Often, substance use is viewed from a binary perspective. You either use or you do not. Therefore, many treatment approaches treat “users” with the goal of “not using.” However, any time we attempt to view only the ends of a continuum, we are subsequently ignoring the complexities and experiences that are happening in the middle.
Referring to someone as an addict does not really tell you anything. The word addiction does not make any appearances in European or United States diagnostic manuals of medical and mental health disorders. The word addict also does not indicate what sort of relationship or problems someone has with a particular substance.
Our society shows a little more flexibility in our view of substances with regards to alcohol. If someone calls themselves a social drinker or says they need a margarita, we accept this. Unless, they have had previous issues with alcohol, then we call them an alcoholic on the verge of relapse. (Note: alcoholic is also not a proper term).
When we see our use through the lens of a continuum, we can be clearer about what our substance use looks like. When we can decide where on the continuum we want to be, we tend to be more engaged in our treatment. Certainly, not everyone is able to moderate their use. However, it is also true that not everyone with problematic substance use patterns will inevitably progress into worsening use.
This sh*t is complex.
Continuum of substance use
The idea of the continuum is that someone can use a substance in different ways. Their use may get worse, but it may not. A continuum is not an inherent linear progression. Someone may use more one than one substance, and those substances may be on different places on the continuum as well. Let’s explore this continuum I keep prattling on about. There are a couple of different versions out there, but I prefer the versions from Denning & Little who practice harm reduction psychotherapy.
0. No use.
1. Experimentation. You have tried a psychoactive substance, or maybe more than one.
2. Social/Recreational. You are using a drug for a particular effect, but with no pattern.
3. Habituation. A pattern to your use has emerged, but you have not experienced problems yet. For example, Friday night happy hour or cocaine on the weekends.
4. Abuse. You are using despite negative consequences. Maybe your use was impacting your work and you lost your job, but you are continuing to use.
5. Dependence/Addiction. Now there is a strong compulsion to use, your tolerance has been built up and you might experience withdrawal when you do not use. This is formally referred to as a substance use disorder or alcohol use disorder.
6. Persistent addiction. We might call this “chaotic” use. Often there is frequent relapse and you might suffer emotional, mental, physical, fiscal, or legal harms.
All use is not created equal
Harm reduction does not consider all illegal substance use to be abuse. This is an important distinction. Just like a person might be a social drinker, in harm reduction it is accepted that some people can use illicit substances in non-problematic ways.
So, let’s say Mr. X uses alcohol, marijuana, cocaine, and Vicodin. We should not assume that Mr. X has the same level of problems with all four substances. Perhaps he reports his alcohol use as dependence/addiction. The cocaine use is abuse, but he only uses cocaine when he drinks. He identifies marijuana as habituation, and smokes it regularly, but with no ill effects. The Vicodin is recreational, bordering on habituation.
Mr. X knows he needs to change his drinking, but he is unsure of his goals. He knows his use is problematic and he wants support.
Harm reduction in action
Rather than look at Mr. X’s substance use as one great big, amorphous problem, we can see where on the continuum his problems really are. We can first begin to look for ways to minimize harm. Mixing alcohol and cocaine is quite dangerous, so perhaps Mr. X is willing to begin there. Ultimately, we are looking for ways to make use safer, more controlled and with more moderation.
Mr. X may select to first focus on the Vicodin use. He may decide to work on stopping that before it becomes problematic. Now, he may continue to drink and use other substances, but by ceasing the Vicodin use he has done a couple of important things.
Although Mr. X is still drinking, his drinking is now safer by not combining it with another central nervous system depressant (Vicodin). He has also decreased the likelihood of developing a tolerance or any other problems associated with his Vicodin use. He has also shown himself than he can make safe, important life changes even while struggling with a substance use disorder. Any improvement is a step in the right direction. Success breeds success.
Treatment on a continuum
If our use is on a continuum, then our treatment should be as well. Everyone deserves to have a choice about what kind of treatment and when. However, due to legal issues, financial constraints, geographical limitations, insurance restrictions, etc. not everyone gets those choices. It is unfortunate because treatment tends to be most successful (during and after) when the treatment is the right fit for us.
I do not believe any one treatment is better than another. I like to think of treatment like exercise. You might really need it, but no one will tell you it has to be tennis or jogging. It is not that a specific exercise is right—it is about what is right for you, at this time. Ideally, treatment functions in the same way.
Support if you need it
If you want to explore your use along the continuum, Substance Use Therapy is here for you. Whether you want to reduce harm, work towards moderation, or are ready for abstinence we are ready to meet you where you are. Whatever you are facing, you do not have to face it alone.
Denning, P. (2000). Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions. The Guilford Press.
Denning, P., & Little, J. (2017). Over the Influence: The Harm Reduction Guide to Controlling Your Drug and Alcohol Use. The Guilford Press.
About the Author:
Kimberly May, LPC-S, LMFT is a therapist at Substance Use Therapy in Austin, TX. Kimberly works with individuals, couples and families whose lives have been affected by substance use. By utilizing a harm reduction framework, Kimberly works effectively with people in any stage of use. In addition to substance use, she works with other issues such as anger, burn-out, anxiety and grief. Contact today to schedule a no-charge, 30 minute, in-person consultation. *Note: telephone and telehealth sessions are currently available.