New Insights on Old Observations about Addiction

I have yet another media link to recommend. Charlie Rose, on his PBS program, has commenced a second series designed to provide new insights on the brain and its connection to human experience, and the first installment provides a great overview, led by neuropsychiatrist and Nobel laureate Eric Kandel. The panelists are Gerald Fischbach (neurology), Thomas Insel (of NIMH, on psychiatric disorders), and – most relevantly to this blog – Nora Volkow, director of the National Institute on Drug Abuse. With her unmistakable accent (the outgrowth of growing up in a Russian family while living in Mexico), she is a remarkably articulate explainer of addiction from a neurobiological standpoint.

What often strikes me is that new brain-based descriptions of how addictions develop and operate often dovetail with old observations. Those of us who have been working with alcoholics/addicts for a long time have tended to develop conclusions based on our collected observations. Now, we have some possible ways to understand the neurobiological mechanisms that may underlie these observations. For example:

[Observation] Even people who express a sincere wish to abstain from substances, or who think they should be able to exert enough “willpower,” usually find that they return to the kind of behavior that they have sworn off. [Neurobio Explanation] The process of developing an addiction includes developing a linkage between drug- or alcohol-related stimuli and a drive toward addictive behavior, co-opting the same reward circuit that drives us toward doing things we need to survive (such as eating and procreating). In addition, the repeated intrusion of drugs into our brains injures the prefrontal cortex, the part of our brains that helps us exert appropriate caution before acting.

At first, individuals enjoy getting high when they choose to use alcohol or addictive drugs. For those who become addicted or alcoholic, however, substance use has the primary function not of feeling good so much as feeling normal or OK. Neural reward circuits “light up” in real-time brain scans of non-addicts when they use the substance, but those who have developed addictions show little or no change. This fact, however, does not extinguish their urge to use, which is now driven by other factors.

With rare exceptions, addicts/alcoholics do not “rewind” and return to an earlier, more normal pattern of use. A purely learning/unlearning model does not seem to apply. Although learning and memory clearly play a role in the development of addiction, changes in brain circuits persist. Even in the absence of active substance use, the disorder is typically chronic.

A 30-day rehab alone is rarely successful if not followed by frequent and consistent follow-up, in some combination of support groups, professional contacts, and safer living environments. Brain changes resulting from months or years of addictive drug use endure for months or years; short-term treatment is far short of what’s necessary to reverse or compensate for those changes.

Addiction and Neuroscience

One of the treasures of radio (nowadays expanded to include podcasts), even within the wonderful world of NPR, is Terry Gross’ daily Fresh Air program. To my mind, she’s the best interviewer in broadcasting. I recently listened to a podcast of her June 23 interview with Dr. David Linden, professor of neuroscience at Johns Hopkins University School of Medicine, and author of The Compass of Pleasure. He does a nice of job pulling together the exploding body of scientific research that reconfirms that addiction is a largely genetic and neurobiological condition rather than simply a matter of choice and self-control, as some opponents to the so-called “disease model” have argued for years.

There has been evidence for decades, from a large number of studies of identical twins, adoptees, etc., that addictions (most studies focusing on alcoholism) are largely genetic. (Dr. Linden quotes a figure of 40%; almost all the recent research references I have found say 50%.) Thus, a number of people, usually with genetic family histories of alcoholism/addiction, appear to be born with a predisposition to addiction. However, environment (including stress level), personality, and learning also play large roles. People who do have this predisposition but who barely use alcohol or drugs will still not become addicted to these substances. On the other hand, people without these genes (and there seem to be many genes involved, not just one) will have a lower chance of developing addictions despite heavy exposure to substance use.

Even the process of learning to drink or drug in progressively greater amounts, and increasing frequency, is heavily influenced by biology, which, for example, determines how good or relieving it feels to use a given drug and how much of the substance is needed to get an effect.

What is kind of exciting is how many of the characteristics of addictive behavior that we have observed for generations are now understood to be paralleled by neurobiological processes that can, at this point, be identified rather than merely inferred.

