good.

It’s really liberating to find your people. To find people who you relate to. To find people that ask you to come back. And that was what I experienced. I didn’t have people asking me to come back. . . . And being able to feel true happiness, just feeling like I was OK, and there was no crisis, that was what I learned in Alcoholics Anonymous. That is the irony, right? I’m not an alcoholic, but my life was saved by AA.

Tina’s story illustrates the elasticity of terms like “addict” and “alcoholic.” In one sense it also challenges the sense of the saying, “Once an alcoholic, always an alcoholic.” But it doesn’t negate the validity of 12-Step recovery organizations like A.A. Here’s why I think so. What Tina really grew out of was her addictive behavior.

The addiction researcher Carlton Erickson doesn’t like the terms “addiction” or “alcoholism.” He said in his book, The Science of Addiction, that they aren’t scientific. They are too broad, too vague and too easily misunderstood. He said he prefers the terms alcohol dependence or drug dependence, saying they are closer to what scientists mean when the terms alcoholism or addiction are used by nonscientists. Similarly, he prefers the term drug misuse to drug abuse, “because it more clearly places the responsibility for drug use on the person.”

Erickson’s distinctions become important when we turn to how drug users are diagnosed within the DSM, the Diagnostic and Statistical Manual of Mental Disorders. Well, that is how they were diagnosed within the fourth edition of the DSM, when there was substance (or drug) abuse and substance (or drug) dependence. The current edition of the DSM, the fifth, has a continuum of substance use disorders, which confusingly combines two distinct types of substance use problems into one continuum.

Drug abuse (or misuse) is the intentional overuse of drugs “in cases of poor judgment, self-medication, overcelebration, and other situations where drugs can be harmful or illegal.” Drug dependence is “compulsive, pathological, impaired control over drug use, leading to an inability to stop using drugs in spite of adverse consequences.” Erickson then said:

Anyone who has a drinking problem and who wants to stop is welcomed into their group [A.A.] and declares, “I’m an alcoholic.” There is no formal distinction between “abusers” and “dependents” in community A.A. meetings. . . . A proper diagnosis is not important when people are trying to find a way to stop drinking. If successful, they are much better off than before they worked the fellowship program” (p. 20).

An individual like Tina can use A.A. to stop abusing alcohol, as described by Erickson, and then turn her life around. She would identify as an “alcoholic” during the time she was an active member of A.A. But, applying A.A.’s Third Tradition (which says you are a member of A.A. if you say you are), if she no longer had the desire to stop drinking, if she does not see herself as a member of A.A., then in that sense, she’s no longer an alcoholic. Diagnostically, it would seem she was an alcohol abuser who grew out of the need to self-medicate because of the dysfunction of her early life.



The Most Addictive and Harmful Drugs

image credit: iStock

image credit: iStock

Despite the press given lately to heroin, if you were to say that it was the most addictive or harmful drug there is, you would be wrong. It is the drug most likely to result in an overdose death when used, but there is a more harmful and more addictive drug than heroin.

In The Science of Addiction, Carlton Erickson reported on research done by Anthony, Warner & Kessler in 1994 on the “dependency liability” of various drugs and classes of drugs. A dependency liability is the likelihood that a person will become dependent (addicted) upon a drug if they use it. To get a “dependency liability” a drug has to have an effect on the mesolimbic dopamine system, the reward center or pleasure pathway, of the brain.

The research of Anthony et al. suggested that the percentage of users who became dependent upon a particular drug were as follows: nicotine, 32%; heroin, 23%; cocaine, 17%; alcohol, 15%; stimulants, 11%; cannabis, 9%; sedatives (includes tranquilizers), 9%; psychedelics, 5%; inhalants, 4%.  So according to their research, nicotine is the most addictive drug. But it wasn’t the most harmful drug.

There was an interesting British study done a few years ago on the harm caused by the misuse of various drugs. 12 Keys to Recovery recently put together an inforgraphic of data from the study, which can be found here. You can also read the original study in The Lancet, after a free registration. The goal of the study was to provide guidance when making policy decisions in health, policing and social care. However, it also provided some helpful information on the harm done by drugs to both drug users and to others.

The first stage of the process was to select the harm criteria that were to be assessed. These criteria were then organized by harms to users and harms to others; and then clustered under physical, psychological and social effects. See Figure 1 in the original study, which is a chart of the criteria and how they were organized. The second stage consisted of a meeting of drug experts who scored every drug on each harm criterion; “and then assessed the relative importance of the criteria within each cluster and across clusters.” The result was a common unit of harm across all the criteria. From that data, a new analysis of relative drug harms was done. The ratings were scaled from 0 to 100.

The following chart compiles the scores for the top ten drugs according to their overall score and that for harm to others and harm to users.


Overall harm

Harm to users

Harm to others









Crack cocaine
































  • The 5 most harmful drugs overall were: alcohol, heroin, crack cocaine, meth, and cocaine.
  • The top 5 harmful drugs to others were: alcohol, heroin, crack cocaine, tobacco, and cannabis.
  • And the 5 most harmful drugs to users were: crack cocaine, heroin, meth, alcohol, and cocaine.

Alcohol earned the highest overall rating by having over twice the rating of “harm to others” than heroin, its nearest competitor.  Interestingly, it was only rated at 26, 4th, for “harm to users.” Heroin and crack cocaine were always in the top three for each of the categories: overall, to users and to others.

There was also data on the types of harm and the drugs judged to be the most responsible for that type. Heroin was considered to be the drug most responsible for four types of harm. Alcohol was most responsible for seven types. Meth was most responsible for three types, most notably intoxication and psychosis, and loss of relationships. LSD was judged to be most responsible for mood disorders, which is an interesting finding as it is being researched as a treatment for alcoholism and other psychedelics are proposed to treat mood disorders. Look for a coming blog post: “Back to the Future with Psychedelics.” See the following chart for the information on which drugs were rated as being the most responsible for the types of harm.

Types of Harm




Accidents and suicide


Related disease


Self harm; unwanted sexual activity




Mood disorders


Intoxication and psychosis


Loss of tangibles


Loss of relationships






Environmental damage


Family adversities


International damage


Economic cost




There were no real surprises here for me, except maybe the rating of LSD as the most responsible drug for mood disorders. Yet the study was useful in providing a systematic way to quantify the amount of harm done by drugs to their users and to others. I’ll close with a caveat from the discussion of the British study:

“Finally, we should note that a low score in our assessment does not mean the drug is not harmful, since all drugs can be harmful under specific circumstances.”