When is it Addiction?
Could your couple of drinks in the evening be a problem? When does smoking a ‘zol’ or taking a drug – be it cocaine, tik, or even a seemingly harmless tranquilliser – become an issue? Gillian Warren-Brown looks at addiction and when it’s time to get help.

When those ‘couple of drinks’ start multiplying themselves, and you tell yourself you need this extra drink to get you through a stressful time… that’s when it could be a problem. Similarly, if occasional drug use becomes more regular and you start thinking about when you can get your next ‘fix’… that’s when alarm bells should ring.

Addiction is a disease. It’s not just an issue of willpower, of mind-over-matter, of pulling yourself out of it or even getting over it. It’s a disease that renders the addict powerless to control the quantity of the substance they’re using, be it drugs or alcohol.

‘It’s the only disease that tells you you haven’t got it. And, without a constant reminder that you have this illness, it can become a silent killer,’ says Nicholas McDiarmid of Harmony Addictions Clinic in Hout Bay, Cape Town. He emphasises that recognising addiction as an illness that needs treatment is an essential starting point – for an addict, as well as their family and friends – in the lifelong journey of recovery.

Abuse vs Addiction
There’s a difference between alcohol or drug abuse and addiction. However, abuse could lead to addiction. Andreas Plüddemann of the Medical Research Council’s Alcohol and Drug Abuse Research Unit says, ‘In the case of alcohol, abuse could take a number of years to turn into addiction, but some drugs cause dependency quite quickly and the person will need help within two or three years.’

An example of how alcohol abuse can turn into addiction is: a student or young person binge drinks over weekends and is thrown out of clubs or has motor accidents and gets arrested. Over time they have to drink more to get the same effect – two drinks becomes three, three becomes four…

McDiarmid says, ‘People who are dependent usually hide the amount and how often they’re having a drink or taking a drug. It becomes a big secret.’

Signs of Addiction include:

• Uncharacteristic behaviour, such as missing work for a day or two and lying about the reason. Privately, the person may feel ashamed and promise themselves that it’ll never happen again.
• Despite their best intentions, they are powerless to say ‘no’ or to control the amount of a substance they consume once they’ve begun.

The Local (South Africa) Landscape
On average, 10 percent of any given population will have the illness of addiction, says McDiarmid. It’s not clear whether this applies to South Africa because the MRC’s statitics on alcohol and drug abuse trends are based exclusively on the number of admissions to counselling or rehabilitation centres. However, of these people who seek help, probably 95 percent are dependent on (or addicted to) the substance they’re using.

The more shocking thing is that about 95 percent of addicts are not receiving treatment, says McDiarmid. ‘It’s a problem of accessibility. There are very few state-run facilities in South Africa and the existing ones don’t have enough skilled addiction counsellors. They also lack an aftercare service, which is the most important thing after treatment.’

There are also no facilities targeting the needs of the black population – such as offering counselling and treatment in vernacular languages within the context of the individual’s culture – which, says McDiarmid, is important for effective intervention.

He says there are several religious-based treatment centres, as well as some independently owned outpatient centres. Most are under-resourced and relapse rates among ex-patients tend to be high. ‘In metropolitan centres, occupation per facility is usually limited and, as treatment is extremely expensive, many profit-based centres are now marketing their services overseas.’

There are a number of non-profit centres with successful treatment programmes and aftercare facilities but, without enough government-funded facilities, the problem of addiction continues to grow, especially with the introduction of drugs such as Tik and other methamphetamines.

McDiarmid says, ‘As a society, we lack understanding of addiction as a disease. Consequently, people with an alcohol or drug problem are rejected by society, so very few seek help themselves. If they do want help, they are often not guided to the right places. Few doctors and psychiatrists are properly trained to treat addiction – and it’s essential for an addict to work with an appropriately trained counsellor.’

Alcohol and Drug Abuse Trends
The MRC’s report on alcohol and drug abuse trends, released in November 2008, indicates that alcohol tops the list in South Africa.

It is followed by cannabis (dagga), cocaine, heroin, methamphetamine (Tik), mandrax, over-the-counter/prescription medications and ecstacy.

Of the patients in treatment countrywide, between 42 and 71 percent (depending on region) have alcohol as a primary or secondary drug of abuse. In the Western Cape, for example, Tik takes first place – and indeed has the highest abuse figure for this substance in the world.

‘Alcohol is not only the most commonly abused substance,’ says Plüddemann, ‘We also have a particularly harmful pattern of drinking in South Africa.’ Large amounts are usually consumed in a short space of time, which leads to behaviour that endangers both the drinker and others.

McDiarmid, who believes we have a substance abuse pandemic in this country, says ‘Remember that alcohol is a drug like any other, it’s just a socially acceptable one. The reason it’s most commonly used here is because it’s comparatively cheap, accessibile, and often goes hand-in-hand with sport and social activities.’ In other words, it’s entrenched in our culture.

