Signs and Symptoms - What to Look for
The signs of substance use disorder (SUD) tend to be both obvious, and hidden. Once someone has crossed the line into addiction, hiding use behavior becomes the norm. This is difficult on those close to the addict. Nobody wants to believe that the person they love, work with, or rely upon has a substance abuse problem, leading many who are close to the addict to dismiss or rationalize SUD behaviors. Nearly all just hope and pray it will go away, but far too often the dysfunction only progresses.
Sometimes a precipitating crisis event (PCE) is enough to jolt the afflicted person into quitting. Just as often, stopping isn't possible without treatment and help. Hidden use is a hallmark of addiction. It breaks trust bonds and leaves loved ones and colleagues in a constant state of questioning. Close relationships become very strained and unhealthy.
Many of the signs that one has lost control are obvious, while others aren't quite as clear. An addict will typically do all he or she can to minimize the obvious signs of use. These signs and symptoms will also differ somewhat depending on the individual and the primary drug of abuse. All addiction, no matter the drug of choice, has a common theme - Isolation. Addicts tend to withdraw from family, friends and colleagues. They seem more distant and preoccupied. They tend not to be around as much, and alternate between elated moods, and angry, depressive affect. Unfortunately, many of these behaviors are also typical of overworked, stressed lawyers who don't have SUD.
SUD rarely occurs suddenly. Its akin to the boiling frog fable. A frog will immediately jump out of a pot of boiling water, but If the frog is put into tepid water that is slowly brought to a boil, it won't notice its being cooked alive. Alcohol addiction in particular, tends to develop gradually. Neither the alcoholic, nor those close to the him, recognize the progression until dependence has taken hold. At this point, the pull of addiction is often too strong, causing the afflicted to engage in ever more secretive use behavior.
Signs and Symptoms of Alcohol Use Disorder (AUD)
AUD is one of one the most recognizable forms of SUD, but it can also be effectively hidden for years. Alcohol pervades society, and is legally and socially accepted. In many environments, consumption is encouraged. AUD also progresses relatively slowly compared to addictions involving other drugs of abuse, e.g. opioids/opiates.
Alcohol, contrary to popular conception, is a hard drug. Ethanol is a relatively small, water soluble molecule that has wide reach, and profound effect throughout the body and the brain. It produces intense euphoria, disinhibition, mood volatility, and disruption of motor control functions (stumbling, slurred speech, etc.). The pupils in the eyes of drunk people become dilated, and the skin takes on a flushed appearance. Alcohol also has a very strong odor that is easily detected on someone who has had a lot to drink.
As someone progresses along the AUD spectrum, tolerance builds. More alcohol is needed to achieve the same effect. These people can "hold their liquor." Those with high tolerance tend to fly under the radar because they don't act overtly drunk, however, increased tolerance is a tell-tale sign that AUD is taking root and becoming more manifest.
A typical AUD progression scenario usually involves a PCE, with the afflicted engaging in some form of inappropriate behavior spurred by behavioral disinhibition caused by excessive alcohol, e.g. DUIs, making wholly inappropriate comments at a social event, groping, sending inappropriate texts, extreme and unwarranted outburst of anger, failing to meet family or work responsibilities due to a hangover, etc.
Its usually at this point that the individual is confronted by someone close to him. He begins to question his use and promises to stop, or swears to rein it in. He truly means to cut back or quit. Many do, but studies show that only about half of the people who have had an alcohol problem are able to recognize the profound implications and quit on their own. For the other half of us, there is something within, probably influenced by our biochemistry, that prevents us from asserting rational control over our drinking. In order to continue using, we engage in manipulation strategies because to us, using has become akin to survival.
The Manipulation Strategies
The Rein It In Phase. Nearly all of us with AUD go through the rein it in phase, and we truly want to rein it in, but we've past the point of no return, and don't realize we've crossed the line into addiction. Our family, friends, and colleagues also want to believe that we can rein it it. So we try, but we find that having one drink is too much, and having twenty is never enough. We can't control how much we drink, and we find that we need to drink to function.
Seeking motivation is a primary factor in this stage. We can't motivate ourselves to do much of anything without some alcohol on board. We don't realize that the motivation circuits in our brains - The dopaminergic neural pathways - have been hijacked. Normal levels of dopamine are essential in motivating all of us to attend to the activities of daily living, perform at work, and seek healthy, natural rewards - hobbies, etc. Persistent alcohol abuse results in significantly lower naturally occurring levels of dopamine. Over time, our brains adjust and attempt to return the dopamine system to stasis. When this occurs, and alcohol isn't present, dopamine levels remain abnormally low. We feel unmotivated, stressed, depressed and lack any sense of pleasure in living an abstinent, "normal" life. The only way to stimulate our dopaminergic pathways to feel functional is to consume more alcohol. This paradigm is one of the primary reasons early recovery is so difficult. It takes months, and sometimes more than a year of abstinence, for dopamine circuits to adjust to a sober state and return to naturally healthy homeostasis through the process of neuroplasticity. The same basic phenomenology and biochemistry manifest in addiction to drugs of abuse, other than alcohol.
