Addiction comes in packages – not the type of packages you want on your birthday or for Christmas, but packages that develop over periods of time and involve excessive behavior with more than one object of addiction. Rarely in my clinical work and research have I experienced patients that struggle with only one addiction. If you abuse methamphetamine or cocaine, chances are good you have struggled with out-of-control sexual behavior. If you gamble, chances are good you also drink or smoke. If you use drugs of any kind, you likely drink and use cannabis as well.

And of course the packages usually include a lot of other issues as well: mental health problems (trauma, depression), physical health problems (chronic pain, diabetes, hypertension), and a wide range of psychosocial problems (relationships, debt, unemployment, legal problems). When we combine all the issues with addiction what we see clinically is a complex mess. What makes treatment so difficult is really understanding how all the issues interact with each other, and where to start with intervention. Many who receive treatment from a private practice clincian rely on what happens in just one hour out of 168 in a given week. Not much time to intervene when so many issues are present.

One of the best descriptions of the “packages” is a chapter written by Patrick Carnes, Robert Murray, and Louis Charpentier titled “Addiction Interaction Disorder” found in the Handbook of Addictive Disorders: a Practical Guide to Diagnosis and Treatment, edited by Robert Coombs (2004). In the chapter, the authors define 11 dimensions in which different addictions interact with each other. For example, masking occurs when “an addict uses one addiction to cover up for another, perhaps more substantive addiction.” Such is the case when a patient says “I did all those sexual things because I was high on methamphetamine.”

The key point of all of this:  to successfully intervene it is necessary to address the package of addictive behavior, and the co-occurring issues that go alone with the addictions as well. We must move away from treatments and interventions that focus exclusively on specific objects of addiction, and learn to think systemically about all of the various issues causing problems. This is why I am not a fan of certifications focused exlusively on drugs, gambling, or sex. What we need are clinicians who can treat the entire package.