Don’t You Know about Tolerance and Withdrawal aka Physical Dependence?

Yes, I do know about tolerance and withdrawal symptoms, or what is sometimes referred to as physical addiction. Unfortunately, I know about it all too well, as I went through it too many times, both unassisted and under medical supervision in the detox unit of some hospitals, long ago when I had a substance use problem.

I do not deny that these symptoms happen, nor do I ever deny the danger that withdrawal from alcohol and some prescription drugs poses. I will say now, as I say every time I mention this topic, that if you think you may need professional help with withdrawal symptoms, go to your doctor or local hospital and get checked out. There is good help for this issue. By the way, here’s a little info on which drugs can be dangerous to withdraw from: Alcohol, benzos, and opiates – Withdrawal that might kill you!

And now, moving on – I’m sorry to say, but what we know of today as “addiction” really has little to do with physical tolerance and withdrawal. Those things are easily addressed by medicine, and furthermore, not all substances or any of the so-called “process addictions” (such as gambling, sex, overeating, shopping, videogame playing, porn-watching, etc) cause physical withdrawal symptoms. It’s not even close!

People often bring up “physical addiction” as if it’s proof that addiction is a disease, or that substance users can’t control themselves. But since it’s not involved in all addictions, and all addictions look the same, then it’s probably not a good explanation for addiction – it’s certainly not a conceptual common denominator. Furthermore, curing physical withdrawal symptoms doesn’t necessarily stop people from using. They get over the withdrawal, and then they go back to using again. Just ask the staff at any of the revolving door detox clinics for proof of that. Occasionally, there are people who never realize they had a physical addiction, and some just get over and feel sick for a few days, while others may detoxify once and move along with their lives knowing they won’t use so much drugs or alcohol to get to that point again. These are not the folks that people are talking about when they speak of addiction though – these people don’t exhibit most of the other behaviors associated with “addiction”.

Addiction theorists recognized this, and they defined addiction in ways that don’t have to include physical withdrawal symptoms. Again, remember that if physical withdrawal and tolerance symptoms are the defining feature of addiction, then they can be handled very easily with 3 to 10 days of medical care. This doesn’t offer any explanation for the people who keep going back, or who refuse detoxification help, or worse, those who switch to cocaine and other drugs once their opiate withdrawal symptoms are covered by the use of methadone or suboxone.

The leaders of the addiction as a disease movement regularly dismiss physical addiction as having little to do with what they call addiction. Don’t take my word for it, listen to Alan Leshner, former head of the NIDA, and the first big pusher of the currently popular brain disease theory of addiction, in a 1998 interview with PBS’s Bill Moyers:

People have a lot of confusion about what addiction actually is and what matters in it. I’m very frequently asked, “Is this drug addicting? Is this drug more addicting then that other drug?” and what people want to hear is whether or not it causes physical addiction. That means when you stop using it you go through these dramatic withdrawal symptoms we’ve all seen in the movies and on television like shivering, gastrointestinal problems, and cold sweats, but the truth is that doesn’t really matter in addiction. What really matters is that the drug has become central to the addict’s life. The physical symptoms can be managed relatively easily, and in fact for many drugs like crack and methamphetamine, there are no dramatic physical withdrawal symptoms. Two of the most addicting substances ever known to humankind really have very few physical withdrawal symptoms associated with stopping their use.

Although I don’t happen to agree with Leshner on most points, on this one point he is correct. The phenomenon we know as addiction actually has very little to do with physical tolerance and withdrawal. Again, it can easily be handled medically, and is the only truly valuable thing the medical world has to offer people with drug and alcohol problems. But, it doesn’t address choices. It doesn’t address the long-term problem – that is in people’s own hands – although Leshner really doesn’t think so. Around the time of this interview, he was pushing the brain disease theory hard, and most of what he said in that same interview is the standard position from the authorities speaking on the topic today. Leshner went on to present the brain disease view which holds that repeated substance use changes the brain until the user becomes an “addict”, loses free-will, and is unable to make the choice to stop using drugs and alcohol. I will offer longer quote from the transcript further down the page, so you might see what that’s all about, but for now, let’s stay on tolerance and withdrawal.

The National Institute on Drug Abuse has an answer on this topic as well (on their website as of Feb 6 2013):

Is there a difference between physical dependence and addiction?

Yes. Addiction—or compulsive drug use despite harmful consequences—is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal. The latter reflect physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). Physical dependence can happen with the chronic use of many drugs—including many prescription drugs, even if taken as instructed. Thus, physical dependence in and of itself does not constitute addiction, but it often accompanies addiction. This distinction can be dificult to discern, particularly with prescribed pain medications, for which the need for increasing dosages can represent tolerance or a worsening underlying problem, as opposed to the beginning of abuse or addiction.

I hope that settles the idea that I’m not coming out of left field when I downplay the significance of tolerance and withdrawal. It’s actually almost the only thing that I agree with the authorities on about addiction. But doesn’t withdrawal make you use?

Does Withdrawal Force People To Continue To Use Substances?

No, it actually does not. Most of withdrawal is simply discomfort. What happens when someone uses large amounts of substances frequently and regularly is that their bedy becomes acclimated to the presence of the substance. As the substance leaves the body and is not replaced, the body now has to struggle to find homeostasis without the presence of the substance. Things go haywire, this causes discomfort, but it doesn’t force anyone to use. People can and do go through withdrawal cold turkey – that is, with no help, and no one restricting them from giving up and getting high, all of the time. Again, this is not recommended, see above, but it’s just a fact that people do it. Physical withdrawal does not rob you of your free-will, although it may rob you of your life should you have a seizure from it.

