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Addiction-categories: Process-Appetite  or  Substance/Behavioral

In 2012 the American Society of Addiction Medicine smartly set forth a definition of addiction that encompasses both substance abuse and certain compulsive behaviors. Using ASAM’s definition a clinician can assess process and appetite addictions. Some discussion of this classification is topic today.

In most ways, substance and behavioral addictions are incredibly similar. Essentially, substance addicts are people who’ve lost control over their use of nicotine, alcohol, prescription drugs, and/or illicit substances such as methamphetamine, heroin, and cocaine.   Behavioral addictions (also called “process addictions”) involve the same basic loss of control. The only real difference is that with behavioral addictions the loss of control involves not substances but potentially pleasurable activities such as gambling, working, eating, spending, sex, others.

Sadly, numerous people, professional and lay public, mistakenly view behavioral addictions as “moral flaws” that are “less serious” than “real” addictions. However, those of us who treat these concerns on a regular basis continually witness the consequences of out-of-control impulsive, compulsive behaviors.  Addictive behaviors wreak as much havoc on families, careers, and lives as substance addictions nicotine, alcohol, prescription medications, and others. Furthermore, we see the ways in which behavioral addictions often pair with substance abuse. For instance, many who suffer from compulsive sexual disorder or impulse control disorder, also struggle with stimulant abuse or addiction, to such substances as cocaine or methamphetamine. Usually, if such a person/patient is to find lasting sobriety he or she needs to  be treated for both addictions simultaneously. Otherwise, whichever addiction it is that hasn’t been treated can easily lead to active recurrence with the other.

The Process of Process Addictions

Part of the confusion around behavioral addictions stems from the fact most addictive behaviors are – for most people, most of the time – healthy, perhaps even essential activities. Things like eating and being sexual, for instance, contribute to survival of the individual and the species. Without these activities the human race would quickly die out. Because of this, our brains are programmed to encourage these behaviors. And for people who become addicts, this is where the problem starts. Simply put, eating and being sexual trigger, among other things, the release of dopamine in the rewards center of the brain, resulting in feelings of pleasure. (Addictive drugs trigger a similar neural response.) Not surprisingly, this biochemical pleasure process is a key element in the development and maintenance of addictions. Essentially, the brain remembers that eating or being sexual or gambling,  causes feelings of pleasure. The dopamine surge in  the brain overrides homeostatic responses, the easy way to feel better is to engage in the pleasurable (and  potentially addictive) activity.  

To further understand the similarities between substance addictions and behavioral addictions, it may help to consider the individual who, cash in hand, has found a source for the addictive substance he so desperately wants. He leaves work early without informing his boss, hops in the car, and speeds to the source of purchase. The brain dopamine release is occurring prior to the purchase,in anticipation of  substance use. The brain adapts, (neuroplastic changes occur) to the surge of the dopamine from the expectation of substance use. After all, his thinking is impaired (he’s making bad decisions), his pulse racing, and he desires/feels compelled to purchase and use the substance, no matter the consequences. The closer he gets to using, the higher the pusle, respiration, body temperature, and the more tunnel-visioned and impulsive his thinking becomes. Yes, indeed, he is becoming mind altered in anticipation. Yet at this point there has been no current use of substance !

Behavioral addictions operate on the same “anticipatory high” principle. For instance,  sex addicts find as much (if not more) pleasure and relief (from stress and emotional pain) in the fantasy and pursuit of sex as in the sex act itself. They sometimes refer to this elevated, fantasy-driven state of neurochemical excitement as “the bubble” or “the trance.” They simply lose touch with reality for hours or even days at a time – high on the idea of sex – with little or no actual physical contact. Very similar changes are described by gambling addicts. Thus we see that for both substance addiction and behavioral addiction, the fantasies and actions that lead up to actually using/acting out (the ritualized process of the addiction) are every bit as compelling and desirable as the actual drug or behavior.

Identifying Behavioral Addictions

Behavioral addictions are often initially identified during substance abuse treatment or soon thereafter. Usually they pop up as either a cross-addiction or a co-occurring addiction. (Cross-addictions are when the addict uses one addiction to replace another; co-occurring addictions are when two disorders are present at the same time.)


  • Cross-Addiction: While in residential treatment for alcohol addiction, Sydney gains 20 pounds, replacing her drinking with compulsive eating. Later, when she eventually decides to go on a diet, she suddenly finds herself drinking again.
  • Co-Occurring Addiction: Jack leaves treatment for cocaine abuse, thinking he is cured. Once home, he calls up a sexual partner, thinking he’ll “treat” himself because he’s been sober for 30-plus days. Within minutes of partner arrival, he’s doing lines of cocaine, little realizing that his cocaine use and his sexual behaviors are directly linked.

As is the case with substance abuse recovery, the journey toward sobriety from behavioral addictions is a long-term process that typically requires professional counseling with a clinician or team of clinicians experienced in addressing the specific addiction, along with any cross- or co-occurring disorders that may be present. Happily, such treatment is now available at facilities, which we can refer to.

