Understanding the Stages of Addiction

About 39.5 million people worldwide had drug use disorders in 2021, says the United Nations Office on Drugs and Crime. Unfortunately, only one in five of these individuals got treatment, UNODC says.[15]

Addiction is a chronic and complex condition affecting motivation, pleasure, reward, and memory that develops over time. While some people may be able to use substances in moderation, others may, influenced by many factors, progress to substance misuse, dependence, and addiction, creating a cycle that is difficult to break without help.

Although everyone’s progression from substance use to full-blown addiction might look different, there are some general stages people share, including the following:

• Initial use
• Abuse
• Tolerance
• Dependence
• Addiction
• Relapse 

These stages can occur simultaneously or one after the other. Some people may make their way through these stages rather quickly while others may progress over months or even years. 

Stage 1: Initial Use

While some people may never try substances like drugs and alcohol, others may begin their addiction with initial use. There are many different reasons people may try a substance, whether it’s due to peer pressure, trying it at a party, wanting to relax or enhance performance, or receiving a prescription for pain or anxiety.

Regardless of how or why someone tries a substance for the first time, there are risk factors that can increase the likelihood they will progress through the stages of addiction. These known risk factors for addiction include:[3,4]

• Aggressive behavior in childhood
• Delinquency
• Deviant behaviors
• Antisocial behavior
• Lack of parental supervision 
• Parental substance abuse
• Poor social skills 
• Ready access to drugs
• Living in a poor community
• Diagnosis of a mental health disorder
• Exposure to trauma

That said, not everyone with one or several risk factors will even try drugs, let alone develop an addiction. Substance use disorder is a complex brain disease and many factors contribute to its development. Research shows that between 40% and 60% of vulnerability to addiction is related to genetics. [4] Even still, that doesn’t mean you’ll become addicted with initial use.

Are You in Stage 1?

People in this stage use substances like drugs or alcohol either for the first time or on occasion. If you’ve ever used substances, you’re either in or past this stage.

Stage 2: Substance Abuse

Medical experts define drug abuse as using substances without a prescription or using drugs in a manner other than directed. [5] Under this definition, anyone who buys a prescription painkiller from a friend is abusing it. Other examples of substance abuse include:

• Taking higher or more frequent doses than prescribed
• Mixing prescriptions with other substances like alcohol
• Using medication in a way other than prescribed (e.g. injecting, snorting)

Addiction medicine clinicians use a slightly different definition. To them, drug abuse involves using substances to do the following:

• Counteract a negative mood 
• Augment a happy mood 
• Reduce feelings of boredom 
• Tolerate a difficult occasion, such as a job interview

People who abuse drugs are looking for ways to hijack the brain’s normal processes. They hope to self-medicate or manage difficult feelings and make themselves feel happy, content, or sedated. They may not understand that these tweaks can have serious consequences. 

Moreover, while prescription drug abuse doesn’t occur until someone uses it in a way other than intended, using illicit drugs, like heroin, cocaine, and crystal meth, even once is considered drug abuse. 

And with legal substances like alcohol, nicotine, or marijuana (in some states), abuse can be harder to define—however, it is typically related to the desire to get high rather than to use it socially.

Are You in Stage 2?

People who are in Stage 2 are using prescription drugs in a manner other than prescribed, or they’re using illicit substances regularly. This stage is characterized by regular use, not just experimentation.

Stage 3: Tolerance

Tolerance to drugs or alcohol occurs with chronic substance use or abuse. This is because, over time, these substances cause important changes in the brain that result in a diminished response to drugs or alcohol. 

In an effort to overcome these diminished effects, people will take larger and more frequent doses to experience the same high or pleasurable feeling.[6] And while this may work temporarily, they will eventually build more and more tolerance, leading to ever-increasing doses and severe substance abuse.

Anyone who uses drugs for a long period can develop tolerance. For example, people using prescription painkillers, like fentanyl, for cancer-related discomfort often need bigger doses over time to stay calm and comforted. 

Tolerance alone doesn’t indicate addiction, but when it accompanies drug and alcohol abuse, it is a risk factor. Someone with a tolerance for a painkiller like hydrocodone or oxycodone, for example, might begin using more potent opioids like heroin or fentanyl in order to feel the desired effects.

As someone’s tolerance builds and their brain changes and adapts to the presence of substances, this process can contribute to the next stage of addiction: physiological dependence.

Are You in Stage 3?

People who are in Stage 3 need to use more of the same dose to get the same effect that a smaller dose once delivered. If you find yourself using two pills where one once did the trick, or you’ve asked your dealer to sell you even more doses than usual, you could be in this stage.

