“I have absolutely no pleasure in the food in which I sometimes so madly indulge"

“I have absolutely no pleasure in the stimulants in which I sometimes so madly indulge. It has not been in the pursuit of pleasure that I have periled life and reputation and reason. It has been the desperate attempt to escape from torturing memories, from a sense of insupportable loneliness and a dread of some strange impending doom.” ~ Edgar Allan Poe

Addiction medicine poses particular challenges in management as recognition by the person who is addicted, or their family and friends, may be difficult or delayed. For instance, the most commonly used substance, alcohol, may not be an obvious concern to either the person or those around them, especially initially. Given the social aspect of alcohol, the problem can be more conspicuous. Ultimately, recognizing the problem is the first step toward managing it.

Diagnosis of a substance use disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the tool that both physicians and mental health professionals use to categorize mental health disorders. The current 5th edition, combines the categories of substance abuse and dependence from the 4th edition into a single disorder – substance use disorder.

It used to be divided into abuse or dependence but the latter diagnosis was often confused with addiction, whereas dependence can be a normal physiological response. In turn, a specific substance use disorder, such as alcohol, is measured on a continuum from mild to severe.

Regardless of which substance, the disorders are based on the same criteria from the National Institute on Alcohol Abuse and Alcoholism for Alcohol Use Disorder (AUD) outlined in DSM-5. The presence of at least 2 of these symptoms indicates an AUD:

  1. Alcohol is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
  3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
  4. Craving, or a strong desire or urge to use alcohol.
  5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
  7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
  8. Recurrent alcohol use in situations in which it is physically hazardous.
  9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
  10. Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of alcohol.
  11. Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal) b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

The severity of the AUD is defined as:

  • Mild: The presence of 2 to 3 symptoms
  • Moderate: The presence of 4 to 5 symptoms
  • Severe: The presence of 6 or more symptoms

Ways to recognize an alcohol use disorder

The diagnostic criteria outlined above are useful for diagnosing an alcohol use disorder, but how do you really identify a problem in either you or a loved one? The Centre for Addiction and Mental Health (CAMH) indicates 2 key signs that a person’s substance use is a problem: harmful consequences and loss of control.

Harmful Consequences:

If you have ever over-indulged in alcohol, you have likely experienced one of its most common harmful consequences – a hangover. Recently, my daughter’s middle school experienced a serious consequence of alcohol – an intoxicated man entered the school, threatened both children and staff, and subsequently went to jail. Other harmful effects include physical injuries, relationship problems, and various psychological symptoms such as depressed mood and hopelessness. If a person continues to use alcohol despite the consequences, they may have an alcohol use problem.

Loss of Control:

This is an important sign that a person may have an alcohol use problem. Loss of control can be seen as excessive use despite trying to stop, use despite the intent not to, or lack of awareness (denial) that their alcohol use is out of control. Intervening at this point may mitigate some of the more serious consequences.

Next week, we will conclude our discussion around addiction medicine by addressing approaches to the management and improvement of the well-being of the person with an addiction.

Have you ever recognized an alcohol use disorder in either yourself or someone you love? What key signs tipped you off?