Anyone who took an introductory psychology course heard about both Operant (or Instrumental) and Classical (or Pavlovian) Conditioning, both of which are hugely important in the development of addictions. In operant conditioning, when a particular action of an animal (such as yourself) is followed repeatedly by a reinforcement/reward, the individual is likely to engage in more of that behavior. In classical conditioning, when a particular stimulus (e.g., a pub; white powder) becomes associated with a response (e.g., drinking, drug use), exposure to the first tends to trigger the body to prepare for the second (e.g., craving).

What neuroscientists have clarified is that underlying these behavioral experiences are chain reactions in the brain’s reward system (located in the medial forebrain and involving structures you may have heard of, such as the ventral tegmental area and nucleus accumbens, as well as chemicals, neurotransmitters, especially one called dopamine that is increased in reaction to addictive drugs). This reward system evolved because it promoted the survival of our species; it is turned on by food, water, sex, and also by exercise, altruism, and the experience of learning – all essential and all pleasurable to most humans. (And Linden notes that non-substance related behaviors, such as eating and sex, can also become addictive for predisposed individuals.)

One kind of genetic predisposition, according to Linden, is that people born with a “blunted pleasure circuit” are driven to put more energy into risk, and seeking pleasure and novelty. Clinicians have noticed for years that some people seem unusually drawn to seek excitement/sensation and that they are more prone toward substance abuse – now we have a way to understand why that may be.

As Linden also notes, the heavy and repetitive substance use of addicts seems to actually change the cellular structure of their brains, in a way that tends to be irreversible. Over time, the addictive behavior actually comes to have less to do with pleasure/reward than with simply feeling OK and functioning adequately. He calls this a transformation from “liking” to “wanting.” I think “wanting” is too weak a word, and that in the addict’s experience it is closer to “needing.”

None of this is to say that addicts are without any level of choice or responsibility. Obviously, the only way anyone moves in the direction of recovery is by acknowledging and taking responsibility for his or her addiction, and making choices, developing new behaviors, etc., in an effort to get around these established but ultimately self-defeating patterns. But let’s recognize that when we advise people to give up addictive behavior, we are typically asking them to take on a herculean task, to use their intelligence and consciousness to override what has become their natural mode of brain functioning. That’s why so often they need strong support, frequent reminders and motivators, etc. And, since changed brains don’t revert to their pre-addictive structure, it is for good reason that the term “recovering” has replaced the term “recovered.”

Report on Marijuana

The National Institutes of Health are a kind of clinical national treasury, staffed by researchers who may be motivated to make a name for themselves, but at least not by a need to make a profit for a pharmaceutical company or other greed-driven enterprise. Based on what they pay my daughter, who is currently involved in a post-baccalaureate research fellowship there, they are certainly not doing it for the income.

The two particular institutes that I follow most closely are the National Institute on Alcohol Abuse and Alcoholism, now celebrating its 40th anniversary, and the National Institute on Drug Abuse, which recently published the latest revision of its “Research Report Series” on Marijuana Abuse (http://www.nida.nih.gov/PDF/RRMarijuana.pdf).

These plainly worded summaries of the current state of knowledge on various substance-related topics are so valuable as relatively objective sources of information. It is easy, on the web and elsewhere, to find those who celebrate the wonderfulness of marijuana and its medicinal uses, or, on the other hand, those who warn us vehemently of its dangers (reminding me of the narcotics officers at assemblies in my Baby Boomer high school, who assured us that this “gateway drug” would lead inevitably to cooking heroin in rusty spoons).

As usual, reality is somewhere in between. Marijuana certainly can be addictive, and can also produce adverse effects including psychosis, impaired learning/memory, and possible negative impact on the body’s immune system. On the other hand, it also appears to have some legitimate medical uses, and certainly its negative impact on the body is much less than that of drugs such as alcohol. (Speaking of high school talks, I myself once acknowledged, in response to a question, that alcohol could be regarded as the more dangerous of the two drugs – and was never invited to speak there again.)

