This is part two of a series looking at different mental models of understanding addiction. I think of substance use disorders as an extreme form of human behavior, and they are prevalent. This series is designed both to be a resource for people impacted by substance abuse, and also as a window into human nature more broadly. After all, all of us have the urge sometimes to check out: to scroll our phones, eat too much, or lie to ourselves.
Last week, I explored addiction through the lens of the medical model. This week, I present models for trying to understand how substance use is an understandable, almost logical response to the difficulties we face.
Coping Strategy
When people hear the phrase "coping strategy," they often assume it refers to something healthy. But coping strategies are simply ways of dealing with life's challenges. Some are helpful and some are harmful. Exercise is a coping strategy. Talking with a friend is a coping strategy. Meditation is a coping strategy. So is drinking a bottle of vodka.
One of the reasons addiction can be so difficult to treat is that substances often work remarkably well in the short term. They reduce anxiety, numb emotional pain and quiet self-criticism, creating a sense of relief. Substance use is close to 100% effective, whereas healthier coping strategies are not. If drugs did not work, people would not keep using them.
This perspective helps explain why simply telling someone to stop using is rarely effective. Taking away someone’s primary coping mechanism, without offering an alternative, is unlikely to be effective. When someone decides to stop using, that is effectively what is happening– we are removing that person’s primary strategy for dealing with distress.
Recovery therefore requires building larger and more effective strategies for responding to that distress. If someone has spent years using alcohol to manage anxiety, recovery involves learning other ways of managing anxiety. If opioids have been used to cope with loneliness, grief, or trauma, recovery involves developing other ways of relating to those experiences.
From this perspective, addiction is an over-reliance on a destructive coping strategy that creates more problems than it solves. Moving away from substance use is really about building new strategies for coping with distress.
Push and Pull
The pull of addiction is relatively easy to understand. Substances generally make us feel good, at least initially. They create pleasure, relief, comfort, confidence, connection, excitement, or escape. There is something obviously attractive about them. They pull us toward continued use.
The push is less obvious, but often equally important. The push is everything about reality that feels difficult, painful, uncomfortable, or overwhelming. It is anxiety, loneliness, grief, boredom, shame, trauma, depression, stress, and uncertainty. While the substance is pulling us toward itself, these experiences are pushing us away from sobriety.
Most addiction involves both forces operating at the same time. People are not simply moving toward the pleasurable effects of a substance. They are also moving away from a life that feels lousy.
This duality matters because treatment needs to focus on both sides of the equation. Medications often reduce the pull, making the cravings weaker, reducing the rewarding effects of substances, and creating more distance between urges and actions. But eliminating the escape is unhelpful if someone is then stuck in a reality that sucks.
Therapy, community, meaningful work, healthy relationships, exercise, meditation, and personal growth are all tools to help make reality a better place to be. They reduce the push, making regular life more joyful. The long term work of recovery involves building a life that we want to live, rather than a life we want to escape.
Over the short term, it is easier to address the pull– and without addressing the pull, there is no opportunity to address the push. The real, long-term goal is to change the push, to make our lives places that we do not feel compelled to escape from.
Unfixable Problems
Many people who develop significant substance use disorders are living in circumstances that feel untenable. Often, they fall into one of three broad categories. They are in a relationship that is not working, but for various reasons (practical, financial, emotional, or family) they do not feel able to leave or change the terms of the relationship. They are in a job or career that is making them miserable, but changing it feels impossible. Or they are carrying significant trauma, often from childhood, that cannot simply be escaped because it is already part of their history.
In each of these situations, the person is faced with a painful reality that feels inescapable. The distress is not temporary. It is present day after day, month after month, sometimes year after year.In that context, the substance often serves a specific purpose: making the intolerable tolerable.
The substance does not fix the marriage, resolve the trauma or improve the job. But for a few hours, it makes it possible to live with those realities. The drug lowers the volume of the distress enough that the person can continue functioning.
