who uses drugs just about everybody use of psychoactive substances is incredibly common with over 90 of people in the united states taking at least one on a regular basis while many people are able to use psychoactive substances without negative effects on their health a significant minority of people will develop problems as a result of substance use people can experience problems related to substances in three ways intoxication withdrawal and addiction these three things are closely related but they're ultimately separate conditions so it's important to get them straight from the get-go intoxication is an acute state of being under the influence of a psychoactive substance with the specific mix of signs and symptoms associated with each substance being known as its toxodrome withdrawal is also an acute state but this time it involves the physiological and psychological effects of suddenly stopping a substance which are often the opposite of what you would see in a state of intoxication from that same substance in contrast to intoxication withdrawal addiction is a chronic condition characterized by repeatedly using a specific substance or engaging in a behavior despite suffering negative consequences as a result when this involves drugs it is known as a substance use disorder it's worth pointing out that while intoxication and addiction are closely related concepts with addiction typically involving repeated episodes of intoxication from a diagnostic perspective they should be considered separate diagnoses as not everyone who is intoxicated with a particular substance is necessarily addicted to it and not everyone who has an addiction is currently intoxicated the dsm-5 lists 11 distinct criteria for substance use disorders and other forms of addiction which you can remember using the phrase time to cut down pal the two will remind you that two or more of these criteria are required for diagnosis the rest of the phrase will remind you that patients spend a lot of time using or obtaining the substance experience cravings or urges to continue using are unable to cut down on using the substance even after repeated attempts experience tolerance to the effects of the substance so that they need more and more to get the same effect can have dangerous results of use affect other people through their use resulting in interpersonal and social problems experience withdrawal when they stop using the substance end up neglecting major roles and responsibilities such as work or family have physical or psychological problems that have been created or made worse by substance use have given up activities like socializing our hobbies due to excessive use and finally have used larger amounts of the substance or for longer than they initially wanted however these 11 criteria are a lot to remember and you can recognize the overall pattern of addiction using just three things we'll refer to these as the three reapers repeated use of positive reinforcers despite negative repercussions if those words describe the pattern of someone's behavior then you can diagnose addiction let's go ahead and look at each of the three reapers more closely the first is repeated use addiction naturally involves doing something repeatedly this can involve use of substances which we've talked about or it can involve specific items or behaviors such as gambling and slot machines next is positive reinforcers the specific substances and behaviors in addiction must be positively reinforcing as a reminder from general psychology a positive reinforcer is something that is given which increases the frequency of your behavior often by giving a sense of pleasure for example giving a child a piece of candy for getting a good grade is using the candy as a positive reinforcer finally we have the negative repercussions these consequences of use such as losing a job alienating family and friends getting into legal trouble or jeopardizing one's health are a key part of the equation for addiction and addiction cannot be diagnosed in its absence none of these components on their own are sufficient to diagnose addiction even any two of them combined is not enough it's only when all three components combine that the specific state of a diction emerges let's see what happens when we remove any one of these components from the equation first is repeated use of positive reinforcers but no negative repercussions repeatedly using positive reinforcers is not a problem as long as there are no repercussions from it technically speaking things like eating an apple a day could fall under the banner of repeated use of positive reinforcers but because they caused no negative consequences they would not meet any reasonable definition of addiction next is use of positive reinforcers with negative percussions but without repeated use this is slightly more problematic as even a one-time exposure to specific substances can cause damage however if it's not repeated then by definition it cannot be an addiction for example someone who tries heroin once could potentially end up in the hospital if they overdose but if they learn from the experience and never go new heroin again it would not make sense to call this an addiction finally repeated use of things that are not positively reinforcing despite negative consequences is the thing that's probably most tempting to call an addiction but it's more accurately characterized as a compulsion we talk more about compulsions in the video on ocd but briefly a compulsion is when someone does a behavior repeatedly to get away from a negative feeling rather than try to get a positive feeling for example someone with a fear of germs may wash their hands repeatedly if they have ocd they may do so so much that they spend eight hours a day on this activity they may even suffer consequences as a result like an inability to work or physical injuries to their hands from rubbing the skin raw however because the behavior is negatively reinforcing that is they are washing their hands because this takes away a feeling of distress and anxiety rather than because hand washing gives them a feeling of pleasure it's not an addiction it's a compulsion while differentiating between compulsive and addictive behavior may seem like just semantics from a clinical standpoint addictions and compulsions require very different approaches to treatment this makes such a distinction crucial so make sure you understand the difference between addictions and compulsions as well as positive reinforcers versus negative reinforcers before moving on let's introduce a few tools that you can use in clinical practice to help diagnose addiction first you can gather a complete substance history using the mnemonic trapped which stands for treatment history route of administration amount used pattern of use prior abstinence effects of use both positive and negative and duration of use next it can be helpful to have a list of all the major substances that can lead to addiction let's use the mnemonic here as well picture someone who is suffering from an uncontrolled addiction his friends stage an intervention to get him into rehab however they realize that now there is no one to take care of his dog the friends look at each other with nobody quite yet willing to step up and volunteer to care for the dog the question on everyone's mind naturally is this guy's having trouble but can his