CHAPTER 1
Why A Person Can't Stop: Understanding the Science of Addiction
Introduction
Addiction has been one of the more perplexing disorders to treat over the years. No other disorder has created more confusion or controversy, or for that matter, debate as to what needs to be accomplished for someone suffering from an addiction. Fortunately, there continues to be an emergence of research in the field of the neurosciences that is shedding more light on addiction and, especially, on how best to address and to treat this life threatening illness (Koob, G.F. and Volkow, N.D., 2010; Kalivas, P. and Volkow, N.D., 2005; Ting-Kai, L. and Volkow, N.D.,2005).
Although researchers have garnered the necessary information to support and strengthen the side of those proponents of the "disease" concept of addiction, understanding the process of addiction continues to remain unclear, if not confusing, for many (O'Brien, C. P., Volkow, N., & Li, T. K. 2006). Despite the widespread use of the term "addiction," the concept of addiction, itself, still has difficulty being accepted by many as a bona fide medical illness or mental disorder. It has only been recently that the Diagnostic Statistical Manual (DSM), the basic text for mental health and addiction professionals, has referred to the term "addiction." Even still, there are those professionals that argue that the term "addiction" continues to remain too vague and too general.
Contributing to this confusion is the inconsistency to what actually constitutes an addiction. Is the person who is physically dependent on prescribed pain medications as a result of a chronic injury or illness, yet functioning effectively in the environment, considered addicted? Is there a difference between a young adult in college who binge drinks on the weekends and the middle age man who engages in similar behavior on the weekends?
To complicate matters further, there is also a qualitative issue present. Does the person who engages in compulsive gambling, shopping, or sex have the same illness as the person who engages in compulsive drinking or drug taking? Is an "addiction" to chocolate qualitatively different than an "addiction" to heroin? If so, why? If not, why not? The answers to these questions have significant consequences. As our understanding of the addiction process deepens, so will our ability to effectuate a more valuable recovery process.
One of the other challenges that have emerged from this confusion regarding addiction is that there is no consensus on what a person needs to do in order to achieve a successful recovery. Despite the considerable amount of attention devoted to the science of addiction, there is no similar effort devoted to the science of recovery. Clearly, if there is a science of addiction, there must also be a science of recovery.
For the purposes of this book, it cannot be emphasized too strongly that the phenomenon of addiction does, in fact, exist. It is a neurobiological process that can affect anyone, at any time, regardless of a genetic predisposition. It is a further contention that whether a person is addicted to chocolate, or addicted to heroin, the same type of neurobiological brain processes occur. The important ramification of this is that these same neurobiological brain processes need to be considered in the recovery process. Understanding these underlying neurobiological processes can play a crucial role in assisting a person in taking control of their recovery from an addictive disorder.
This book seeks both to explore, and to contribute to, the science of recovery. As previously mentioned, the science of recovery has not been a major source of focus. The limited amount of study has created a significant void regarding those suffering from an addictive disorder. "Just don't pick up" is no longer an acceptable response in light of the wealth of information and research on addiction. The time has come for a deeper and more meaningful exploration of the science of recovery. A science of addiction demands, indeed requires, a science of recovery. This book is designed, in part, to address this deficiency.
Conceptualizing Addiction on a Continuum
For the longest time, the Diagnostic and Statistical Manual (DSM) only recognized abuse and dependency with various substances as mental disorders (American Psychiatric Association, 2000). The problem that these set categories presented was that they were extremely limiting in nature. They either focused on the deleterious effects on a person's psychosocial functioning when abusing a substance or, in the case of dependence, focused on the physiological need for a substance to maintain a sense of normalcy. Either the person was abusing a substance or the person was dependent on a substance.
The problem with this narrow range of focus was it did not incorporate the full scope of behaviors that can contribute to an addictive disorder including what happens when a person simply uses a substance. Additionally, this narrow categorization did not take into consideration that there was a neurobiological process occurring. These limitations, no doubt, contributed to the confusion of what constitutes an addiction.
In order to further develop our understanding of "addiction" as a neurobiological disorder, it will be helpful, first, to examine addiction on a continuum. To accomplish this, it is important to consider how use, abuse, and dependency actually are interrelated and, ultimately, contribute to the development of an addiction.
