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Using 'Choices and Consequences to Assess Levels of Abuse
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In the last section, we discussed the seven ways in which chemical dependence in teenagers differs from chemical dependence in adults. These reasons are polydrug use is higher among teens, the reasons teenagers use drugs are more internal, levels of use are harder to determine in teenagers, addiction happens more quickly in teenagers, emotional arrestment takes place earlier in teenagers, the delusional system in teenagers is more complicated, and teenagers have more "built in" enablers than adults.
In this section, we will discuss the four levels of teenage addiction. These are use, misuse, abuse, and addiction. In my experience, each of these levels is characterized by characteristics, chemicals of choice, and consequences of using. I find that determining which level a teenage chemical dependence is at is useful in planning which intervention approach will be most helpful.
Four Levels of Teenage Addiction
♦ Level #1 - Use
I find that Level One, Use, is analogous to Phase I of the Feeling Disease, as discussed in Section 2, where the user learns about mood swings caused by the drugs. This level involves the teenager’s first experience with the drug. Tolerance is low, and it does not take much to feel the effects.
I find that experiences at the use level are often considered acceptable by the people in the teenager’s life, for example, drinking a glass of wine at holiday dinners, or taking a painkiller
prescribed by a doctor. Experimental use also occurs at level one; this is use of varying frequency, usually with friends, without the parent’s knowledge.
In my experience, the level one drugs of choice are alcohol (mostly beer or wine), locally-grown marijuana, over-the-counter medications, and inhalants. The social and personal consequences are minimal, perhaps the first hangover, at level one. The exception to this, as you know, is with inhalants, which can cause immediate physical consequences, including the possibility of heart failure even with the first use.
♦ Level #2 - Misuse
Level Two, Misuse, involves regular use, usually confined to weekends. Tolerance increases, but the user is still in control, and can choose not to use, and how much to use. A pattern of use begins to develop. Teenagers at Level Two begin to come up with reasons to use without parental permission.
Toby, 14, told me "My folks would let me have a glass of wine at Christmas and Thanksgiving. It felt nice, relaxing. So I figured it’d be a nice way to relax before a big party on the weekends." At the misuse level, users also start making rules to govern their using, as discussed in Section 2. I find that Level Two drugs of choice usually include hard liquors, foreign marijuana, perhaps including hashish, stimulants such as amphetamines, depressants such as Dexedrine, natural hallucinogens like peyote or mushrooms, and cocaine.
Level two social consequences may include the first arrest for possession, school activities and assignments beginning to suffer, sneaking out at night at home, and feeling strong peer pressure to use at social events. Personal consequences include more frequent hangovers, "bad trips", trouble sleeping, spending large amounts of time planning for the next use, minimizing, severe and unpredictable mood swings, and the delay of normal emotional tasks such as grieving.
Are you currently treating a level two misuse client that might benefit from listening to this section?
♦ Level #3 - Abuse
In my experience, level three, Abuse, begins the early stage of addiction. At this stage, the teenager is preoccupied with alcohol or other drugs, and uses 2-3 times during the week, as well as on weekends. At level three, the teenager has far less control over whether to use; and rituals are established. Teenagers become more ingenious about hiding from parents and deceiving authorities, for example, by avoiding family meals or staying overnight at a friend’s house. In my experience, level three is when solitary use begins. In addition, self-imposed rules are violated.
Mia, a 17 year old crack user, stated "It used to be, no getting high during school. But then I thought, well, I won’t get high at school. But if my friends skipped to go smoke, I’d go too." In my experience, drugs that characterize the abuse stage can include speed, barbiturates, synthetic hallucinogens, increased use of cocaine with crack being preferred, and designer drugs such as ecstasy; drugs from the previous levels, especially alcohol, are still used in greater quantities. At the abuse level, shoplifting, vandalism, dealing drugs, and the first DUI may occur.
As you are aware, in school, grades drop, and truancy may become more frequent. In my experience, at the third level, teenagers may begin stealing from their parents, and may become physically or verbally abusive at home. All of the teenager’s friends are using friends. Personal consequences include injuries, respiratory problems, weight changes, and overdoses.
In my experience, personal hygiene begins to suffer, and severe blackouts begin. At the abuse level, the teenager begins blaming others for their problems, and feels depressed and worthless. I find that some teenagers abusing chemicals at level three may become suicidal.
♦ Level # 4 - Middle and Late Addiction
Level four, middle and late addiction, is characterized in my experience by compulsive use. The addict can no longer control their use. Rituals become more rigid, self-imposed rules are abandoned, and binge use resulting in a high lasting one or more days may occur. I find that grandiose and aggressive behavior occurs at level four, and the teenager becomes obsessed with always having their drug of choice on hand.
The teenager may also use more recklessly, leaving drug paraphernalia where the parents may find it. I also find that teenagers at level four may make repeated, unsuccessful efforts to stop using. In my experience, teenagers at level four will use any available drug, including increased amounts of alcohol and drugs mentioned previously. Some teenagers in mid and late addiction may begin to use narcotics such as codeine, percodan, morphine, and heroin, perhaps by needle.
Legal consequences of level four may include serious crimes such as assault and battery or prostitution, resulting in jail time. In my experience, teenagers in middle or late addiction may sell drugs at school, and may stay away from home for long periods of time, or leave altogether. Substance-using friends of the addict may show concern, and the addict may avoid or be violent towards them. Physical consequences may include withdrawal symptoms, a chronic cough, and severe weight loss.
I find that in level four, self hatred is projected onto others, and blackouts are a regular occurrence. I have also found that many level four addicts experience deep remorse or despair, feelings of paranoia, and may make suicide plans or attempts. The conflict between values and behaviors no longer serves to restrain or inhibit using behavior, and the addict finds no peace from inner conflict even when high.
♦ "Choices and Consequences" Technique
To better assess which level of addiction Mia, a 17-year-old crack user, was currently at, I asked her to work through the "Choices and Consequences" exercise with me.
In this exercise, I asked Mia to write down answers to the following questions:
a. "Identify times when you have missed school, work, or dates with friends."
b. "How does your behavior change when you use drugs?"
c. "Identify times when you’ve tried to control your use and ended up using more than you planned."
d. "How many times were your problems caused by chemicals?"
e. "When have people commented on your use?"
Mia stated "Well, I miss school usually three times a month or so. And some friends I used to hang with keep bugging me about how much weight I’ve lost cause of the crack." Based on her answers, I was able to determine that Mia was most likely at Level three, Misuse.
In this section, we have discussed four levels of teenage addiction. These are use, misuse, abuse, and addiction. We have also discussed the characteristics, chemicals of choice, and consequences of use at each level.
In the next section, we will discuss the four tasks of adolescence I have observed in my practice. These are, to determine a vocation, to establish personal values, to explore personal sexuality, and to establish personal authority.
At which level of addiction do teenagers begin solitary use?
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