Over the decades there have been many attempts to find “the cure” for addiction. It really depends on how you define “cure”. Many people stop their compulsive addictive behavior and never go back, changing their lives forever. Others have long periods of relapse and recovery. In either case, even if the person stops using completely, there is often an enduring struggle to remain sober and clean or to stop the compulsive behaviors. Because of their biological/psychological make-up and personal history, many people need to take greater care to avoid relapsing. Because it is a lifetime journey, they are never “cured”, but they can develop a powerful mindset and change their lives. We will review the literature to show how science addresses the changes in the brain and how recovery is possible. This process is a day-at-a-time approach, and recovery can be achieved: millions of people around the world are living that mindset today. There has been extensive research to understand addiction, to explore where it comes from, and to learn how to manage it. We will look at how society views addiction and how that view is limited in the face of neuroscience. We will also consider the question as to whether addiction is a brain disorder/syndrome or a matter of choice, and finally, we will look at treatment and the variety of approaches used to achieve long-term recovery.
Definitions of substance use disorders and addiction have changed substantially over the years. We have gone from addiction to dependency and now substance use/addiction. The term substance use disorder was introduced by the American Psychiatric Association (APA) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and refers to the recurrent use of alcohol or other drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home (American Psychiatric Association, 2013). Depending on the severity, the disorder is classified as mild, moderate, or severe. This terminology can be confusing, and affects how we view individuals and how we treat them. The term addiction is used to indicate the most severe, chronic stage of substance use disorder, in which there is a substantial loss of self-control, as indicated by compulsive drug taking despite the desire to stop taking the drug. In the DSM-5, the term is synonymous with the classification of severe substance use disorder (American Psychiatric Association, 2013).
The prevention and treatment of substance use disorders has been a challenge for society, which includes communities, families, and the workplace. Why don’t substance users seek treatment? Research shows that shame and stigma are the number one reasons. Studies of public opinion from around the world have found that the stigma attached to people with substance use disorders appears to be more severe and persistent compared to other mental illnesses, and people reported having greater fear for and more negative attitudes toward substance use problems compared to other stigmatized conditions such as depression, schizophrenia, or homelessness (Room, 2005).
Society tends not to see substance use and loss of control as a brain condition or syndrome, but rather an act of choice and voluntary. Australia, for example, has a history of attributing weakness to people with substance use and mental health issues. This attitude needs to change to reduce the shame and stigma so that people who need treatment will seek it. Looking at substance use as a brain disorder can increase the likelihood that people affected will seek treatment and have better outcomes (Volkow, 2018; Volkow, Koob, & McLellan, 2016), which will have a flow-on effect on society in general.
Substance Use: The Levels
What is substance use and its connection with the brain? How do we assess people with substance use disorders? What does that mean in terms of an integrative treatment approach, and when we look at craving management, how do we maintain recovery in the face of the brain function and relapse cues?
We start with the idea that at some point substance use is a brain condition. In the past two decades, this view has increasingly been supported by research. Yet, because many of the behaviors that users display can be impulsive, compulsive, and sometimes aberrant, some argue that substance use is not tied to neurobiology, but is a behavior of choice. This argument negates what happens in the brain’s reward system, however; ingrained attitudes that people’s actions are a product of self-determination and personal responsibility challenge the scientific evidence of the brain syndrome.
Substance use disorder has been segregated from the rest of health care and as a result is treated very differently from other chronic conditions such as anxiety or depression. Biological markers of disease states need to be considered. In the disease/condition model, there is an organ, which in substance use is the midbrain; the defect is the cause (e.g., genetics, trauma, mental health issues, stress); and then there are the symptoms such as loss of control, “bad behavior”, criminality, and so forth (McCauley, 2009). From a physiological perspective, addiction to alcohol and other drugs (and compulsive/pathological behavior) is considered a brain disease whereby drug actions on brain circuitry result in changes in the control of behavior (Tomberg, 2010). The cycle of addiction, as seen in severe use, is a drug reinforcement circuit (reward and stress) that includes the extended amygdala (the central nucleus of the amygdala, the bed nucleus of the stria terminalis, and the transition zone in the shell of the nucleus accumbens). A drug- and cue-induced reinstatement (craving) neurocircuit is composed of the prefrontal (anterior cingulate, prelimbic, orbitofrontal) cortex and basolateral amygdala, with a primary role hypothesized for the basolateral amygdala in cue-induced craving (Galanter & Kaskutas, 2008). A drug-seeking (compulsive) circuit is composed of the nucleus accumbens (NAcc), ventral pallidum, thalamus, and orbitofrontal cortex (OFC), and is important to the craving mechanism.
Thus, natural and artificial rewards (food, sex, drugs of abuse) have been shown to activate this dopaminergic pathway, also known as the mesolimbic dopamine pathway, causing an increase in dopamine levels within the NAcc. From an evolutionary perspective, this brain reward circuit has ensured survival by giving priority to essential actions such as reproduction (Tomberg, 2010). It is the interaction with these survival mechanisms that separates substance users who use for social and recreational reasons from people described as addicted. There is a clear delineation of how people use alcohol and drugs and the mechanism by which various drugs alter the activity of this neuroanatomical system. To illustrate the levels of use, we need to understand the effects on the reward system and the development of treatment.
How neuroscience research offers new opportunities for prevention and treatment depends in part on an appreciation of the current definitions of substance use. A clear definition and evidence supporting the research findings into acquired disease of the brain are needed to avoid misunderstandings. Clarity and understanding will help to reduce addiction and its damaging effects on individuals and society. If this is to happen, health professionals—and society—must consider an overarching approach and not a one-size-fits-all approach.
The brain does not care what drug (alcohol, tobacco, marijuana, or ice) or which compulsive behavior (gambling, sex, codependency, video gaming) is being used. The brain’s reward system goes into action, and for some, it becomes a matter of survival. Susceptibility to the drug or compulsive behavior varies because for various reasons people differ in their vulnerability to it. Many genetic, environmental, developmental, and social factors contribute to the determination of a person’s unique susceptibility to using drugs in the first instance, sustaining drug use, and undergoing the progressive changes in the brain that characterize addiction (Demers, Bogdan, & Agrawal, 2014; Volkow & Muenke, 2012). When considering what level a substance user is at – mild, moderate, or severe – all these issues need to be considered in a comprehensive assessment. The proposed treatment also needs to be integrative in its approach.[Content protected for subscribers only]