In the early stage of addiction, a person has some awareness of seeking relief from discomfort. It may simply be an awareness of feeling stressed, anxious, or self-conscious. The following
is a typical progression of feelings and responses in the early stage of addiction:

In the middle stage of addiction, the unsafe feeling is not experienced as a thought. It is experienced only as danger or discomfort. The person knows that immediate relief comes with use of the substance. The following is the typical progression and recurring pattern in the middle stage of addiction:

People in the depths of addiction rarely talk about feeling high. The need is more frequently described as a desire to feel “normal.” The impulse is to escape a feeling that is intolerable. At the late stage of addiction, physical instability replaces the emotional vulnerability. The addiction has come full circle. What was initially used as an answer to unsafe feelings has become the source of unsafe feelings. Mental instability and confusion, mental terrors and paranoia, and hallucinations or feelings of unreality are all possible results of the neurological damage from the substances. The following is the recurring pattern of the late stage of addiction:

In the medical model, the emphasis is on the physiologic effect of the substance itself. The body’s tolerance for the drug leads to the need for greater and greater amounts to achieve the desired effect, which results in addiction. The absence of the drug leads to cravings, and then to a withdrawal or abstinence syndrome characterized by symptoms such as fever, nausea, seizures, chills, hallucinations, and delirium tremens. In this model, the progression toward addiction is a property of the drug’s effect. Those in the media often demonstrate this attitude toward addiction when they describe a celebrity who has attended a 30-day alcohol or drug rehabilitation program as “free” of drugs. In fact, 30 days is just the beginning of treatment. Most drugs of abuse directly or indirectly target the brain’s reward system by flooding the circuit with dopamine. Dopamine is a neurotransmitter present in regions of the brain that regulate movement, emotion, cognition, motivation, and feelings of pleasure. The overstimulation of this system, which rewards our natural behaviors, produces the euphoric effects sought by people who abuse drugs and teaches them to repeat the behavior.

Research in the area of genetics has focused primarily on alcoholism. Much research points to strong patterns of alcoholism within families. People with close relatives who are alcoholic are at a greater risk for alcoholism by three to four times. The closer the genetic tie and the higher the number of affected relatives, the greater the risk. Adoption studies show a three times greater incidence of alcoholism in children of alcoholics, even if they have been raised in a nonalcoholic family.¹⁵ There is evidence that alcohol and tobacco both act on a part of the brain that is involved in rewards, emotions, memory, and thinking. Both alcohol and tobacco have an impact on the neurons that release dopamine binding at the receptor sites. The presence of a common mechanism of action may shed light
on the interplay of alcohol and tobacco addiction.¹⁶ The possibility that genetics play a role in a greater vulnerability to these addictions in some individuals fits in with the idea that genetically based differences in biochemistry are a factor in being susceptible to addiction.

The emerging field of epigenetics is advancing our understanding of the role of genetics in addictions. Epigenetics is the study of changes in the regulation of gene expression and gene activity that are not dependent on DNA sequence. The field of epigenetics refers to the science that studies how the development, functioning, and evolution of biological systems are influenced by forces operating outside the DNA sequence, such as environmental and energetic influences. Studies indicate that there is an alteration in gene expression by repeated substance abuse that can produce lasting changes in gene expression within the reward pathways of the brain. Epigenetic mechanisms are providing insight into how drugs alter genetic expression. Insights into the long-lasting adaptations that underlie the chronic relapsing nature of addiction are on the edge of research and have implications for new treatments.¹⁷

The frequent appearance of addictions within the families of addicts may indicate that substance abuse can be a learned behavior. In effect, children learn by daily close observation of the adults in their environment that conflicts and stressors are to be dealt with using drugs and alcohol. Children usually do not have a conscious awareness of this message. They may not have a full understanding of the role that addiction played in their home life until they reach adulthood and begin their own recovery. It is important to acknowledge that many other people who have grown up in such an environment are aware of the damage done and make a conscious choice to abstain from alcohol or other substances.

According to the self-medication model, the addict has an underlying psychiatric disorder and is, in effect, self-prescribing to alleviate symptoms. For example, in a Canadian survey of more than 14,000 residents ages 18 to 76 years, there was a significantly greater use of alcohol among those who were suffering from depression.¹⁸ Addicts characteristically have tried a variety of substances and have found that they have a strong preference for a particular category of drug and drug effect. It is not unusual for addicts to say that their preferred substance makes them feel “normal.”

Emerging from Freud’s conceptualization of psychosexual stages of development, addiction appears to be a fixation at the oral stage of development. In the psychosexual, psychoanalytic model, an infant or child whose basic needs are unmet becomes focused on seeking gratification of those unmet needs. Emotional development becomes fixated at the age of this early trauma.^14p23

Oral gratification is the most basic need of the infant, as seen in the way an infant receives nourishment and pleasure through sucking. In adulthood, people continue to seek comfort and pleasure from gratification of oral needs through behaviors such as eating, smoking, talking, touching their mouth, and various chewing behaviors. Whereas healthy human activity includes some limited seeking of oral gratification, the addict is fixated at this developmental phase. The compelling need for comfort derived from oral gratification then becomes focused on the consuming of substances.

