The Addiction Cycle: What Are The Stages of Addiction?

There is sometimes a perception that addiction is something that either exists in a person’s character or does not. This idea can lead to a belief that a person who is struggling with a substance or alcohol addiction may have had one drink or tried an illicit drug one time and immediately became addicted. However, the reality is a bit more complex than that.

The stages of addiction include:

1. Initial use.
2. Misuse.
3. Tolerance.
4. Dependence.
5. Addiction
6. Relapse.

As defined by the American Society of Addiction Medicine, addiction is a chronic brain disease that affects the brain’s reward, pleasure, memory, and motivation.¹ Like many chronic diseases, it does not just spring up one day. Often, several circumstances line up that, over time, cause a person who would otherwise enjoy casual drinking or avoid substance misuse to become addicted to drugs or alcohol. The process of developing addiction, in this case, tends to occur over a series of stages and, like other chronic illnesses, often turns into a cycle of addiction, treatment or abstinence, and relapse.

The multiple stages of addiction can occur over a short period of time, or they can take months or even years to develop. A person who has only occasionally had a casual drink may, over years, develop a habit that can turn into an alcohol use disorder.

The Stages of Addiction

Sometimes, these stages may occur simultaneously. As an example, for illicit substances used to feel a “high,” even one use is considered misuse. Some of these illicit substances can also result in tolerance within one or two uses. Nevertheless, in the majority of cases, all of these steps are part of the chronic cycle of addiction.

On the other hand, the addictive potential of some drugs may be so strong that what seems to be an immediate addiction may develop. However, for the vast majority of people struggling with addiction, there are stages of substance use or misuse that lead to the circumstances resulting in the person becoming addicted.

Stage 1: Initial Use

There are many reasons that the individual who ends up struggling with an addiction might initially try the substance. It can be as seemingly benign as getting a prescription to manage pain or a mental health issue, as culturally typical as trying a first drink at the age of 21, or as insidious as being pressured by friends or family to try illicit drugs. Regardless of how the initial use occurs, it is the first step toward addiction.

Whether or not that initial use is more likely to lead to addiction is often a matter of individual circumstances. A number of risk factors can contribute to a person having a higher risk of developing an addiction, including:

• A family history of substance misuse or other mental health disorder.
• Abuse or neglect.
• A chaotic living environment.
• Having a peer group or family that is permissive about substance use.
• Depression, social issues, or loneliness.

Nevertheless, even these risk factors won’t necessarily lead to the high-risk individual developing a substance use disorder.

Stage 2: Misuse

The next stage of the addiction cycle is substance misuse. This is the point at which the person is using the substance on a recurring, improper basis; more simply, the World Health Organization defines substance abuse as using a substance in a way that is harmful.² Perhaps the individual who is taking a prescription painkiller decides to take higher doses or use the medication more frequently. Another example is the person who engages in regular binge drinking or who occasionally uses cocaine. Whether or not a substance is being misused often depends on the substance itself and how it acts on the body.

As described above, with illicit drugs like heroin, misuse occurs the first time a person uses the drug. With legal substances like tobacco or alcohol, or with prescription medications, misuse is a little harder to delineate, but it is often defined as the point where the person is using the substance for the euphoric response, or high, that the drug creates, rather than for the treatment aspect of the substance. In some cases, substance misuse first occurs if the person is using the drug to self-treat mental or physical issues without the advice of a doctor.

Stage 3: Tolerance

When a person has been using a prescription drug or misusing other substances over a long period of time, the substance can cause changes in the brain that result in tolerance–a condition in which the original dosage or use of the substance no longer produces the same physical or mental effect. As a result, the person using the substance may increase the dosage or frequency of use to try to recapture the original result. For a while, this might work. Then, over time, tolerance to this new dosage occurs, and the person increases again, creating a progression into heavy substance use.

Tolerance is an indication that the brain has changed in response to the drug. For methamphetamine or other stimulants, this could include the loss of certain brain chemical receptors or a decrease in brain chemical production. Slowly, the person’s brain adjusts and changes how it responds to the presence of the drug. This, over time, will lead to the next stage in the addiction cycle: dependence.

Stage 4: Dependence

At a certain point, the body or brain becomes dependent on having the substance to be able to function properly. As an example, a person who has been using cocaine or meth for a long time may find it impossible to feel pleasure without the drug–a condition called anhedonia.

Not all drug dependence is addiction.³ For example, a person with chronic asthma may be dependent on a daily medication in order for that person to be able to breathe properly. However, this is not addiction. In this case, the body was not working properly before the drug was introduced, and the individual is using the medication to correct that function; the drug does not cause the dysfunction.

However, if the person has been using a drug to treat another condition and becomes dependent on that drug to feel good separate from the condition being treated, it may be a type of dependence that leads to addiction.

Stage 5: Addiction

Addiction is a specific, chronic mental health disorder that results in defined symptoms and behaviors that can be used to diagnose the condition. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the 11 signs and symptoms of substance use disorders include:⁴

• Using more of the substance than the person originally planned.
• Being unable to stop using the substance.
• Experiencing relationship problems because of substance use.
• Spending large amounts of time seeking or using the substance, or recovering from use.
• Reducing participation in favorite activities in favor of substance use.
• Being unable to keep up with daily responsibilities due to substance use.
• Craving the substance.
• Continuing to use the substance despite negative health effects.
• Regularly using the substance in dangerous situations (while driving or operating machinery, etc.)
• Developing tolerance for the substance, as described above.
• Experiencing withdrawal symptoms when use is stopped.

In general, experiencing 2-3 of these symptoms is considered a mild substance use disorder. Reporting 4-5 of them leads to diagnosis of a moderate disorder. If the person is experiencing 6 or more of the symptoms, it indicates a severe substance use disorder.

Stage 6: Relapse

A hallmark of any chronic condition is the potential for the person to relapse. In chronic conditions like diabetes or asthma, relapse is often expected as the individual and medical personnel work together to determine the treatment that makes it possible to manage the condition.

Addiction is no different from these conditions. In fact, relapse rates for addiction–between 40% and 60%–are similar to those for asthma (50-70%) and adult-onset diabetes (30-50%). Sometimes, the initial treatment is not quite right, or the person starts by trying to quit without help, and over time, control is lost and the person returns to substance use. However, this is not an indication that the person has failed, only that treatment needs to be adjusted.

Interrupting the Cycle

An individual may go through multiple attempts to stop using a substance before realizing that addiction is a factor. However, when addiction is diagnosed, it is possible to interrupt the cycle of addiction. Professional treatment that is backed by research has the ability to help. Multiple methods, including cognitive and behavioral therapies, peer group support, and other physical and mental health treatments can encourage the person to develop tools for managing this chronic, recurring condition.

As with the medications and therapies used to treat asthma and diabetes, the treatments in addiction rehab are designed to help the person learn to manage a chronic substance use disorder and reduce the likelihood of relapse to drug use. With motivation and experienced, certified help, these individuals can learn to interrupt the addiction cycle and move forward into the sustained recovery, which results in a more positive future.

Finding Help for Addiction

If you or a loved one struggle with addiction, American Addiction Centers (AAC) can help. AAC operates treatment centers throughout the country, offering the complete continuum of care and providing evidence-based therapies and individualized treatment plans. Reach out to connect with one of the knowledgeable and compassionate admissions navigators, who can answer your questions, explain your options, and help you begin a path to lasting recovery.