As in the case of alcohol, someone who uses marijuana on an occasional basis, perhaps less than once a week, with no distressing symptoms or impairment, can probably be regarded as a non-problem “social” user (though often less social in behavior than a drinker). Let us not deny that. But let us also not deny that many of our peers use marijuana daily, or more or less continuously, and have great difficulty coping with life without it. Their drug use is more than a casual choice, and their ability to assess its impact is probably compromised. With all such substances, a particular concern is that use begins, often heavily, among individuals in their teens and early twenties, whose brains have not yet fully developed – further development may well be altered by the drug, in ways not yet fully understood.

It is very difficult to “treat” marijuana abuse or dependence, because the negative consequences of use are so often less than catastrophic, i.e., providing quite limited incentive for change. Though I approve of the moves toward decriminalization, those changes have only increased the difficulty of developing “healthy fear” of marijuana dependence. That is one of many factors to be taken into account in the assessment of each individual, as an individual.

Alcohol/Drug Relapse

It will not come as news to you that the relapse rate among those addicted to alcohol and/or drugs is quite high. Of course, the same is true for a number of chronic conditions, including other mood/behavior problems. Alcohol/drug relapse can be more discouraging to new therapists (not to mention family members), because it is often marked by a dramatic change in the individual’s state, and it is easy to feel as if any progress has evaporated. When treating, say, depression, a setback is more likely to seem like an expectable and non-catastrophic event.

When I was collecting background material for my dissertation, back in the late 1970’s, Emrick’s relapse curve was commonly referred to. Statistics have become more sophisticated (sometimes to the point of not meaning much) since then, and thousands of studies done, but I have not found another picture of relapse that is as comprehensible or that matches my own clinical experience as well as Emrick’s curve. (Here is an approximation of that curve -- not precise.)

Please note that this representation of relapse (a) is based on individuals (mainly alcoholics) who have entered treatment programs, and may be way off when it comes to people in the community who somehow deal with drinking or drugging problems on their own, and (b) looks at relapse from a standpoint of continuous abstinence (in the AA tradition), which is only one way to measure it.

The headline is that, on average, only about 20% to 25% of alcoholics have sustained continuous sobriety for a year after initially stopping (which, in many studies, means leaving detox). And the vast majority of these relapses occur within the first 3 months.

But 100% sobriety is a high “bar” (perhaps not the ideal word here). It is also usually true, and much more encouraging, that about two thirds of such individuals show great improvement over the course of the year – e.g., they drink much less frequently and/or less heavily. Some small percentage probably achieves a lasting pattern of low-level use, but total sobriety is by far the most stable outcome.

Again, these statistics are fairly old and often challenged, but they match my own clinical experience. One dimension that makes for different conclusions from different researchers is the nature of the population we look at. College students and soldiers, for example, often meet diagnostic criteria for alcohol/drug dependence but evolve into non-problem users within a few years after they’ve left school or the service. My own contention is that those who seem to “recover” in this way differ biologically from those who exhibit a more lasting, chronic course of alcoholism/addiction.

The nature of the biological aspects of, especially, alcohol dependence is not fully understood and is certainly complicated – for example, there will be no one gene that accounts for all the possible features, and no two people have exactly the same combination of features. Nevertheless, and despite the fact that people continue to argue about it, there has been compelling evidence, dating back decades, that alcoholism (and probably other addiction) runs in families, and that this tendency is based more on biological heredity than on family culture or learning from parents’ behavior. Much of the early work was done by the late Donald W. Goodwin, whose name (sadly) I can barely find in a Google search. In those days when we were far from being able to examine genomes, researchers looked, for example, at identical twins (if one is alcoholic the other is much more likely to be alcoholic than, say, another sibling), as well as adoptees (whose drinking status more closely resembled their biological parents than their adoptive parents).

So, those whom we might assume are less biologically “wired” for alcoholism/addiction, and who might self-correct their behavior in their natural habitats, may not fit the relapse curve as closely as the people we see in treatment settings (who, in most cases, have failed in their own attempts to correct their drinking or drugging behavior).

