The Addiction Continuum
Controlling the uncontrollable.
Posted February 13, 2023 | Reviewed by Kaja Perina
- Addiction falls along a range of severity from low to high; a high level is the strongest predictor of unsuccessful quitting.
- Trying harder to quit may lead to more attempts at quitting, but not more quitting depending on severity of addiction.
- Emotional confidence and belief in the capacity to quit is one of the most important predictors of a successful quit attempt.
- Trying to control the uncontrollable is the core of addiction.
Addiction falls along a range of severity from low to high; a high level is the strongest predictor of unsuccessful quitting.1 Researchers have also shown that there are emotional burdens that overwhelm some people who are addicted more than others. Evidence suggests, for example, that those with childhood trauma or psychiatric problems are more afflicted by addiction.
Although individuals (especially teenagers) choose to experiment with drugs such as tobacco, cocaine, heroin, or alcohol, no one chooses to become addicted. This is because most users of these substances do not even realize they are addicted until after it has already happened!
Once addicted, denial is the psychological defense used to disconnect from the problems of addiction, particularly the pain of being out of control. Once addicted, however, there is also a great deal of variability in the level of addiction. People who are addicted are not all running the same race, and some have much higher hurdles than others, although this is seldom recognized by outside observers.
Like pathogens, medications, and even experiences, individuals vary widely in their responses to drugs and alcohol. John Bowlby2 described this succinctly:
In living creatures variation of response is the rule and its explanation is often hard to fathom. Of all those who contract poliomyelitis less than 1 percent develop paralysis, and only a fraction of 1 percent remain crippled.
Why one person should respond one way and another another remains obscure. To argue that, because 99 percent recover, polio is a harmless infection would obviously be absurd.
In the same way, many people, if not most, who are mildly or even moderately addicted to tobacco, alcohol, and even “hard drugs” quit on their own without professional assistance or outside help. However, at the other end of the addiction continuum are those with severe addiction who exhibit a different disease process. For these people coping with addiction, the drug often fits their brains like a specially designed lock and key. These are the “hard-to-fathom” people with addiction and often require clinical help.
The most widely used measures of addiction now recognize the importance of the degree of addiction.3,4,5 For example, the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association now assesses substance use disorders based on the number of problems observed:
Two to three indicate a mild disorder; Four to five, a moderate disorder; Six or more, a severe disorder.
A second example is The Fagerstrom Test for Nicotine Dependence (FTND) which is the assessment measure most widely used by nicotine and tobacco researchers. FTND is the best predictor of how difficult a smoker will find it to quit. It has also long recognized the importance of the degree of addiction in its classification system:
Zero to two is Very low; three to four is Low; Five is Moderate; Six to seven is High; Eight to 10 is Very high
Mixing up mild or moderate addiction with severe addiction is a serious conceptual mistake.6 Some individuals clearly struggle much more than others to overcome addiction. This can make it difficult to interpret research results when mildly or moderately addicted smokers are combined with severely addicted smokers in the same study. Comparing a person with a mild addiction to one who is severely addicted would be like comparing a runner wearing a light backpack to a runner carrying a sack of cement blocks.
Over time, carrying the heavier burden leads to demoralization. It undermines emotional confidence in those with an addiction, and belief in their capacity to quit, a belief that is also one of the most important predictors of a successful quit attempt.7
In my experience, emotional confidence is an intangible capacity that produces very tangible results. It includes a belief that one can tackle life's problems, including the problem of being able to quit addictive substances. Severe addiction, on the other hand, erodes a pre-existing sense of emotional confidence and active agency so they can choose to be drug-free.
Controlling the Uncontrollable
Ivan is a long-time smoker who spent much of his life either falling off the “achievement treadmill” or fearing its unrelenting and escalating demands. Based on his experience with another addiction, he says that when you are addicted, you think you have control but don’t. “You don’t realize,” he says, “that addiction is a disease that tells you ‘you don’t have a disease.’”
The neuroscience of addiction shows a disconnect in addicts from their rational selves.8 Serious addiction wears away neural connections in their brains that grow over the years and are a developmentally normal part of turning an adolescent into a mature adult. The National Institute on Drug Abuse website9 states:
The initial decision to take drugs is typically voluntary. However, with continued use, a person’s ability to exert self-control can become seriously impaired; this impairment in self-control is the hallmark of addiction.
Nora Volkow, the director of the National Institute on Drug Abuse (NIDA), compares the impaired self-control in addiction to “driving a car without brakes.” Without brakes, how can a driver match their intentions with their outcomes? Who would be responsible for the damage if you were driving such a car?
Just try harder?
The tobacco industry, at least in court, does not recognize severe cigarette addiction as a possibility in any given individual case, much less a reality. Smokers aren’t addicted, the tobacco defendants argue, and they haven’t lost control, but rather they smoke by choice and can quit any time they choose.10,11
Unfortunately, according to the latest science, trying harder may lead to more attempts at quitting, but not more quitting. In fact, trying harder can also bring on a demoralizing failure syndrome and make future quitting success even less likely.12
Many people with an addiction, of course, do eventually quit. That is often, however, after paying a very high price for their addiction. Here again, lumping light to moderate addiction in with heavy addiction glosses over a painful reality.
This does not argue that people who are addicted have no agency and no personal responsibility to overcome and recover from their addiction. But the research does help explain the challenges involved and why many people who are addicted require outside help and support rather than just relying on “willpower” alone.
The hardest lesson for a person with an addiction to learn is there is no middle ground. Trying to control the uncontrollable is the core of addiction. Recognizing powerlessness over your drug and letting go of addiction is core to recovery. You are either on the bus or off the bus. If you don’t use your drug, the wound will heal, and the addiction will go into cold storage where it belongs. It only comes back out when you take that drink, drug, or smoke.
Keith Richards of the Rolling Stones (13) describes the process this way in his memoir, “Life:”
“I was bigheaded in that I thought I could control heroin. I thought I could take it or leave it. But it is far more seductive than you think, because you can take it or leave it for a while, but every time you try and leave it, it gets a little harder... The taking of it is easy, the leaving of it hard... You’ve got to think about that and say, hey, there’s one simple way of never being in that position. Don’t take it."
Or, as Brendan Behan, the great Irish writer, famously said, “One drink is too many for me and a thousand not enough.”
Vangeli, E., Stapleton, J., Smit, ES., Borland, R. West, R. (2011) Predictors of attempts to stop smoking and their success in adult general population samples: a systematic review. Addiction, 106, 2110- 2121
Bowlby, John (1973). Attachment and Loss Volume II. Basic Books. http://wwwbasicbooks.com. Page 5.
Fagerstrom K, Schneider N: Measuring nicotine dependence: a review of the Fagerstrom Tolerance Questionnaire. J Behav Med. 1989; 12: 159 182.
Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom K. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction 1991;86:1119-1127.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
David Wilson, J. Melanie Wakefield, Neville Owen, and Lyn Roberts (1992). Characteristics of Heavy Smokers. Preventive Medicine 21, 311-319.
Peter S. Hendricks, Kevin L. Delucchi, and Sharon M. Hall. Mechanisms of change in extended cognitive behavioral treatment for tobacco dependence. Drug and Alcohol Dependence 109 (2010) 114–119
Fowler JS, Volkow ND, Kassed CA, Chang L. Imaging the addicted human brain. Sci Pract Perspect 3(2):4-16, 2007.
Richards, Keith. Life. Weidenfeld & Nicolson, 2011