Use, Abuse, and Dependency
Use would include situations where a person may use a substance or a set of behaviors for recreational, social, or ritual purposes without any negative ramifications. This may include drinks before dinner or at a celebratory function. The main emphasis is that the use of the substance or behaviors has no negative impact on the person nor is it the primary focus for the person.
Abuse is when the substance or set of behaviors has a deleterious effect on the level of functioning areas of a person's life. Although that person may have yet to have develop a dependence, the excessive use has created problems or difficulties that have interfered with daily functioning and responsibilities such as DUI, domestic violence, job difficulties, or physical illness.
With dependence, there is a build up of tolerance or a reliance on particular substances or behaviors whereby a person increasingly needs more of the given substance or the specific behaviors to maintain a sense of normalcy. With dependence, the person becomes physically ill when there is the absence of the substance in the person's system.
Addiction
Addiction can be defined as a primary, chronic, neurobiological disease that is influenced by genetic, psychosocial, and environmental factors that culminates in compulsive behaviors on the part of a person which prevents the controlled use of a substance or behavior despite self-harm and, as a result, there is an inability to maintain an independent, stable level of biopsychosocial functioning.
The contention, here, is that abuse and dependence need to be seen on a broader continuum, a continuum that culminates in addiction. Further, the concept of use must be considered as the starting point on this continuum. This is because it is the occasional use that sets in motion specific neurobiological processes of the brain that can trigger abuse and dependency, and can eventually lead to addiction. Since it is indisputable that use can lead to abuse, abuse can lead to dependency, and dependency can lead to addiction, use is clearly an organic member of the addiction continuum.
The question arises then does use always culminate in addiction? No, not all. The person who has an occasional drink to relieve stress may never abuse, become dependent, or become addicted. This is because of certain neurobiological processes occurring in the brain that will be discussed later on. However, because of a dysregulation that is occurring within these same neurobiological processes, use can lead immediately to addiction due to the genetic predisposition of faulty wiring in the "reward pathway" of the brain (Kipper, D. and Whitney, S., 2010; Urshcel, H.C.,2009; Erickson, C.K., 2007; Kalivas, P. and Volkow, N.D., 2005).
The same holds true for a person who may be chemically dependent on a substance but still maintains a high level of functioning in their psychosocial environment. The person may be dependent on the substance to obtain a sense of "normalcy" but never really loses control of their daily functioning. This is the case with people who have been on methadone or suboxone maintenance for extensive periods of time yet are seemingly still able to live a normal life.
The key factor with respect to this continuum is that the addicted person has not only lost control, but has actually lost control of their control. That is, that person can no longer act in their own best interest. Their life has been consumed by the substance or behavior to the detriment of their own well-being, good judgment, and life goals.
What causes a person to lose control of their control? This will be addressed in the following section. There, we will explain certain basic neurobiological processes that are linked to addiction. These processes will illustrate conclusively why this falls into the arena of a medical condition or a "brain disease."
Neurobiology and Addiction
Much has been written in recent years regarding the science of addiction. Recent research, particularly in the field of neurobiology and the neurosciences, has delineated quite conclusively the neurobiological underpinnings of chemical dependency and addiction (Koob, G.F. and Volkow, N.D., 2010). Researchers have been able to show that addiction is not simply a matter of a "loss of will power" but a neurobiological process that literally hijacks the brain of a person. If untreated, the dysregulation in the brain of the addicted person will almost surely lead to certain death. Hence, addiction must be understood as a "brain disease." These findings have significant ramifications to understanding addiction. Even more importantly, these findings have great significance for understanding the science of recovery.
First, these findings show that addiction is indisputably a medical condition that gravely affects the individual. Like all medical conditions, a predictable pathogenic process, or breakdown, occurs. We now know the source of the problem. Further, and more importantly, we can also predict what is going to happen next.
This knowledge changes the entire landscape of addiction treatment. Because of this knowledge, we can intervene much more quickly and effectively. This profound clinical breakthrough is so critical, perhaps even revolutionary, because it disputes the notion that a person with addiction needs to "hit rock bottom." That draconian, and possibly life threatening, position is no longer required. We really can, as Bill Wilson, the co-founder of Alcoholics Anonymous, foresaw, raise the bottom. Only now, we have the tremendous advantage of incorporating scientific processes to our repertoire.