When the AUD afflicted person is in the rein it in phase, we know we're being watched, so we have to be sneaky about our use. We haven't yet been hit with the "quit or else" ultimatum, so we maximize one of the alcoholic's most effective strategies - "The Cover."
The Cover: The Cover takes advantage of alcohol's pervasiveness throughout society and allows the alcoholic to drink at abnormally high levels while covering his overconsumption. The Cover works like this. An attorney has a work related social event. He knows that he is going to be watched, so just prior to the event, he drinks heavily. He has one visible drink at the event to show his colleagues that he is successfully reining it in. If he has later stage AUD, he might bring a alcohol with him, and go to the bathroom to drink out of view. His tolerance is high, so he is able to maintain proper decorum and appear appropriately sober. He has his acceptable and allowed "rein it in" drink, which provides cover should anyone smell alcohol on him.
There are any number of cover moves, and its amazing how many of us with AUD came up with the same, intricate strategies all on our own. The objective of the cover is to find a venue where it is acceptable to consume a drink or two. Use that consumption to cover the excessive drinking we do secretly, in close temporal proximity to the cover event. The cover can work for years. Occasionally, we'll go overboard and get in trouble, but we'll rein it in again for a while, and continue to use cover strategies to hide our excessive drinking.
"The Switch" is a version of the cover. It usually starts as a genuine attempt to switch to non-alcoholic beer as a substitute for the real thing. It often ends up being used as a cover to mask the alcohol smell created by the alcohol secretly consumed. Our hypothetical attorney can have a couple shots of vodka, and if he's questioned about the smell, he points to the non-alcoholic beer as the culprit.
Slight of Pay: Another move is the slight of pay. Our same attorney goes out after work, intending to have one drink with a colleague. He tells his wife he's going to be late because they need to strategize about a case. He promises he's only going to have one drink. He and the colleague each order a drink. He immediately pays with his credit card, closes the tab, and gets the receipt showing two drinks. After the one drink is finished, they decide to order another. This time, the colleague pays, and says he has to get home. They both leave the bar, but our attorney can't control his drinking once he's started. He craves more, so he tells his friend he's going to the bathroom to avoid waling out with him. He then goes back to the bar alone. He orders four more drinks in quick succession, and pays with cash. He gets home, and his wife is suspicious that he's again had too much to drink. He pulls out the credit card receipt and shows it to her - "See, we only had a one drink each." Our hypothetical lawyer semiconsciously knew that there was a good chance he'd be coming home "hot" that night, so to hide his use he employed the slight of pay to manipulate his wife.
There are many variations of the slight of pay. The financial aspect of addiction has to be managed. Alcohol and drugs cost money, and a spouse who closely monitors finances is likely to notice financial discrepancies. When someone is in the "rein it phase" a drink here or there will show on credit or debit card statements, but the heavy, secretive drinking is almost always paid for with cash. A pattern of inexplicable cash withdrawals can be an indicator of heavy, secretive use.
The Substitute: A common strategy involves substituting another substance of misuse for alcohol, typically marijuana. With weed now legalized in a number of states, and easily obtainable by many, the "marijuana maintenance" strategy is an attractive option to secretly keep using intoxicants, while trying to rein in alcohol consumption. Marijuana use is harder to detect. It tends to be less debilitating than alcohol, and it doesn't smell. This may surprise the uninitiated. Marijuana smoke does have a characteristic, pungent odor when smoked, but unlike the lingering smell of alcohol, the odor of smoked marijuana quickly dissipates. The advent of wide spread legalization has brought new ways to ingest marijuana without smoking. Only 35% to 40% of the "legal" marijuana sold is the traditional smokable bud or joint form. The majority of legal weed is now consumed as edibles, vape cartridges, and other concentrates. There is no smell associated with the use of these other forms of marijuana and they are compact, making use much easier to conceal.
Sedatives are another common substitute. A significant number of us with AUD have been told to go see our doctors; that we're drinking too much because we're too stressed. Unfortunately, this is an all too common scenario with attorneys. We go see our physicians, and explain that we're stressed and anxiety riddled. Doctors do what they're taught to do, and prescribe anti-anxiety medication, usually in the form of benzodiazepines (Valium, Xanax, Klonopin, Lorazapam, etc.). We have evidence that lawyers consume benzodiazepines at rates greater than the general public, and seek treatment for benzo addiction at twice the rate of the public at large. Benzo's are dangerous drugs, with a high overdose potential, especially when mixed with alcohol. Those of us with AUD also tend to really love these drugs. Opioid pain medication is another common substitute for alcohol.