 One significant treatment difference between substance and behavioral addictions lies in the definition of sobriety. Whereas complete abstinence from the addictive substance, is typically expected in drug and alcohol treatment, those addicted to things like food and sex must  learn to carefully identify the behaviors that do and don’t compromise the values and relationships they hold most dear. Then they contract to not engage in the problematic activities and to limit their engagement in the non-problematic activities to moderate and appropriate levels. Otherwise, the treatment and recovery process is incredibly similar for both substance and behavioral addictions…

Progress not perfection.

Legislating Limited Treatment Will Worsen Outcomes

Recovery , stable sustained abstinence,  does not alleviate the accountabilities of addiction treatment by the healthcare professionals. Each year, more than 13,000 specialized addiction treatment programs in the United States serve between 1.8 and 2.3 million individuals, many of whom are seeking help under external duress.  Those who are the source of such pressure are, as they see it, giving the individual a chance — with potentially grave consequences hanging in the balance.   Now with recent intended legislation, we again see non medical professionals attempt to limit the chances one is given to obtain “remission” from their disorder.  Imagine telling the diabetic or asthmatic —  one 6 month period of treatment, that’s it. 

Accepting the mantra that “Treatment Works”, families, varied treatment referral sources and the treatment industry itself, as well as legislators, believe that responsibility for any resumption of alcohol and other drug use following service completion rests on the shoulders of the individual, even with mandated limitations of care.  This is unique in the annals of medicine.  With other medical disorders, continuation or worsening of symptoms is viewed as an indication that the initial treatment is not effective for this particular patient and that changes in the treatment protocol are needed.  In contrast, when symptoms continue or worsen following addiction treatment, it is the patient who is blamed and often punished.  The stance is, “You had your change and you blew it!  You must now suffer the consequences of your actions.”  And those consequences are often quite dire, including divorce, loss of children, loss of housing or educational opportunities, termination of employment, discharge from the military under less than honorable conditions, loss of professional licenses, loss of driving privileges, and incarceration, to name just a few.  Such punishments are often meted out with an air of righteous indignation in the belief that the person for whom we have done so much has failed this chance we have given them.  The question I am raising in this blog is:  Was it really a chance?  Does this pending legislation  appropriately address or provide adequate care, or raise the quality of healthcare for our citizens?

Put simply, we are routinely placing individuals with high problem severity, complexity and chronicity in treatment modalities  whose low intensity and short duration of service (possibly mandated by law) offer little realistic hope for successful post-treatment recovery maintenance. By using terms like “completion of “, ” limited clinical treatment”, and ending the service relationship following such brief clinical interventions, we convey to patients, to families and to all other interested parties at “discharge” from treatment that recovery is now self-sustainable without continued professional support.  And this is true just often enough (but often attributable to factors unrelated to the treatment) that this expectation is maintained for all those treated.  For those with the most severe problems and the least recovery capital, I believe this expectation is not a chance, but a set-up for failure with potentially greater consequences than might have naturally accrued.   This proposal will not provide evidence-based improved outcome to our patients.  I would posit, quite likely as many of us have seen before, we will see recurrence in the disorder (recurrent illicit drug use and all its consequences).

What we know from primary medicine is that ineffective treatments (via placebo effects) or an inadequate dose of a potentially effective treatment (e.g., as in antibiotic treatment of bacterial infections) may temporarily suppress symptoms.  Such treatments create the illusion of resumed health, but these brief symptom respites are often followed by the return of illness — often in a more severe and intractable form.  This same principle operates within addiction treatment and recovery support services.  Flawed service designs, or mandated statutory laws, may temporarily suppress symptoms while leaving the primary disorder intact and primed for reactivation.  But now the treated individual has three added burdens that further erode recovery capital.  First, there is the self-perceived experience of failure and the increased passivity, hopelessness, helplessness, and dependency that flow from it.  Second, there are the perceived failure and disgust from others and its accompanying loss of recovery support — losses often accompanied by greater enmeshment in cultures of addiction.  Finally, possibly mandated by law, time/dose limits of care. There are the very real other consequences of “failed treatment,” such as incarceration or job loss that inhibit future recovery initiation, community re-integration and quality of life. That will be the outcome of this proposed legislation.

The personal and social costs of ineffective treatment are immense.  If we as a society and as a profession, and dare I say, legislators, commissioners, law enforcers, clergy, educators and others, want to truly give people with severe and complex addictions “a chance”, then we have a responsibility to provide systems of care and continued support that speed and facilitate recovery initiation, buttress ongoing recovery maintenance, enhance quality of personal and family life in long-term recovery, and provide the community space (physical, psychological, social and spiritual) where recovery and sustained health can flourish.  Anything less is a set-up for failure.  We are closing the door to medical care and recovery to attempt to legislate limits on scientifically based, proven effective medical treatment such as office based opioid  treatment using buprenorphine and other medications. 

As addiction professionals, we should always be mindful of the power we wield and its potential effects on people’s lives.  That power comes from our professional decisions and actions, but it also flows from the treatment designs within which we operate.  If we are going to participate in giving people a chance, then we need to make sure it is a real chance and not a set-up for what is ultimately more a system failure than a personal failure.  As Dr. Standridge has requested,  it is time for leaders of addiction treatment to contact our legislators and law makers.  Perhaps addiction treatment as a system of care is itself in need of becoming active in patient advocacy  and active in the  legislative process.  Our  voice, that  of our specialty, Addiction Medicine, has for too long been silent.  Let’s advocate for our patients, NOW.