Physical withdrawal, when not accompanied by life threatening seizures or DT’s, makes you extremely uncomfortable. Sometimes people choose to address the discomfort in the short-term by procuring and using more of the substance, and sometimes they choose the path of going through the discomfort, and weathering the pain so that they may be free of withdrawal symptoms in the long-term. But either way, they are choosing. And again, sometimes they choose to get medical help to relieve the discomfort of withdrawal and ensure safety while going through detoxification.

There is one more important thing that I have to say about withdrawal. The mother of my childhood friend told me about her first husband, who was a veteran and a heavy alcohol user who had been through withdrawal many times, and regularly experienced seizures in the process. He needed to be in the hospital for the process – which he did many times, and went back to heavy drinking every time. The particular hospital he went to at the time used small amounts of alcohol in the detoxification process. The last time, he decided to swear off alcohol altogether, knowing that detoxifying without it could kill him. Everyone involved warned that it could kill him. Yet he refused to even ingest the small amounts of alcohol the hospital used in the detox process. He went into seizures and died – but he chose this fate. Withdrawal does not rob you of your ability to choose whether you use substances or not.

Tolerance

Tolerance, as the NIDA states above, is when “the body adapts to the drug, requiring more of it to achieve a certain effect”. The effect in question, is a high or drunk feeling. Tolerance does not rob people of the ability to choose to use substances or not, nor does it rob them of the ability to choose how much they will use. What it does, is to create a conditional situation in which if you want to achieve X feeling, then you will have to use X amount of substance to achieve that feeling. It is conditional upon your wants. You freely choose to use the larger amounts of substances. Tolerance may be inconvenient, but it does not create a situation in which anyone is powerless or has lost the ability to choose.

So yes, I do know about tolerance and withdrawal, but no, I don’t think they’re very relevant to the wider topic of addiction. There is a difference between physical dependence (tolerance and withdrawal) and what’s known as “addiction” as the NIDA succinctly states in the quote above.

The Brain Disease “Highjacked Free Will Model” of today

I don’t spend time on this blog worrying about physical dependence symptoms, because the medical system is set up to appropriately deal with those. Below you will see the theory that rules the treatment industry today. It is the theory I spend my time fighting on this blog. Here’s a bigger excerpt from the interview with Alan Leshner, former head of the NIDA, which I mentioned above, which should acquaint you with the current view that I am arguing against (link to full transcript):

Leshner: Like most people in this country, I believed that addiction was just a lot of drug use. You use drugs and then you become addicted and you could move back to being just a drug user. And, you could just stop any time if you were really serious. A lot of people felt that way, especially about cigarette smoking, but the truth is addiction is not a voluntary circumstance. It’s not a voluntary behavior. It’s more than just a lot of drug use. It’s actually a different state. It’s hard for people to understand that, but if you take drugs to the point of addiction, functionally you move into a different state. A state of compulsive, uncontrollable drug use.

Moyers: So the addict has no choice?

Leshner: That’s right.

Moyers: But the first time is a choice, surely?

Leshner: Yes. I think what is frequently confusing is that although initial drug use is a voluntary behavior, at some point when you move over into addiction, it’s no longer voluntary. It’s a change. A user has a choice about that next drug, but an addict does not.

Moyers: So what does this say about free will?

Leshner: Most people are able to control their initial drug use. They’re able to exert their will over it, but once they are addicted, it’s a myth that many people just decide to break their addiction. Very few people are able to just say, I’m done, I’m finished. Most people need treatment. Why do they need treatment? They need treatment to deal with the cravings. They need help to deal with the compulsive, uncontrollable drug use.

Moyers: So let’s explore the scientific grounding for that. What, scientifically, is the essence of addiction?

Leshner: Well, each of those words I’ve just used is an important part of the definition of addiction. Compulsive and uncontrollable means that you can’t exert your will over it. And using becomes the center, the essence of the person’s life. People have a lot of confusion about what addiction actually is and what matters in it. I’m very frequently asked, “Is this drug addicting? Is this drug more addicting then that other drug?” and what people want to hear is whether or not it causes physical addiction. That means when you stop using it you go through these dramatic withdrawal symptoms we’ve all seen in the movies and on television like shivering, gastrointestinal problems, and cold sweats, but the truth is that doesn’t really matter in addiction. What really matters is that the drug has become central to the addict’s life. The physical symptoms can be managed relatively easily, and in fact for many drugs like crack and methamphetamine, there are no dramatic physical withdrawal symptoms. Two of the most addicting substances ever known to humankind really have very few physical withdrawal symptoms associated with stopping their use. On the other hand, crack and methamphetamine produce unbelievable craving. Unbelievable compulsion to use them, and that’s really the essence of addiction. The psychological part, not that dramatic, cinematic withdrawal seen with alcohol or heroin.

Moyers: From the scientific perspective, what do we mean when we say someone is an addict?

Leshner: You are an addict because your brain has been changed by drugs. You’re in a state where the drug has totally taken over your being.

Moyers: Would you call it a disease?

Leshner: Yes. Addiction is a brain disease. It’s a chronic, relapsing disease. It’s a disease because it’s a result of drugs actually changing the brain in fundamental and long lasting ways, and it’s a chronic, relapsing disease because, sadly but typically, people don’t have only one one episode of addiction. They have repeat episodes. Even if they’re treated successfully, often there will be occasional relapses. We need to conceptualize this disease more in the same way that you would think about diabetes — it doesn’t stop with one episode of treatment.

My answer to the brain disease theory can be found here: Addiction Is NOT a Brain Disease, It is a Choice.