This framework is important because it helps explain why simply taking away the substance is often unsuccessful. If the chemical is the thing making an otherwise unbearable situation bearable, removing it without changing anything else leaves the person exposed to the full force of the problem.
From this perspective, recovery frequently requires more than stopping a substance. It requires honestly examining the circumstances that made the substance necessary in the first place. Sometimes the work of recovery is learning new coping skills. Sometimes it is healing old wounds. And sometimes it is recognizing that the life a person is living has become unsustainable and needs to change.This is not to say that people need to get divorced or quit the job (though sometimes that’s true). Rather, it might mean renegotiating the terms of work, or finding new ways to be with a partner.
In the context, substance use is not the original problem. Often it is the adaptation that developed because the original problem felt impossible to solve. Granted, the substance use likely makes the original problem worse, but the real fix involves addressing whatever was driving the substance use in the first place.
Chemical Coping
Chemical coping is a pretty simple cycle at baseline: Feel distress→take chemical→feel better. The thing that is so important about chemical coping is that the source of the distress is totally irrelevant. Feeling hungry? The chemical fixes that. Upset with your partner? The chemical fixes that. Unhappy with the job? Chemical fixes it. Over time, our brains learn that the fastest way to fix whatever it is that is bothering us is to take a chemical. Worse, the chemicals that we use do not just resolve the distress, they actually make us feel good.
By definition, chemical coping involves using a chemical– heroin, alcohol, cannabis– but the pattern actually extends much more broadly. There are strong analogies to how people use food, phones, or gambling. For me, chemical coping is perhaps the purest distillation of what addiction is really about.
The challenge with the chemical coping cycle is that our brains are both lazy, and are learning machines. If our brain has learned through 1000 repetitions that the way to solve a problem is by taking a chemical, its lazy nature means it will automatically look to that same strategy the 1001st time it encounters distress– it won’t look for alternatives. This becomes so automatic over time that people can mistake hunger cues for cravings. After long-term use, many people early in recovery have to actively re-learn these cues. Is this craving I am feeling actually a hunger cue? Fatigue? Our brains are endlessly malleable, and we can re-learn these cues, but it takes time, and repetition, for that to happen.
Habit
Habits are behaviors that become automatic through repetition. The more often we do something in a particular context, the less conscious thought is required to do it again. We all have habits: we brush our teeth, check our phones, take the same route to work, and make coffee in the morning without much deliberate thought.
Addiction shares many characteristics with habits, but in a much more powerful form. A person may begin using a substance intentionally, but over time the behavior becomes increasingly automatic. Certain places, people, emotions, times of day, or situations become linked with use. The brain learns these associations and begins to anticipate the substance before conscious thought is even involved.
One of the reasons relapse can be so surprising and discouraging is that people often assume they are making a deliberate choice in the moment. In reality, much of the process has already been set in motion by habit loops operating below conscious awareness. We may drive past a familiar location, encounter an old friend, feel stressed after work, or experience a difficult emotion, and suddenly find ourselves thinking about using before we have even recognized what is happening.
This perspective is helpful because habits can be changed. The brain remains capable of learning throughout life. Recovery is, in many ways, the gradual process of building new habits that compete with and eventually replace old ones. The goal is not simply to stop using a substance. It is to create new automatic responses to stress, boredom, loneliness, celebration, disappointment, and all the other situations that previously triggered use.
Like any habit, this process takes repetition. We do not replace years or decades of learned behavior overnight– and like building any new habit, the earlier repetitions are more difficult, but they get easier the more times we do something.
All of us, to some degree, engage in the behaviors laid out here– to me, the real question regarding addiction is one of degree more than presence. And again, none of these models are perfect, and none apply to all circumstances. In part three next week, I’ll explore addiction in the context of larger models for navigating life, and how addiction disrupts, and is viewed, within these models.
Love,
Doc
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