Die without Coffee? Treating a Legal Addiction

This psychoactive stimulant causes 13% of addicts to suffer from symptoms so severe, they cannot psychologically or physiologically function without it. It causes them to experience heart palpitations, irritability, sleeplessness, distraction, headaches, mood swings, hyperactivity, depression, nausea, dehydration, and other side effects. It accounts for an estimated 20,783 emergency room cases in 2011. It has killed before, and it probably will kill again.

And it’s entirely legal.

Caffeine addiction seems almost laughable in a social climate where the word “addict” is more synonymous with alcohol and illicit and prescription drugs. After all, the substance permeates daily life. Billions of us humans (and even some nonhumans) perk ourselves up with daily doses of coffee, tea, soda, and other caffeinated consumables. But psychology professionals find the phenomenon of caffeine addiction disconcerting enough to make a compelling case for it as a diagnosable disorder.

What is Caffeine Addiction?

Caffeine addiction is exactly what it sounds like. It happens when the body and the mind require the stimulant to keep themselves pressing forward throughout the day.

To some extent, we’re all at least a little bit hooked. Some of this stems from increased work hours and decreased vacation days. We percolate and perk up in order to meet demands levied by our jobs and our lives. And, as our consumption swells, businesses tailor their products to meet our jittery needs. This establishes a dysfunctional loop. Our bodies keep requiring more and more caffeine in order to maintain equilibrium. We keep getting sold more. Our bodies “level up,” so to speak, and we are no longer able to function on what the market offers.

Dr. Steven Meredith, a behavioral pharmacologist at Johns Hopkins University School of Medicine, does not believe that caffeine addiction and consumption increased with time. Social and commercial factors involving the substance have, however, which might create the impression that more of us tweak out than ever before.

“There is no empirical evidence to suggest that the prevalence of caffeine addiction has increased recently. In fact, to my knowledge, there is no evidence to suggest that caffeine consumption has increased,” he says. “However, there has been a relatively recent change in the way some people consume caffeine, especially adolescents and young adults.”

“For example, Red Bull didn’t appear in the U.S. until 1997. Although soft drinks typically contain about 40 mg of caffeine in a 12-ounce serving, the same serving size of most energy drinks contains three times or more than this amount. And these products are marketed very differently than soft drinks, or even other caffeinated beverages like coffee,” he continues.

He notes the increasing significance of marketing and advertising in shaping caffeine ingesting habits: “Energy drinks are marketed as performance enhancers. And they’re consumed differently than other beverages that contain similar quantities of caffeine. My guess is that most kids don’t chug cups of hot coffee before playing sports. But, energy drinks are more likely to be consumed in this way,” Meredith says. “They are also often combined with alcohol. So energy drinks are quite different than the types of caffeinated beverages that have been consumed historically.”

Between 2010 and 2011, sales of energy drinks spiked by 31.6%. The average cup of coffee in the 1950s was only about five ounces and dosed sleepy drinkers with 70 to 100 milligrams of caffeine. Today, we require a 16-ounce cup containing 330 milligrams or more. And we’ve become so collectively dependent, it only takes between 12 and 24 hours of abstinence from 100 ounces of caffeine to start experiencing withdrawal symptoms.

How Does Caffeine Addiction Work?

As with the addicts receiving more media attention, caffeine dependents experience a tragic barrage of symptoms destroying body and mind alike. These range in severity from mild and curable without medical intervention to, unfortunately, critical health concerns – including death.

“Like other drugs of abuse, habitual caffeine consumption can also result in physical dependence. For example, drug users develop tolerance to the effects of many abused drugs, which means they need to consume more of the drug to achieve the same effect that lower doses previously produced,” Meredith explains.

“Moreover, when drug users abstain from some drugs after chronic use, they experience withdrawal, which often has the opposite effect of the drug – usually consisting of a number of unpleasant symptoms,” he says. “Thus, habitual caffeine users often consume the drug just to relieve withdrawal symptoms.”

The Psychology

Addictions are commonly referred to as “self-medicating,” and despite society’s collective obsession with the substance, some consumers do have a higher psychological risk of dependency. Individuals already possessing a genetic predilection toward anxiety tend to abuse caffeine at slightly higher rates than their calmer peers.

Caffeine activates the very same adenosine receptors as anxiety. While some may rely on the substance for comfort, it does actively subvert the desire at the physiological level.

“Genetic polymorphisms in the adenosine A2A receptor gene (ADORA2A), are associated with caffeine consumption; sensitivity to the effects of caffeine following sleep deprivation; and the effects of caffeine on anxiety, sleep, blood pressure, and psychomotor vigilance,” explains Meredith. “In addition, variability in the cytochrome P450 1A2 (CYP1A2) gene, which codes for the primary enzyme responsible for caffeine metabolism, is associated with variability in caffeine consumption.”