One of the real dangers when dealing with someone with AUD engaged in the substitution gambit is the overdose potential. Combining alcohol with sedatives and opioid pain medication is a leading cause of accidental overdose death. Monitoring a person with AUD solely for excessive alcohol consumption often has the deleterious effect of pushing the afflicted into using substances that aren't being monitored, often those drugs with dangerous overdose potential,
If someone who is trying to rein it in or quit alcohol, appears to have limited their drinking, or quit, but still shows the tell-tale signs of intoxication, the substitution ploy may be the reason.
The Disappearing Act: This is a favorite move of attorneys with AUD. The law is a time consuming profession. Working late is accepted, and often expected. If our hypothetical attorney loses control of his afternoon drinking and is too drunk to go home, he will often play the "I have to work late" card. He'll continue to drink and won't go home until after his wife has gone to bed. He'll sneak in and sleep in the spare bedroom to avoid being smelled, under the auspices of not wanting to wake her.
Alcoholics tend to disappear a lot. Our attorney's secretary may notice that he leaves his office every few hours in the afternoon for no apparent reason, and comes back ten to fifteen minutes later, after he's gone to his car where he has a bottle stashed. He keeps a bottle of hand sanitizer on his desk and uses it when she walks into his office. The hand sanitizer acts a cover for the smell of the alcohol consumed.
Our lawyer's wife may notice that he frequently goes to the garage in the evening for no apparent reason. He may go to the bathroom a lot. A favorite place to hide bottles is in the toilet tank. The bathroom is close, convenient, private and tends to draw less suspicion. Virtually nobody just randomly checks a toilet tank. He might make nightly trips to his vehicle to get the briefcase, or some other item he "left" in his car.
Bottle Management: Bottle management issues are the bane of having AUD. Alcohol is voluminous and It isn't compact, like other drugs. It produces empty bottles - Lots and lots of empty bottles. These bottles need to be dealt with. They can't be put into the recycling bin at home. They can't be dumped in the office trash can. There is usually a stash of empties hidden somewhere, typically in close proximity to the home, or in the trunk of the car. These bottles are then periodically dumped somewhere - The trash cans at gas stations, grocery stores, malls, McDonalds, etc. are favorites. Often bottles are thrown out the car window on the way home. If you happen to run across a stash of hidden empties, its time to understand that help is necessary. The AUD has progressed to a point where "reining it in" has failed and addiction has taken hold. At this point, your loved one is unlikely to be able to stop without help.
The Breathalyzer: Nightly breathalyzer checks conducted by the spouse are often the next step when reining it has failed a number of times. It seems like a good accountability measure, but Its usually not. It sets up an exceptionally dysfunctional paradigm within the marriage. A spouse should never manage SUD, and a nightly breathalyzer protocol too often drives SUD drinking patterns to become more morning focused. There are also a myriad of ways to manipulate a spousal managed breathalyzer program. Those of us with AUD figure out how to side-step and get around the breathalyzer. Monitoring is critical in early recovery, but should always be handled by professionals, not those close to addict.
There are any number of strategies that those with AUD use to secretly drink, or use other intoxicants. Many of them are outlandish, yet effective. The ingenuity we addicts can conjure to manipulate and hide our use is astonishing. Unfortunately, a lot of the outward signs of AUD are also prototypical presentations of overworked, stressed, attorneys who aren't drinking alcoholically. Those close to the attorney tend to pass off suspicious behaviors, and odd smells as something other than aberrant alcohol or drug use.
The fear of those close to the addict tends to make unwitting enablers of family, friends, colleagues. The wife is petrified he'll lose his job, and they'll lose the house. The secretary likes her job, and likes her boss, and doesn't want him to be fired. Colleagues are busy and either don't notice, don't want to rock the boat, or think someone else should deal with it.
Those closest to the afflicted attorney don't know what to do. Those of us who have been trapped in active SUD also don't know what to do. The uncertainty among all stakeholders inherent in not knowing what to do, coupled with the stigma and irrational nature of SUD, lead to a heightened bystander effect. The bystander effect occurs when there is ambiguity or diffusion of responsibility to provide help. Those close to the addict think someone else will or should be dealing with it. Too often, the result is that nobody finds the afflicted attorney the appropriate help until the AUD has created too much destruction.
If your observations and your gut keep telling you that something isn't right, it probably isn't right. The best thing to do if you notice repeated patterns of manipulative hiding use, is to contact a professional to seek help. Addiction is progressive. Too many of us can't stop without help, but that help is out there, its just a matter of reaching out to get it.