Substance abuse is one of the most egregious public health issues globally. In this case study, a twenty-eight-year-old unemployed Caucasian male John N. is presented. He drank beer heavily for two years before taking up gin, vodka, and cocaine. Two months ago, he began smoking crack and has been suffering from high blood pressure. His girlfriend has given him an ultimatum due to his mood swings and hostility under the influence of alcohol. John N. exemplifies the typical pattern of alcohol and nicotine abuse escalating into drug addiction.
According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5), the key issue of addiction is not consumption but the inability to abstain despite harmful consequences (American Psychiatric Association, 2013). The criteria for substance abuse include lack of control over use, resulting in failure to fulfill life obligations, exacerbated interpersonal problems, and recurrent physical or psychological problems (American Psychiatric Association, 2013). John N. should be diagnosed with addiction due to his continued alcohol and drug intake despite his acknowledgment of the problem, previous unsuccessful efforts to quit, substance-related issues with his girlfriend, and recommendations from his doctor to stop drinking because of high blood pressure.
Substance Abuse vs. Substance Dependence
The DSM-5 no longer differentiates between abuse and dependence, rather presenting them as mild and severe manifestations of substance use disorder based on the number of symptoms endorsed (American Psychiatric Association, 2013). Essentially, abuse is an early stage of addiction characterized by unintended excessive substance use despite negative consequences. With time, this spirals into mental and physical dependence. Individuals develop higher tolerance and start suffering from withdrawal symptoms, such as autonomic hyperactivity, hand tremors, or insomnia (American Psychiatric Association, 2013).
In the last year, John began drinking vodka and gin almost every day after two years of heavy beer consumption. Alcohol activates the ventral tegmental area, which releases dopamine in the nucleus accumbens and increases the inhibitory action of g-aminobutyric acid, resulting in feelings of euphoria and pleasure (Mack et al., 2016). John N.’s case may be classified as substance abuse. He has developed high tolerance for alcohol and does not feel any effects until he has consumed at least six to eight drinks. John becomes angry, hostile, and prone to mood swings under the influence of alcohol, causing significant relationship issues with his girlfriend. He is also prone to infrequent blackouts. However, he has had no withdrawal symptoms indicating that his body is not physically dependent on alcohol yet. Therefore, it would be correct to state that John is abusing alcohol.
In addition to alcohol, John began using cocaine in the last year and started smoking crack over the last two months. Cocaine is considered a stimulant that can become addictive in as little as one week (American Psychiatric Association, 2013). It inhibits dopamine transporters and causes a dopamine buildup in the nucleus accumbens, producing feelings of euphoria, increased energy, and mental alertness (Mack et al., 2016). Crack is a form of heat-treated powdered cocaine that is typically inhaled and produces more intense, short-lived effects (Mack et al., 2016). The effects of cocaine and crack on John are not explicitly described in the case study, but it is mentioned that his drinking has escalated considerably since he began smoking crack. He acknowledges that his drug use is problematic and recently attended Cocaine Anonymous meetings with a friend. John’s high blood pressure is probably due to cocaine’s vasoconstrictive effects. According to the DSM-5 criteria, John’s inability to abstain from cocaine despite his persistent efforts, relationship problems, and health hazards indicate that he is suffering from Stimulant Use Disorder (American Psychiatric Association, 2013).
Although addiction is typically thought of as chemical dependence, it involves a complex interplay between brain circuitry, genetics, sociocultural factors, and individual life experiences (American Society of Addiction Medicine, 2019). There is no proof of John’s genetic predisposition to substance abuse or significant psychiatric problems. However, his alcohol-related aggression can result from his early childhood experiences and genetic variations in executive functioning (Gutwinski et al., 2018).
The psychological component of addiction is usually based on low self-esteem and the desire to seek distraction from life problems. First, John is unemployed. Several studies indicate that unemployment increases psychological distress, which in turn increases drug use (Mack et al., 2016). Second, a calculation of his body statistics results in a BMI of 35.0, indicating obesity. While there is no conclusive link between obesity and substance abuse, John may be using cocaine as a form of weight control and psychological relief. Third, John used tobacco and beer heavily for years before escalating to liquor and cocaine. Beer and cigarettes are often thought of as “gateways” to harder liquor and drugs. Ninety percent of cocaine users had first smoked tobacco, drank alcohol, or ingested marijuana (Mack et al., 2016).
The social dimension of addiction is also relevant in this study. Alcohol is considered a social lubricant essential for group gatherings. John quit two years ago because of his relationship problems but began drinking again on the weekends with colleagues. He initially planned to limit his alcohol intake to weekends but quickly returned to daily drinking.
To summarize, John’s potential early childhood stress, unemployment, obesity, and the social aspect of drinking may have contributed to his alcohol addiction that eventually spiraled into cocaine use.
Behavioral and Substance Addiction
The DSM-5 now includes gambling and Internet gaming among its non-substance-related disorders (American Psychiatric Association, 2013). Non-substance, or behavioral addiction, is a pathological compulsion to engage in a certain activity that triggers a dopamine rush, such as sex, eating, exercise, or shopping. Common criteria for both behavioral and substance types of addiction include the need for greater stimuli to achieve the same results, the inability to abstain despite negative interpersonal and professional consequences, experiencing withdrawal symptoms, and the possibility of relapse years after discontinuation (Hellogoodbye, 2010). The neurobiological mechanisms for both types center on dopamine, but the amount released when engaging in an evolutionary activity is minuscule compared to ingesting addictive substances (Hellogoodbye, 2010). As a consequence, there is no gradual reduction in dopamine receptor availability with behavioral addiction (Hellogoodbye, 2010). Furthermore, behavioral addiction does not impair cognitive functions and is usually motivated by external rather than endogenous factors (Zhang et al., 2017).
In conclusion, any stimulating activity has the potential of becoming addictive, whether it involves ingesting a substance or engaging in maladaptive behavior. It is considered a pathological problem when an individual is unable to stop despite multiple harmful consequences. John N. continues his excessive substance abuse despite its negative impact on his health and relationships. This is due to various biopsychosocial factors, such as unemployment, obesity, and the pervasiveness of alcohol in social settings.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Web.
American Society of Addiction Medicine. (2019). Definition of addiction. Web.
Gutwinski, S., Heinz, A. J., & Heinz, A. (2018). Alcohol-related aggression and violence. In Beech, A. R., Carter, A. J., Mann, R. E., & Rotshtein, P. (Eds.), The Wiley Blackwell Handbook of Forensic Neuroscience, Vol 1 (pp. 455-480). John Wiley & Sons. Web.
Hellogoodbye (2010) Who’s an addict? Neurobiological similarities between chemical and behavioral Addictions. [Video]. YouTube. Web.
Mack, A. H., Brady, K. T., Frances, R. J., & Miller, S. I. (Eds.). (2016). Clinical textbook of addictive disorders. Guilford Publications.
Zhang, X., Shi, J., & Tao, R. (Eds.). (2017). Substance and non-substance addiction. Springer.