Also emerging from Freudian theory, ego psychology suggests that when an infant’s or child’s environment does not provide an adequate degree of nurturance and acknowledgment, the child grows into adulthood with an impaired sense of self. This results in feelings of emptiness and hypersensitivity that lead to a selfabsorbed and narcissistic relationship with the world. The addict’s behaviors are then seen as self-soothing attempts to relieve the basic feelings of emptiness.^14p24

Our culture may be a contributing factor in addiction because it teaches us to seek materialistic answers outside ourselves to experience well-being. People in the United States are confronted with a relentless message of consumerism and
quick fixes. This then leads to a society of consumers with impulse disorders who seek instant gratification and believe that there is a pill for every ill.

In recent years, media advertising has bombarded people with messages about both over-the-counter (OTC) and prescription medications. In light of this, it is interesting to note the following information. The total number of drug-related emergency department (ED) visits increased 81% from 2004 (2.5 million) to 2009 (4.6 million). ED visits involving nonmedical use of pharmaceuticals increased 98.4% over the same period, from 627,291 visits to 1,244,679. The largest pharmaceutical increases were observed for oxycodone products (242.2% increase), alprazolam (148.3% increase), and hydrocodone products (124.5% increase). Among ED visits involving illicit drugs, only those involving Ecstasy increased more than 100% from 2004 to 2009 (123.2% increase). For patients aged 20 years or younger, ED visits resulting from nonmedical use of pharmaceuticals increased 45.4% between 2004 and 2009 (116,644 and 169,589 visits, respectively). Among patients aged 21 years or older, there was an increase of 111.0%.¹⁹,²⁰

There is also an increased awareness of the abuse of substances among athletes. The primary abuse is of “recreational” drugs such as cocaine and alcohol. There is a significant increase in the use of performance-enhancing (i.e., ergogenic) drugs such as amphetamines, as well as “designer” stimulants such as Ecstasy (i.e., methylenedioxymethamphetamine, or MDMA). Two readily available drugs that are amphetamine mimicking when taken in high doses are pseudoephedrine, available in cold medications, and ephedrine marketed as a dietary supplement. Anabolic steroids and other drugs are taken in an attempt to enhance performance and build muscle mass. Additionally, human growth hormone (HGH) precursors are marketed in various forms, promising increased muscle mass, increased energy, and performance enhancement.²¹ This is another situation in which to consider the role of media and other cultural influences in the patterns of abuse and choice of substances.

Alcoholics and other addicts are seen having different characters and morals from nonaddicts in the character defect model of AA. Although the idea of a “moral” defect is not used extensively in addiction treatment settings, it is a concept that pervades the AA literature. A person in recovery may explain his or her “character defect” as the reason for his or her difficulty in making behavioral and attitudinal changes.

Derived from learning theory and the principles of hypnosis, the trance model proposes that the memory of the intense pleasure experienced in response to a substance is never forgotten. The experience is recorded by the pleasure-seeking, pain-avoiding part of the brain and remains, in effect, a deeply planted, posthypnotic suggestion that repeatedly seeks expression. The addict essentially falls in love with the feelings that the addictive behaviors produce. The AA literature speaks to this idea in stating, “The urge to repeat the experience of becoming ‘high’ is so strong that we will forsake … our responsibilities and values, … our families, our jobs, our personal welfare, our respect, and our integrity … to satisfy the urge.”²²

According to the transpersonal intoxication model, the desire to break free of a limited, time-bound, socially defined sense of self as well as the desire to expand consciousness are the driving forces in addiction. Many people have experimented with lysergic acid diethylamide (LSD), marijuana, psilocybin mushrooms, peyote cactus, and other psychedelic substances and have experienced expanded states of awareness that have resulted in spiritual and creative breakthroughs. The challenge then is to integrate these insights into daily life.

There is a significant degree of substance abuse and addiction among artists, writers, performers, and musicians. This model suggests that their desire to break free of mental and emotional limitations is at the heart of their substance use. One part of the artistic process is about finding a way to express the most intimate, subtle, and spiritual aspects of human experience. Artists often mention a fear of losing this creative capacity—of becoming “ordinary” —as they enter recovery. They have given the creative power to the substance rather than
trusting that it resides within themselves. The ability to practice their creative endeavor while sober then becomes a major milestone in the recovery process.

In the transpersonal-existential model, the human condition is such that humans are inherently anxious because they have knowledge of their mortality. Everyone finds ways to bypass or deny this awareness of reality. Becker, in a book authored when he was dying of cancer, wrote that a person

This heightened awareness and sensitivity to the human condition can lead to addiction as a solution to the existential pain.