Secondly, like most medical conditions, there are specific areas that need to be the focus of attention or intervention. Understanding addiction from a neurobiological perspective has shed important light on just how our neurobiology can impact the functioning of a person. This includes emotional states and behaviors that are extremely crucial in sustaining an addictive disorder.
The most valuable, indeed exciting, aspect of these findings is that we can now develop a science of recovery. This fact has very important clinical significance. As was emphasized previously, a science of addiction virtually demands a science of recovery. With this newfound knowledge, we can now develop and utilize more meaningful and effective interventions than ever before.
The "Broken" Brain
Research has demonstrated that it is in the mesolimbic dopamine system or the "reward pathway" of the brain that is being affected (Koob, G.F. & Volkow, N.D., 2011; Koob, G.F. & Volkow, N.D., 2010; Erickson, C.K., 2007). This includes the ventral tegmental area (VTA), nucleus accumbens, and certain parts of the neo-cortex (thinking part of the brain).
Diagram 1b
The ventral tegmental area (VTA) is located in the center of the brain and is the beginning of the reward pathway where there are receptors for neurotransmitters that produce a sense of pleasure and well being for all people. Another critical area is the nucleus accumbens, which is that portion of the brain that is responsible for releasing certain neurotransmitters that signal the neo-cortex of a person that a pleasurable experience is occurring. The pre-frontal and orbital cortex of the neo-cortex is considered the end of the "reward pathway" where that pleasurable experience is imprinted and remembered by the brain. It has been demonstrated that use of substances creates a definite dysregulation in the neurochemistry in this area of the brain, creating a malfunctioning in the reward pathway. It is this part of the brain that is or becomes "broken."
Green Beans and Ice Cream
In some respects a person who is suffering from an addictive disorder is no different than a ten-year-old child who has not eaten all day. If at the end of the day, two things are placed in front of that ten year old, a bowl of ice cream and a bowl of green beans, which one is the ten year old going to choose? The child is going to choose the ice cream. Why? The child has an overwhelming need for immediate gratification for what is going to feel good. In a ten-year old, this overwhelming need will almost always prevail. So, too, with the person suffering from an addiction.
Similarly, in addictive disorders, like the ten year old, the brain does not take into account what is going to be the better selection. It just reacts impulsively for immediate gratification. However, unlike the ten year old who lacks the foresight and knowledge of what is the better choice, the person who suffers from an addictive disorder is actually experiencing a malfunctioning of the brain.
In other words, the brain is no longer able to remember or recognize the potential negative consequences of the person's choices that may have occurred days or even hours earlier. Due to the chemical dysregulation of the reward pathway, the person only remembers the pleasure of the addictive behavior. As a result, the person compulsively becomes overwhelmed and preoccupied with the use of the substance. That person is unable to acknowledge the potential negative consequence of their actions despite the fact that they may have already been through the same misery numerous times before. The negative consequences are no longer a part of the person's consciousness or the neo- cortex. The "thinking part" of the brain is shut down.
The following diagram is a good depiction of what transpires in the brain of an addicted person. Whereas the person who is not suffering from an addiction is able to "think" about the consequences of their actions, i.e., "I better not eat that piece of chocolate because it is going to make me fat and I will not be able to fit into my jeans," the brain of an addicted person is no longer receiving signals from the neo-cortex. It is as if the negative consequences no longer exist. Why? That part of the brain is no longer functioning properly. It is no longer sending the appropriate signals to the person to slow down or stop. This explains why addiction, or even use, is not a "will power" issue.
Dopamine and Other Neurotransmitters of Well-Being
The culprit in all of this are a number of neurotransmitters of well-being produced in the brain to reduce any type of pain or discomfort that a person may be experiencing (Refer to diagram 1d). The problem arises when the brain produces too much of these neurotransmitters of well-being. Although there are a number of these neurotransmitters that have been implicated in the addictive process, dopamine is one that has received special attention (Kipper & Whitney, 2007; Volkow, N. D., Fowler, J. S., Wang, G. J., & Goldstein, R. Z.,2002).