A similar effect occurs in depression patients. Minute amounts of caffeine might alleviate some of the condition’s symptoms, but in abundance it could exacerbate them. Unlike anxiety, however, consuming the substance does not directly correlate with the diagnosis. Rather, it worsens the effects of common triggers – sleeplessness, for example. Insomnia and other sleep difficulties do immediately lead to depression.

But even consumers with no history of mental health still may suffer from caffeine-induced medical issues.

The Physiology

“As with other drug dependencies, caffeine dependence appears to be influenced, in part, by genotype,” Meredith says. “Studies comparing monozygotic and dizygotic twins have shown that the magnitude of heritabilities of caffeine use, tolerance, and withdrawal is similar to those for nicotine and alcohol.”

Known as caffeine intoxication, the physical side effects of consumption impact pretty much everyone. Depending on their weight, body chemistry, and the amount of caffeine ingested, individuals could contend with one or more of the following: lethargy or exhaustion, nausea or vomiting, a surging heart rate, difficulty concentrating, insomnia, twitching or tremors, gastrointestinal distress, and muscle pain.

Timing and dosage also impact the severity of caffeine intoxication. To meet the diagnostic criteria, a patient must consume at least 250 milligrams and experience five or more symptoms. Withdrawal begins waning between 24 to 48 hours following consumption, depending on abstention.

Energy drinks – either alone (60%) or in conjunction with alcohol (13%) or drugs (27% prescription, 10% illegal) – account for an estimated 20,783 emergency room visits in 2011. Five years prior, that number was 10,068. Most patients were either teens or young adults, and at least five individuals died as a result of overdosing in the fall of 2011 alone.

Even discounting emergency scenarios, caffeine still holds influence over the body’s processes. Its overall impact on heart health remains unclear, but it does alter the metabolism. This poses an especially dangerous risk to pregnant women and their fetuses.

“Research suggests that caffeine can increase perinatal complications. Caffeine is rapidly and widely absorbed throughout the body – it even passes through the placenta to fetuses, and it is absorbed into breast milk,” explains Meredith. “In addition, caffeine metabolizes at different rates across individuals. For example, caffeine metabolism is slower in infants, pregnant women, and individuals with liver disease, and some medications slow caffeine metabolism, which may result in caffeine intoxication.”

“Women who are pregnant or breastfeeding should avoid excessive caffeine consumption, and individuals taking medications and those with liver disease should check with their physicians before consuming too much caffeine,” he says.

Mainstream medicine is not calling for the government to make caffeine illegal. Despite recent inquiries into regulation, very few with any amount of power or influence, save for Alderman Edward Burke of Chicago, seem too concerned with instigating an outright ban. Eliminating access likely won’t eliminate usage, anyway. Curing caffeine dependency requires willpower and medical, not federal, intervention.

But How Do You Know Who’s an Addict?

As Meredith points out, “about 90% of adults in the U.S. use caffeine regularly, and the vast majority of these caffeine users consume the drug without encountering any negative financial or social consequences associated with continued use.”

The delineation between user and abuser happens when consumption begins interfering with daily life, work, relationships, and physical functioning.

“Addiction is essentially a choice disorder,” he explains. “Thus, all drug addictions have in common certain behavioral mechanisms. This is because drug use is operant behavior, which means it’s maintained and modifiable by its consequences. Most abused drugs function as reinforcers … Although some reinforcers are good for us, like food and water, other reinforcers, like drugs of abuse, can be detrimental to our long-term well-being.”

Meredith explains how addiction works from a psychological perspective. These habits separate the average caffeine consumer from an individual qualifying as a dependent: “Each time we choose a reinforcer or choose to engage in an activity (e.g., eating), we are essentially choosing not to engage in incompatible activities (e.g., sleeping, jogging, sky diving, etc.). Whether we make this choice consciously or not, we tend to choose the activity that results in the most valuable reinforcer,” he says.

“So if there are enough reinforcers available to us to compete with drug use, many of us choose not to use drugs,” he continues. “For example, if we have plenty of money, food, clothing, shelter, a job, a spouse, a family, and, especially, if we risk losing all these things if we become addicted to a drug, we may choose not to use a drug.”

“So, this is essentially addiction in a nutshell – a disorder of choice. Of course, some drugs are more addictive than others, but these fundamental behavioral mechanisms work the same across all forms of substance abuse,” he says. “Thus, some forms of treatment are applicable across a variety of abused substances.”

How Do You Treat Caffeine Addiction?

The staggering majority of caffeine consumers require absolutely no medical intervention. These individuals possess the ability to set their own limits and the discipline to stay within them.

