How many Americans struggle with substance abuse? According to a U.N. report, last year, about 22.2 million Americans, or almost 10 percent of the population age 12 or older, were classified with substance dependence or abuse. But between these people and those who don’t use drugs at all there is a group of regular users who qualify as being “almost addicted,” says J. Wesley Boyd, MD, PhD, an assistant clinical professor of psychiatry at Harvard Medical School. Here, Boyd explains the slippery slope negotiated by those who occasionally pop an upper or downer, or indulge in a line of cocaine—or some other drug of choice—every so often to boost productivity, relieve stress, relax or get into a party mood.

What does “almost addicted” mean exactly?

It’s a term we coined to describe drug use by people who can use drugs here and there and not get into any trouble as a result of it. But it also describes a broad swath of people who fall into an in-between group who use drugs in an unproblematic way and those who are fully addicted. When people are almost addicted, their drug use might not rise to the level of full-on addiction, but it’s currently causing problems in their lives in one way or another. And also if it’s not held in check, it might progress to full-on addiction.

What makes an almost addiction problematic?

Even if their lives have not been ruined because of drug use, people who are almost addicted, in fact, are paying a price for their drug use. For example, they might be giving less than their full effort at work; there might be some problems in the family that arise as a result of their drug use, and so on. Certainly, if their drug use isn’t held in check or addressed at the almost addicted stage there’s the risk that it can develop into a full-blown addiction. In fact, in my book, Almost Addicted, I tell the story of a doctor who for a couple of years was using opiate pain medications in an almost addicted manner. The doctor would use the meds to relax after work here and there, but wouldn’t really get into big trouble in any particular way. But after a year and a half of using meds in an almost addicted range, his drug use exploded into a full-on addiction that ultimately led to his professional and personal life crashing down around him.

What are some of the major signs that someone’s drug use crossed over from almost addicted to full-on addiction?

The biggest signs would be that your life now revolves around drugs. Now, more or less, day in day out you’re thinking about obtaining drugs, using drugs and looking forward to the next time you can use drugs. Often, if you’re fully addicted some part or parts of your life—not just your personal health—may be severely affected. For example, your relationships and work might suffer; your housing might be put in jeopardy because of your addiction. And also there are physiological signs of addiction. For example, when you have to use ever-increasing amounts just to get high and then also you might experience physical withdrawal when the drug is not in your system.

At what point is intervention most effective if you notice any of these signs?

As early as possible. In the book, one of the things we encourage people to do is to have as honest a look at themselves and their relationship to drug use as possible, so they can see the problem early. For someone who is almost addicted, this might mean not necessarily going into rehab, but certainly changing their drug use habits and changing their relationship to the drug. It might mean possibly reaching out to doctors or friends or family and discussing their drug use to try and get help and figure out solutions for either using less of the drug or simply stop using the substance.

What happens if the person is in denial?

Denial is to be expected. That’s really the name of the game when it comes to substance abuse of any sort. Since I’ve finished med school, I’ve worked with drug-dependent people for 20 years, and denial is just a part of the territory. That’s why talking with others and getting their input is one way of helping to break through denial.

What is the best way to approach your friends or loved ones if you know they have this problem?

I would open a dialog with them, and I would try sticking to the facts and avoid rushing to judgment. What that means, for example, is saying “I smelled alcohol on your breath three times in the last four weeks, and you were slurring your words two nights ago, etc. etc.” as opposed to “I think you’ve got a problem with drugs and alcohol.” Just stick to the facts. Try to keep it as unemotional as possible and try to bring up the issue when it’s not hot in the moment. In other words, leave it for the next day or two days from now as opposed to when the person seems like he or she might actually be under the influence.

Your book also focuses on prescription drug abuse. In your opinion, is this type of drug abuse more or less of a problem than abuse of illegal narcotics, such as cocaine or heroin?

I think both of these problems are equally big. The reason prescription drug abuse scares me a little more is because those drugs are prescribed in certain circumstances for medical reasons and they can appear to be more legitimate to some individuals than drugs like cocaine or heroin that are simply illegal across the board. If something appears to be legitimate, or, in fact, does have legitimate medical value, then people might be prone to abuse it and less likely to see it as the significant problem it is.

What advice do you have for people worried about loved ones who engage in casual drug use that may or may not be problematic?

I would keep my eyes open as much as possible and try to keep a dialog going with the individual to let them know your concerns in the moment and also that you’re obviously concerned this might grow into a real problem down the line. Bring in other people if need be so it’s not just a one-on-one confrontation. Bring in other loved ones and bring in clergy if the person is religious, or ask them to see a primary care doctor. Sometimes, that’s less stigmatizing than seeing a mental health worker. Also, for some individuals, trying to get them to go to an Alcoholics Anonymous (AA) or a Narcotics Anonymous (NA) meeting can be helpful. A lot of people think that to go to an AA or an NA meeting you have to be an addict, but all going to those meetings require is simply that you wish to stop using the drug that you’re concerned about, not that you have stopped, not that you’re an addict or anything like that. When you go to those meetings, it’s just that you have a desire to stop using the drug.