One reason for the high relapse rate is that problem of motivation. Pretty much no one is 100% committed to abstinence – their Mr. Spock-like logical minds may see that is the most rational course, but their animal-like side (residing largely in the primitive parts of the brain that we share with our mammal brethren) wants to repeat behaviors that have felt rewarding in the past. In a detox setting, I have met patients with many different levels of motivation, from those who express great and powerful determination to those who would say, “Half of me wants sobriety and half of me wants to use,” to those who quite overtly plan to drink or drug shortly after being discharged (if not before). Compare this, say, to depression. Most people who are depressed want to stop being depressed (though a few would admit that depression is so central to their sense of self the notion of losing it produces anxiety). But addiction is not the only condition for which many sufferers desire no change – many people with bipolar disorder, for example, and many paranoid schizophrenics who believe that their perceptions are realistic, will also have little interest in the kinds of treatment and behavior changes that their loved ones and treatment providers might want for them.

Readers who have no history of alcohol/drug dependence, and who find it difficult to understand the “choice” to relapse, may be able to relate to this irrational tendency through the experience trying to lose weight (a struggle for so many of us). We want to lose weight, to look and feel better, to maintain a good mood during visits to a clothing store, etc. On the other hand…. that sausage pizza looks awfully good, so let’s forget about weight just for now. Here’s what I want: to be thin and to eat whatever I want, in whatever quantity I want. Unfortunately, reality doesn’t work that way, but it is by no means clear whether, and when, rational choice will win the day.

OK, so let’s say I really, really want to achieve and sustain abstinence from my substance. What makes a difference in the long run?

Type of Treatment? You’d think so, you hear so many claims. But, no. There is precious little evidence that one treatment approach works better than another, even when we attempt to make a careful match between patient and approach. In fact, the same people tend to have a better prognosis regardless of the type of treatment.

The Specific Treatment Provider? Well, yes, there is some evidence that the match, and the quality of the relationship, between patient and therapist make a difference (not only with addictions).

Amount of Treatment? Yes. Although the long-term rehabs (typically 28 days or more) never made a great case for their lasting effectiveness (hence, no longer covered by most insurance), plenty of studies indicate that those who attend more treatment (broadly defined to include self-help groups as well as professional treatment, and probably even abstinence-oriented yoga or meditation classes would count) tend to have better outcomes than those who do less. Most commonly, this means more 12-step meetings, since no other resource is even close to being as available every day.

Environment? Yes. Newly sober alcoholics who continue to spend significant time in the settings where they usually drank, or with fellow heavy drinkers, are more likely to relapse. Duh, you may say, but many individuals insist on returning to those situations, over-estimating their ability to exert mind over urge and conditioned responses. Some clinician-researchers have experimented with intentionally exposing addicts to their substances in treatment, as a means of reducing the power of such exposure in “real life.” The results are mixed. My own strong impression is that what works best is to avoid exposure to substances and to settings and people strongly associated with the addictive behavior, for something close to a year, and then, depending on how things are progressing, gradually return to settings that still seem desirable. (A music fan, for example, may really want to go back to the club or concert situation. There is no reason (and usually no great wish) to return to settings that offer little besides substance use, such as a no-frills bar or someone’s parties where everyone is always “wasted.”

The Individual’s Characteristics? Yes. This makes a lot of difference, though most of it may be beyond one’s control. If you are employed and living in a home as a family or couple (in both cases, making for a stable, somewhat structured environment), your chances of staying sober are greater. Not a surprise when you think about it. In addition, the less severe your addiction (less charitably, we might say, the less “far-gone” you are) and the less severely affected by mental health problems (such as depression, schizophrenia, or sociopathy), the better your odds of staying in recovery.

One piece of good news about relapse in alcoholism/addiction is that it’s never too late to try again. I have met countless alcoholics/addicts who relapsed many times for many years and who, somehow, at some point, go on the sobriety train and stayed there. I have often asked them what made this last effort more effective than all its predecessors, wishing that I could learn a secret to impart to others who continue to struggle. Unfortunately, beyond the odds-improving factors noted above, the answer remains elusive.