Dagga is widely used and, depending on region, is the first or second drug of choice for 27 to 62 percent of patients attending treatment centres.

The use of other drugs varies from region to region, and consuming more than one type of drug is fairly common – with 20 to 46 percent of patients admitting to this practice (polysubstance abuse).

The Effects
Each drug (including alcohol) impacts on the body differently. What they have in common is an effect on mood – some pep you up, while others calm you down.

‘Common effects also include memory loss, an impaired ability to function normally and high-risk behaviour,’ says McDiarmid. There’s also the danger of a drug-induced psychosis.

Alcohol, heroin and some pharmaceutical drugs cause physical dependence (and thus withdrawal symptoms), while most other types of drugs create psychological dependence. Over time, the body’s tolerance level for any drug increases, so the user needs more of the substance more often to get the same effect. This can lead to an overdose, which could be fatal.

Long-Term Effects on Health include:

Alcohol

• A range of chronic health problems such as damage to the liver or liver failure, which can be fatal.
• ‘Wet brain syndrome’ – impaired memory, lack of logic and time referencing.
• The misuse of alcohol during pregnancy is linked to foetal alcohol syndrome (FAS) in infants. South Africa has the highest incidence of FAS in the world.

Cannabis (dagga)

• Loss of ability to concentrate and function normally.
• Deterioration in social interactions.
• May trigger the onset of schizophrenia in predisposed people.
• Irregular heartbeat, which may lead to a heart attack or stroke.
• The ‘high’ becomes short-lived and can be followed by irritability, depression, paranoia and anxiety, as well as physical symptoms such as nausea, insomnia and shaking fits.

Heroin

• Creates physical dependency so if a person goes into withdrawal, they can have a seizure if it is not managed properly.
• An overdose may lead to coma and potentially, death.
• Severe weight loss/anorexia, skin problems.
• High risk of seizures and uncontrollable rage/violent behaviour.
• Chronic mental health effects include confusion, impaired concentration and memory, hallucinations, insomnia, panic disorders, and depressive, psychotic and paranoid reactions,
• Increased risk of contracting HIV and Hepatitis C due to injection drug use and sexual behaviour.

Pharmaceutical Drugs

• Benzodiazepines and analgesics (sedatives and painkillers) create severe dependency and psychiatric problems such as paranoia, hallucinations and psychosis.
• Large doses of certain analgesics may cause seizures, coma and potentially death.

Treatment
One of the key obstacles to treatment is denial – ‘I’m just relaxing with a glass of wine, so what’s the problem?’ McDiarmid says most people know deep down that there’s a problem, but they’re ashamed to admit it. They don’t want to disclose how much they consume because they believe no-one will understand.

‘However, most addicts who have been through treatment realise that learning to live without a drug (or alcohol) is not nearly as difficult as living with it,’ he says.

‘It’s important to remember that taking the first step to get help never has to be with someone you don’t trust, or someone who will disclose your secret. Good counsellors use the utmost discretion and are non-judgmental. ‘The first step is to pick up the phone. You don’t need to commit to treatment right away, but at least you’ve made contact,’ says McDiarmid. ‘Diagnosis is not an assumption. We work with the patient for a period of time first to assess whether it is an addiction,’ he says.

At Harmony, a non-profit organisation, they have found a 28-day stay-in treatment to be most successful. This includes one-on-one counselling, family and group counselling and 12-step support groups. It also involves nutritional guidance and may include extended care.

‘If a patient is employed, we work closely with the human resources manager at their workplace. As addiction is a recognised disease, HR is obliged to work with the employee towards a solution. We’ve had fantastic cooperation and good success,’ says McDiarmid.

In general, treatment comprises the following steps:

• To get off the drug or alcohol safely and comfortably. With the right kind of medication, withdrawal can be handled well.
• Diagnosis: is this addiction, substance abuse, a separate psychiatric disorder or a co-existing psychiatric disorder? A large part of the treatment is to establish this.
• If it is addiction, a treatment model is followed that is nurturing, comfortable and as safe as possible for the addict.
• Once the addiction has been explored fully, the patient has to make a decision: do they want to continue with their addictive behaviour or do things differently? McDiarmid says the hardest part for an addict is deciding to live without what they thought was their best friend – and recognising that it never was. ‘It’s a difficult, yet simple, decision.’

Warning Signs
If you answer ‘yes’ to the following, it could indicate that you have a problem with alcohol or drugs:

• Have you noticed changes in your ability to function in your daily life or perform at work (eg, do you often have a hangover)?
• Have you been criticised for, or received a warning letter about, a drop in the standard of your work?
• Have you had arguments with people (eg, your family or colleagues) around your use of substances?
• Do you believe you need the substance to help you cope or function?