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Renaldi et al.6 (1988) described tolerance occurring when the person no longer responds to the drug in the way that person initially responded. Stated another way, it will take a higher dose of the drug to achieve the same level of response achieved initially. For the patient struggling with an SUD, tolerance often develops quickly, and therefore the amount required for relief increases over time to meet their level of tolerance. In some cases, tolerance can be identified at first exposure to substance use, particularly as described earlier, when first exposure to substances occurs during early adolescence. Patients with a likely predisposition to SUD ordinarily report having different kinds of experiences than their non-SUD peers including using more than intended on their first exposure, limited physical consequences (e.g., no hangover), and a quick recovery post-initial exposure. This type of information can be extremely valuable and can quickly assist the medical professional in recognizing some of the initial warning signs or indicators. Recognizing the development of tolerance at the beginning of their using career can help medical professionals clarify their decision-making because symptoms of tolerance early in their substance use will likely include some of the following consequences: reduced academic success and increased medical and legal histories. It also can provide guidance toward determining if this patient took additional significant risks to health, education, and legal freedoms in order to obtain and recreate that initial experience.

Chronicity and Withdrawal

Baldacchino et al.7 (2012) indicated that chronic opioid use and withdrawal experiences have been reported to be associated with a number of neuropsychological impairments during both active use and after a period of abstinence. As drugs produce less and less of the desired effect, risk-taking will become extensive. When the inability to sustain current levels of use is paired with the inability to manage use or afford the consequences of this maintenance, there will be a noticeable increase in anxiety as the patient begins to realize that their current level of substance use is not sustainable. Due to the increase in required substance use to avoid withdrawal, fear will begin to motivate and take over most aspects of this patient’s behavior. For example, in the mind of the patient struggling to find the maintenance solution to their SUD, fear of withdrawal becomes the most important issue that requires resolution with the resolution being more use. It is likely that this patient will display behaviors that are aggressive, irrational, and suggest that any and all measures will be taken to continue using. The brain and the body are “dysregulated” to the point where the patient struggling with SUD will continue seeking use of substances for relief and regulation at all costs.

When fear, increased dosages, and reduced options in obtaining drugs lead to further increases in reckless use, the result will be yet even more examples of extreme negative consequences and cycles of depression partnered with intense mood swings. The downward trajectory of this patient is even quicker when the onset of use occurs at a younger age. Normally, a patient struggling with an SUD has likely considered suicide. Many will not follow through on these thoughts but due to the chronicity of use, consequences, and intense fear of withdrawal it should be expected that there is always potential for suicidal ideations. Some will report multiple suicide attempts. Using an extensive amount of substances on a single occasion just to see “what might happen” should also be considered a suicide attempt.

Even when attempts are made to limit or stop using—most often under external pressure from the legal system/medical professionals, or even family and other social supports—the combination of emotional pain and physical discomfort that goes with withdrawal often becomes too intense. It is common for the outcome in this case to be to see a patient frequently, with periods of sobriety being brief. Remember, for the user substances are now the solution to their problem as long as they can maintain use. For many with an SUD, years have passed with little to no progress toward the expansion of emotional, intellectual, and spiritual maturation. In short, a patient with an SUD has chronologically grown up, but their other aspects of development have likely been inhibited. Interestingly, they are often unaware that they have fallen behind non-addicted peers regardless of their age or developmental stage.

Withdrawal experiences are experienced as extreme negative events, and the emotions (dysregu- lation) associated with the negative events are intense. Patients with SUD often drift toward isolation. Isolation further exacerbates fears and insecurities which further diminishes the ability to receive support from family and friends. Episodes of depression and extreme moods become so intense that the inability to understand or control emotions becomes normalized.

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