But a small subsection needs psychological or physical assistance to preserve their health and safety, as quitting proves a task they cannot overcome solo. Every patient requires something different depending on multiple factors, such as severity and the presence of any comorbid disorders. However, there are some basics most professionals will likely implement – approaches that also help more self-directed dependents.

“Caffeine users who want to quit should consider keeping track of their caffeine consumption in a daily caffeine diary,” Meredith recommends. “Rather than abruptly stopping caffeine use, they should gradually reduce consumption over the course of several weeks (e.g., by consuming fewer or smaller caffeinated beverages each week, or by gradually mixing in more decaffeinated beverages into their caffeinated beverages). This method will help caffeine users avoid withdrawal symptoms associated with acute abstinence.”

He provides examples for what different severity levels might expect when weaning off: “[Milder addicts] should be encouraged to quit caffeine or consume it at safe levels (e.g., no more than 500mg/day), and those individuals who consume excessive amounts of caffeine should talk to a physician to find out if they have any co-morbid conditions that could be exacerbated by caffeine consumption (e.g., heart conditions or anxiety).”

“Unfortunately, there are few other treatment options currently available,” he says. But Meredith reassures us that “researchers at The Johns Hopkins University Behavioral Pharmacology Research Unit are currently investigating behavioral interventions to promote caffeine reduction and cessation.”

What Can Peer Counselors Do?

With the prolificacy of energy drinks and other caffeinated consumables on college campuses, it is entirely possible that psychology students performing peer counselor duties might encounter a dependent. They might consider distributing resources teaching their classmates how to responsibly stimulate themselves with caffeine.

“Education is important … Some people may be unaware of how much caffeine they’re consuming each day. They may also think that caffeine is improving their physical or cognitive performance,” Meredith explains.

“Regular caffeine users begin to experience decrements in physical and cognitive performance due to withdrawal less than 24 hours after consuming their last caffeinated food, medication, or beverage,” he continues. “Therefore, any performance improvements they experience are likely due to alleviation of withdrawal symptoms.”

Keep his points in mind when beginning a peer counseling session. And the following advice will also provide the best possible care for suffering students.

  • Listen: And genuinely listen. Don’t make assumptions or project personal opinions onto students. Let them discuss what’s on their minds. Sometimes, this is all it really takes for them to form their own conclusions; they don’t need their objective third parties to turn into subjective, second, or – even worse – subjective second parties.
  • Be compassionate: Students seek out peer counselors for empathy and nonjudgment. Avoid hurling blame, abuse, and other potentially hurtful commentary during sessions. The old credos about “putting yourself in someone else’s shoes” and “treating others as you want to be treated” apply perfectly here.
  • Keep confidential information confidential: Unless the safety (even life) of a peer or another individual is undeniably at risk, respect students’ privacy. Schools themselves will provide confidentiality agreements their student counselors must sign and honor, outlining specifics of what stays, what can be told, and the penalties for violating the contract.
  • Refer them to professionals: Peer counselors can legally only provide so much support. If a fellow student seems a severe enough case, point him or her in the direction of a suitable professional, located on or off campus. The best peer counselors research and forge relationships with legitimate local mental health providers and know which ones will provide the right attention for their charges’ needs.

Meredith also advises peer counselors and other mental health professionals to understand the potential overlaps between caffeine dependency and further substance abuse. Addicts might display signifiers that their consumptions spread beyond energy drinks and coffee.

“Counselors should also keep in mind that caffeine is a psychoactive drug,” he says. “Although we don’t yet know the long-term consequences of continued use, abuse of one drug often leads to abuse of other drugs, and some survey-based studies suggest that energy drink consumption among young adults predicts alcohol-related risky behavior and subsequent nonmedical prescription drug use.”

Official recognition of caffeine dependence as a psychological disorder crawls despite the compelling evidence and pressure from the medical community. However, researchers do not embrace a lost cause.

“The World Health Organization already recognizes a diagnosis of Caffeine Dependence Syndrome in the International Statistical Classification of Diseases and Related Health Problems (10th Revision; abbreviated ICD-10),” Meredith points out.

“The American Psychiatric Association is including proposed diagnostic criteria for a ‘research diagnosis’ of Caffeine Use Disorder in the DSM-5 [to be released May 18, 2013],” he adds “Although the DSM-5 isn’t recognizing Caffeine Use Disorder as a clinical disorder, including Caffeine Use Disorder as a diagnosis for further study should stimulate much needed clinical, epidemiological, and genetic research on the disorder.”

A precedent for acceptance already exists. Emergency rooms and psychotherapists already combat the adverse effects of the world’s most beloved psychoactive substance. They just need the definitive diagnostic criteria to do it. Once the disorder finally receives its due, medical professionals will possess the education, references, and resources necessary to promote health and happiness.