The Anatomy of Addiction (6 page)

The medication, often dispensed under its brand name Suboxone, is tightly controlled and must be prescribed by a physician specifically trained and licensed to handle the drug. A mere 2.5 percent of all primary care doctors are certified.

As reported in the
Huffington Post
in a 2015 groundbreaking article about the lack of evidence-based treatment (“Dying to Be Free” by Jason Cherkis), multiple states are struggling to manage the heroin epidemic in which “thousands of addicts have no access to Suboxone. There have been reports by doctors and clinics of waiting lists for the medication in Kentucky, Ohio, central New York and Vermont, among others.” In one Ohio county, a clinic's waiting list ran to 500 patients.

To be clear, Suboxone has been so effective in dealing with prescription painkiller and heroin addiction that there is a great demand for it by addicts. When addicts can't get it legally, they turn to the black market. As I said before, America doesn't have so much an addiction problem as a problem with addiction treatment.

J
oanne Campbell, forty-five, is not your idea of an addict. She is a mother with three gainfully employed and happy adult children. She is also a successful retail entrepreneur.

Born in Houston, she was a typical teenager but maybe atypical in that she rarely indulged in drinking or drugging. When she turned twenty-one, the legal drinking age in the state, she started social drinking with friends. She married and, together with her husband, began raising a family.

That's when she discovered cocaine and, by the age of twenty-eight, she was abusing it. She and her spouse split, and she was left to raise her three children on her own. “After my split with the father of my children in 2000 is when I began to abuse alcohol more often,” she says.

Over the next decade she recalls that her abuse of cocaine led her to something more serious. “I think that I became addicted
over a period of years with the misuse and abuse of alcohol,” she says. “It kind of went up and down from the age of 35 to 43. I had some bad years and some fine years, leading up to a couple of really bad years where so many things seemed so overwhelming that I would drink more often and for longer periods of time. I believe that so many emotionally difficult things in my life built up that I had never really dealt with.”

It was shortly after Christmas 2011 that Joanne came to see me. Alone at home during the holidays, her three adult children busy with their own lives, she began a familiar routine—a binge of cocaine and alcohol, except this time it didn't stop. When her concerned children finally showed up on her doorstep and gave her an ultimatum, she knew that she had to get help.

Her fear of losing everything, including her children, finally became a reality. For many years, she thought she could do it on her own. At a certain point she even began to see a therapist weekly and thought that she would be able to fix herself through counseling alone.

She had tried AA and 12-step programs but never identified with them. “I think that was also part of my problem,” she said. “I didn't think anything else was available.”

Realizing the gravity of Joanne's deteriorating health, her therapist recommended that she consider an evidence-based treatment under my medical supervision. After a successful detox, Joanne began a program that managed her addictive cravings through a combination of pharmaceutical intervention and cognitive behavioral therapy (CBT).

Three years later, she is flourishing, running a small business.
She still regularly sees me for management of her addiction disease, but has not relapsed since.

 • • • 

Alcohol and drug addiction is a chronic disease with a strong genetic predisposition. Does that sound familiar? It should, because it basically describes every other leading chronic disease, including heart disease, stroke, cancer, diabetes, and asthma. It's also like mental illness because, in addition, addiction is a brain disease.

Addicts and alcoholics have structural or functional damage to the reward-motivation center of their brains. When damaged, this reward center keeps individuals doing things even when the result is pain instead of pleasure.

Whenever you do something pleasurable, it affects the amount of a substance in the brain called dopamine. If there were a pleasure impact scale based on dopamine, eating food and drinking water rates a 2, sex rates 4, cocaine rates 8, and methamphetamine scores a 12.

It's interesting to note that both methamphetamine and cocaine increase the amount of dopamine in the synapses. However, cocaine achieves this action by preventing dopamine reuptake, while methamphetamine helps the body release more dopamine. So although these drugs have similar effects, they work in entirely different ways.

Bottom line: Addiction is a medical condition, not a moral failing. The seemingly age-old debate over the treatment of alcohol and drug addiction—through willpower, spirituality, and talk therapy versus physical diagnosis and evidence-based therapy—is over. The connection between addiction and brain chemistry is
indisputable. While there is a role for behavioral and cognitive counseling in addiction treatment, a program based purely on psychological therapy or the 12-step philosophy is inadequate for treating a disease with genetic and physiological roots.

The Anatomy of Addiction

Substance addictions, including alcohol and stimulant drugs like cocaine, are not caused by the drink or the drug. Addiction is primarily the result of genetics and overstimulation of the pleasure and reward pathway in the brain.

