Shea McTaggart, Psy.D.
What is addiction
Updated: Jun 8, 2022
Addiction is a chronic and relapsing psychiatric disorder affecting a large number of people worldwide. Ample evidence from basic and clinical neuroscience has demonstrated that addiction is a brain disease marked by compulsive substance use despite a host of negative consequences. Neuroscience has discovered several neural circuits underlying the behavioral expression of tolerance, craving, and withdrawal, which are critical constructs to understanding vulnerability to relapse as well as their prognosis for long-term recovery.
How should addiction be treated?
There is a compelling argument for treating addiction within the framework of chronic disorders, such as high blood pressure, diabetes, and asthma. The shift to a chronic model of care may be instrumental in more adequately addressing the needs of patients suffering from addictive disorders. Moreover, the definition of addiction as a brain disease remains consistent with a biopsychosocial model that emphasizes biological (e.g., genetic, pharmacological, and neural), psychological (e.g., feeling loss of control and intense craving for the substance), and social (e.g., peer influences, access to substances of abuse) components to psychopathology. The notion of addiction as a brain disease helps explain why so many patients sincerely wish to stop using a substance, and yet they simply cannot do it.
What can get better outcomes with addiction treatment?
Personal responsibility for treatment compliance and active engagement with recovery activities involving biological (i.e., pharmacotherapy), psychological (i.e., psychotherapy), and social (i.e., lifestyle changes) components remain the key ingredients to managing this chronic condition, akin to the treatment for diabetes or hypertension.
How does addiction work?
Extensive preclinical research has convincingly demonstrated that alcohol and drugs of abuse activate the same neural circuitry involved in normal responses to natural rewards, such as food and sex. Neuroadaptation in the reward pathway is thought to be central to the development and maintenance of addiction, as it renders a person more vulnerable to (positive and negative) reinforcing effects of substances of abuse. Repeated alcohol and drug use conditions the brain to seek these reinforcers at the expense of natural rewards, which are less potent and over time become less salient. In other words, over time, people experience the urge to use the drug of abuse as a very potent biological drive, akin to extreme hunger or thirst. This is consistent with the effects of alcohol and drugs on the very same brain structures responsible for driving people toward basic survival needs. In clinical terms, while the decision to begin using alcohol or drugs is voluntary at first, over time, people become vulnerable to addiction as drugs of abuse “hijack” the reward circuitry and the drive to obtain and use a drug becomes central. At that point, when addiction has ensued, drug use is no longer simply a voluntary choice but rather a maladaptive response to brain-based urges that are as potent as the drive for food or water.
Why is addiction difficult to overcome?
The process of neuroadaptation can help explain struggles with addiction and the fact that despite sincere desires to quit using the substance, people often feel as though they cannot. This may also be a useful framework for psychoeducation, as a considerable amount of blame is often placed on the person by him- or herself as well as by his or her loved ones. This model effectively distinguishes the initiation of substance use from the continuation of drug and alcohol use despite serious health and psychosocial consequences.
Tolerance and withdrawal represent two important symptoms of substance dependence and are recognized as indices of physiological dependence. Together, these processes provide the neural basis of reward and punishment associated with alcohol intoxication and withdrawal, respectively. Over time, the shift in the balance from positive to negative reinforcement helps explain what patients describe in their experiences with alcohol or drugs, namely that they no longer use alcohol or drugs to feel good and that instead, alcohol and drug use serves to prevent them from feeling sick.
What happens to someone who is addicted?
Recent theories of addiction suggests three stages of the disorder, namely preoccupation/ anticipation, binge/intoxication, and withdrawal/negative affect. These three stages are thought to be cyclical and to spiral, increasing in their intensity and associated distress, over time. The preoccupation/anticipation stage is marked by cravings and a persistent desire to use the substance. As individuals often report, activities related to obtaining and using the drug become increasingly salient to them, requiring more of their emotional and financial resources. The binge/intoxication stage consists of taking the drug in larger amounts or over longer periods of time than intended. This stage is marked by repeated failure to self-regulate and to “put the brakes on behavior.” In other words, people are unable to resist the urge to use, often leading to a binge or, in the case of treatment seekers, to relapse. The withdrawal/negative affect stage represents a later stage in the disorder, consistent with the recognition that withdrawal is not a required symptom of substance dependence. However, as convincingly demonstrated in research, individuals who abuse drugs for extended periods of time are almost certain to develop withdrawal symptoms in the later stages of the disease.
In clinical practice, a careful evaluation of withdrawal symptoms is critical to determining whether a patient is suited to receive treatment on an outpatient versus inpatient basis. Even patients with very high levels of motivation will likely require detoxification prior to outpatient services if their clinical profile is marked by significant withdrawal symptoms. Conversely, patients who show evidence of being able to safely abstain from alcohol or drugs for a period of time are much better candidates for outpatient services.
How to treat addiction
Behavioral techniques for coping with triggers, such as avoiding, taking time-outs, and learning refusal skills, represent important components of cognitive behavioral therapy for addiction. What is often lacking from this effective intervention is the conceptualization of triggers as learned processes that are biologically based and as such may evoke the unwanted, yet learned, behavioral response of alcohol or drug use, leading to relapse. Addiction can also be established and maintained through secondary gains from drugs or alcohol. People will often use to get rid of a feeling they don't want or create one they don't have and can benefit from better understanding their own sources of motivation.
Why is addiction difficult to overcome
Patients in early recovery are often confronted with the fact that despite not using alcohol or drugs, they feel unable to experience reward from activities that used to be reinforcing to them, such as spending time with loved ones. However, it is important to recognize that the neural systems of reward have been subjected to alterations in their organization and that these alterations will not be immediately resolved through short-term abstinence. Conversely, the process of brain recovery from addiction is rather gradual. And while clinical neuroscience cannot effectively estimate how much one’s brain will recover and over what period of time, a few recent studies have documented the neural changes associated with recovery.
From a clinical perspective, increasing recognition of recovery as a brain-based process can have important implications for patients and clinicians alike. One of the major implications of this conceptualization is the notion that sustained recovery is required to fully experience the benefits of abstinence. Patients and their families ought to bring a long-term perspective to the recovery process with regard to the behavioral aspects of the process (e.g., building a life worth living, repairing relationships) but also with regard to the neurocognitive and affective benefits of sustained abstinence. There is not a single path into this disorder nor is there a single “way out” through a common intervention that will work well for all patients.
Written by: Dr. Shea McTaggart, Psy.D