Stage 4: Physiological Dependence

Physiological dependence occurs when someone’s brain and body adapt to the ongoing presence of a substance like drugs or alcohol. This adaptation means that they can no longer function optimally without the substance, resulting in distressing and sometimes even dangerous withdrawal symptoms when they abruptly stop or are unable to obtain the drug.[7]

Physical dependence like this can set in with ongoing use of many different types of drugs, even if the person takes those substances as prescribed by a doctor. But when discussing dependence within the context of substance abuse and addiction, it is the fourth stage that can develop after or alongside tolerance.[7] 

Withdrawal is the hallmark of drug dependence. When the person tries to quit using drugs, difficult physical and psychological symptoms set in, and deep cravings for drugs accompany them.[8]

Withdrawal symptoms vary from substance to substance, with opioids causing flu-like symptoms like vomiting, sweating, muscle aches, and diarrhea, while alcohol and sedatives cause rapid pulse, anxiety, tremors, and possible seizures.[8]

While physical symptoms may resolve in a few days or weeks, psychological withdrawal symptoms can last for months.[9] People may experience anhedonia (inability to feel pleasure), depression, anxiety, irritability, and drug cravings. Because drug withdrawal symptoms can be so painful and uncomfortable, people may return to substance use to relieve these symptoms, which can create a cycle of compulsive substance abuse that ultimately results in addiction. 

​​Are You in Stage 4?

People who are in Stage 4 experience discomfort when they try to quit or cut down on their drug use. Your symptoms might be physical (such as headaches or diarrhea) or mental (such as anxiety and depression). If you’ve ever tried to handle your drug use and felt too sick to do so, you could be in Stage 4.

Stage 5: Drug or Alcohol Addiction

Addiction, clinically referred to as substance use disorder, is a chronic, relapsing condition characterized by compulsive drug or alcohol misuse regardless of negative consequences. This problematic pattern of use leads to significant impairment in a person’s life. 

The criteria for substance use disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), include the following:[8]

• Using substances in greater amounts than originally intended
• Failing to cut down or control use despite a desire to do so
• Spending a considerable amount of time obtaining, using, and recovering from the effects of substances
• Experiencing intense cravings for drugs or alcohol
• Failing to meet home, school, or work responsibilities due to substance abuse
• Continuing to use substances despite interpersonal issues caused by the misuse
• Neglecting previously enjoyed hobbies or important activities in favor of substance abuse
• Using substances in dangerous situations, such as while driving or caring for children
• Continuing to use drugs or alcohol despite knowing they are causing or exacerbating physical or mental health issues
• Developing a tolerance to substances
• Developing a physical dependence

A person only needs to exhibit two of the above symptoms within a one-year period to be diagnosed with substance use disorder. Generally, the more symptoms they present with, the more severe the addiction.[8]

Are You in Stage 5?

People who are in Stage 5 have passed through all the previous stages and now struggle with a chronic brain disorder. You may understand that your drugs are causing problems, but you may not be able to quit.

Stage 6: Relapse

Substance addiction is often compared to medical conditions like diabetes and heart disease due to its chronic, relapsing nature. There isn’t so much a cure for substance use disorder so much as there are treatments to help manage it and live a happier, healthier life.[10]

This, of course, doesn’t mean that everyone who develops an addiction and achieves recovery is going to relapse—it simply means that relapse is often a normal part of the recovery process and shouldn’t be viewed as a sign that treatment has failed. In fact, relapse rates for substance addiction—between 40% and 60%—are similiar to those of conditions like hypertension and asthma.[10]

A relapse isn’t a failure. It might just be a sign that the initial treatment wasn’t the best fit or a sign that someone needs additional support and care. There is no reason to feel shame or guilt if you wind up relapsing. The sooner you reach out for help after a relapse, the quicker you can get back on track. 

Relapse rates for substance addiction—between 40% and 60%—are similar to those of conditions like hypertension and asthma.

Are You in Stage 6?

People in Stage 6 have tried to quit. They may have stayed sober for days, months, or even years. However, they returned to regular use. Someone in this category is using substances again.

​​What’s The Difference Between Use, Abuse & Addiction?

This table can help you understand the key differences between substance use, abuse, and addiction. Defining these terms could help you determine where your habits fall on the treatment spectrum.

Addiction Treatment Works

In the 2021 National Survey on Drug Use and Health, seven in 10 adults who had ever had a substance use problem considered themselves to be recovering or in recovery.[11]

Most of us have seen what addiction looks like firsthand. And many of us know that while addiction is a chronic condition, it can be managed. Recovery is possible.

Treatment programs work best when they last three months or longer. People need time to let their brains and bodies heal. [12]

And they need support to develop new habits and social connections. When psychological triggers appear, as they will, these protective factors can prevent another relapse. 

It’s difficult to measure just how “effective” addiction treatment is, as this is a chronic condition marked by treatment noncompliance and high drop-out rates. 

Studies that measure treatment effectiveness may look at relapse rates only. That measurement doesn’t fully encompass what recovery looks like, especially given that recovery is a typical part of recovery for many people. 

Your recovery will take time, and you may need to work for the rest of your life to maintain it, but you can stop the cycle of drug abuse and live a better life.