In the case of Joanne for example, it was very clear to me when I first diagnosed her that she was motivated to stop drinking. She loved her children, she wanted to pursue her dream of owning her own business, and she knew that she had the skills to turn her life around. But she couldn't stop her craving for alcohol and cocaine. “My addiction would get better for months at a time,” Joanne confessed, “but I would always go back to an alcohol and drug binge when I needed to check out of my world.”

We now know why the Joannes of the world cannot help themselves. Addiction is a disease characterized by anatomical and functional changes in the human brain. The anatomical changes can be clearly seen and studied with brain imaging technology, such as a standard MRI and CT scans. Functional abnormalities can be seen, studied, and evaluated by PET scans or functional MRI. These changes are in the brain's reward, motivation, memory, and related circuitry. Some of these changes are repairable, while others are not reversible—so far.

Just as heart disease causes a blatantly decreased heart
metabolism, drug abuse causes a similar decrease in brain metabolism. The similarities between addiction and heart disease, diabetes, and asthma are remarkable. They each have a genetic basis and are impacted by voluntary behavior.

Because the brain controls behavior, a disease of the brain will have behavioral consequences. Because of these brain changes, people become unable to make conscious decisions in their own best interest. Individuals thus afflicted with the disease will compulsively pursue a detrimental course of action, despite continual negative medical and social consequences. In other words, despite knowing that the next bottle of vodka that he consumes will likely kill him, especially if he gets behind the wheel of car to go buy it, an alcoholic will quite literally drive himself to drink.

About 10 percent of the at-risk population becomes alcoholics or drug addicts—and the rest do not. Let's reframe that: Most people who drink alcohol, snort cocaine, or shoot heroin will not become addicts. Why? Research indicates that fully half the reason is genetic. For instance, we know that the children of alcoholics are four to five times more likely to become alcoholics themselves.

The exact mechanisms of how drugs and alcohol affect the addict's brain are still being worked out. But we know a lot right now. We know that alcohol and drugs in everyone's brains affect the delicate equilibrium in the neurological system. Pulses travel along this network of nerves, carrying information and instructions from the brain to the rest of the body. Substances called neurotransmitters keep our bodies functioning, from our most fundamental tasks, such as breathing and eating, to more intricate processes like pleasure seeking (including falling in love) and
the fight-or-flight response (it's why we automatically jump away from oncoming traffic).

The neurobiology of addiction is very complex, but it appears from numerous studies that two neurotransmitters are especially important in alcohol and drug addiction: GABA and dopamine. GABA is among a group of inhibitory neurotransmitters that regulate and moderate impulses. Dopamine is on the opposite end of the spectrum and belongs to those excitatory neurotransmitters that provide the reward of pleasure. In proper balance, these neurotransmitters allow one to lead a productive and happy life, but without going overboard on the happy part.

In other words, together these two neurotransmitters achieve the moderation that philosophers have extolled through the ages. (The Greek sage Epictetus was among the first to observe, “If one oversteps the bounds of moderation, the greatest pleasures cease to please.”)

Even for the normal person, drugs change the brain just like they change the brain of the addict. Psychoactive drugs artificially overstimulate dopamine flow and block the flow of the inhibitory agents in GABA. Forget the stoic advice of Epictetus. Suddenly the brain goes totally Oscar “Nothing succeeds like excess” Wilde.

But eventually, the inhibitory neurotransmitters of the normal person's brain put the brakes on the overstimulation of dopamine, and the person stops drinking or drugging. Those brakes don't work in the addict's brain. They were made defective or they've burned out. And even worse, the more they drink and drug excessively, the more they desensitize the brain's receptors.

A New Normal

Addicts develop a “new normal” because the brain attempts to adjust to the foreign substances—the toxins—flooding its receptors. Eventually, every addict reaches a tipping point, where the brain receptors remain permanently on. The first puff of marijuana or snort of heroin can send the addict back to the level of addiction when she hit bottom.

That likely is what happened with Oscar-winning actor Philip Seymour Hoffman, who died of a heroin overdose. He admitted quite openly during his career that as a young man he tried every drug that he could get his hands on, not to mention alcohol. His official death, at age forty-six, was ruled as acute mixed-drug intoxication, including heroin, cocaine, benzodiazepines, and amphetamines. Even though he claimed twenty years of sobriety, three months before his death he purportedly snorted a line of heroin at a party, and it was like nothing had ever changed—he was back in an instant to the addiction that he had experienced as a young man.