dog behave this phrase can remind you of the major classes of addictions to remember cannabis alcohol nicotine hallucinogens inhalants stimulants depressants opioids gambling and other behavioral addictions now that we know how to recognize and diagnose addiction in clinical settings let's look at the data behind this disorder including who gets it what happens once they get it and what forms of treatment are effective more than any of the conditions we've talked about in other videos so far addiction is a highly variable disorder that is dependent upon multiple factors most important among these is the specific substance involved as tobacco use disorder differs from alcohol use disorder which differs from opioid use disorder and so on nevertheless despite this wide variation a few consistent themes do emerge when looking at addiction across the lifespan taken as a whole addiction is one of the most common psychiatric conditions with a lifetime prevalence of around 10 percent of people in the united states this gives it a relatively high base rate in the population making it prone to under diagnosis rather than over diagnosis the risk of under diagnosis is compounded further by the fact that many people will attempt to minimize or hide addictive behaviors from their healthcare providers due to the stigma and prejudice that often occur most addictions begin during adolescence or early adulthood with some arguing that substance use is in many cases a pediatric disease however in other cases addictive behavior can continue on into adulthood or older age as well in systematic studies men and women appear to be equally vulnerable to addiction however in clinical settings men are treated for addictive disorders more than twice as often as women this difference in gender ratio is likely due to the fact that men tend to use illegal substances more often than women who may be more prone to addictions involving legal substances such as alcohol or benzodiazepines that are less likely to come to legal or clinical attention even if they can be just as harmful addiction is frequently comorbid with other mental disorders in fact up to half of all people with a mental disorder will meet lifetime criteria for a substance use disorder and vice versa the presence of both an addiction and a mental disorder known as dual diagnosis worsens the prognosis for both types of disorders considerably this makes screening for addictive behaviors important for every patient presenting with mental health concerns like other aspects of addiction the prognosis for addictive behaviors is highly variable with the strongest predictor of prognosis being the specific substance involved substances differ significantly in regard to how addictive they are with some being incredibly addictive and others having only minimal addictive potential for example less than 10 percent of people who try cannabis become dependent on it but this increases to 15 for cocaine 25 for heroin and more than 65 for nicotine the inherent addictiveness of the substance also plays a large role in how easy it is to quit with cannabis use disorder taking on average five years to enter remission while tobacco's disorder can take up to 25 years taken as a whole addiction is one of the largest problems facing society today and it's estimated that up to 20 of all deaths in the united states are related to disorder in some form addiction exacts further costs on society in terms of high medical costs broken families and increased rates of accidents overdoses suicide and violence despite these costs barely over 10 percent of people struggling with addiction receive high quality treatment like its prognosis treatment for addiction is also highly variable for some people quitting an addiction is as simple as deciding to stop for others the initial desire to quit is followed by decades of bouncing between abstinence and relapses for still others the desire to quit is never there at all because of this variability statistics on the efficacy of addiction treatment are not very informative until they are broken down by the specific substances involved as a general process treatment of addiction involves facilitating the initial transition to achieving sobriety known as detoxification or detox some substances don't have a dangerous withdrawal state so detox is as easy as just stopping for other substances like alcohol however detoxification may require admission to a medical facility for intensive monitoring to avoid the potentially harmful or even life-threatening effects of withdrawal detoxification is followed by treatment focused on maintaining sobriety which is known as rehabilitation or rehab rehabilitation can be accomplished using a variety of treatment modalities individual and group therapy can teach skills to decrease cravings and impulsivity for certain substances such as alcohol and opioids medications can play a positive role by preventing withdrawal reducing cravings and blocking the positive effects of the drug however for other substances like methamphetamine or cocaine no medications have yet proven to be helpful of course even beginning the process of detoxification and rehabilitation requires that the patient is motivated for treatment however in many cases addiction can significantly impair one's insight that their use is problematic even in the face of evidence to the contrary in fact it's estimated that less than 20 percent of people struggling with addiction will seek treatment on their own to address this a specific counseling technique known as motivational interviewing can be used to increase a patient's motivation to treat their addiction rather than approaching all patients with addiction in the same way motivational interviewing encourages providers to identify the stage of change that the patient is in and use specific techniques that are appropriate for that stage by matching interventions to the stage of change patients are more likely to quit motivational interviewing is very effective with large effects compared to treatment as usual relapses are common in addiction treatment and relapses should not be seen as failure either on the part of the patient the provider or the treatment itself in fact placing too strong of an emphasis on sobriety as the only endpoint of treatment can sometimes be counterproductive instead of merely eliminating the addiction it's more helpful to replace it with other activities that the patient finds satisfying for many people engaging in meaningful work hobbies or social activities can help to prevent the sense of boredom or emptiness that often leads to relapses some evidence suggests that social support is one of the most important if not the most important predictor of successful treatment because of this it's helpful to think that the opposite of addiction is not sobriety but connection in community thanks for watching there's more to say about addiction than just that but this video should help to serve as a jumping off point for learning about the different substances and behaviors that can turn into an addiction if you're interested in learning more i have a playlist on youtube with videos covering recreational substances in more detail you can also order my books memorable psychopharmacology and memorable psychiatry on amazon links to both books are in the description below thanks again for watching bye for now