Addiction Is a Brain Disease
At the beginning of this book, you read about how the brain’s ability to “put on the brakes” and control impulses malfunctions when you become addicted to something. As a result, you get stuck in go mode even when giving in to your impulses can be harmful to you. In this chapter, you will learn more about how excessive alcohol and drug use alters the brain, and how science-based medication and psychological treatments for addiction can help the brain heal in recovery. You will also become familiarized with some of the medications that are available to promote this healing process.
As you hopefully have started to process by now, you have a disease, and it is serious. The bad news is that this disease can be very destructive and not only ruins but also takes lives every single day. The good news is that it is very treatable. People can and do get better, and you can be one of them. In this workbook, you are going to learn the most effective behavioral therapy techniques that are used in addiction treatment. By practicing the combination of these strategies that are uniquely helpful to you personally, you can increase your chances of getting better. Let’s take a look at how addiction affects the brain, and what you can do to help yourself heal.
The Mind on Drugs Is Not Rational
Though the stigma that follows the illness of addiction is far from gone, advances in medicine and science have deepened society’s understanding of addiction as a chronic disease. As the word has spread about this in the popular media, and more celebrity faces have either come forward or tragically lost their lives to addiction, the growing curiosity about addiction has provided an opportunity to educate the public about the seriousness of the illness.
In this process, addiction experts in the media have at least partially debunked some of the myths about addiction being a “moral failing” or a “choice.” Even though the initial decision to drink or use drugs is made by voluntary choice, research has shown that as alcohol or drug use progresses to addiction, the ability to make rational choices becomes affected (NIDA 2010). Because the ability to choose rationally is what enables us to choose healthy behaviors, take care of ourselves, and act as moral and ethical human beings, the impact of excessive drug use on the brain can be dangerous and disabling. As drug use becomes compulsive, the “choice” to use is not made in the rational way that we make most other choices in life.
Most of the choices we make involve weighing the pros and cons of doing one thing versus another. For example, let’s take a look at the thought process of someone who has never been addicted to alcohol or drugs. Jody gets invited to a party by some friends from work. The party happens to be the day before she has an important meeting that she will need to prepare for. She goes to the party and her friends are drinking and smoking pot. In deciding whether or not she is going to drink and smoke, a lot of thoughts go through her mind—thoughts such as If I smoke and drink with my friends, this is going to be a lot more fun, and I don’t want to come across like a party pooper. As she tries to figure out a solution, she has thoughts such as Maybe I can party with my friends on another night, and If I don’t perform well at the meeting, how will that affect me?
Though the decision-making process may appear simple, the thoughts that run through Jody’s mind reflect a complex process of reasoning and judgment that enable her to plan what to do next. Maybe the plan will be to stay a short time at the party so that she will not be overly tempted. Maybe the plan will be to have just one drink and skip smoking pot this time. This is the process that a “rational brain” goes through to arrive at a decision. Whether or not the decision turns out to be the best one, it comes at the end of a rational thought process.
When you are addicted to something, that rational process becomes impaired; your actions in relation to using drugs and alcohol become dominated by your impulses, while the part of your brain that controls reasoning, judgment, and weighing pros and cons malfunctions. Here’s why:
From the time we’re born, our brains are wired to reward pleasurable experiences. For example, when we eat something that tastes delicious or when we hear music that we enjoy, our brain’s reward system releases brain chemicals that produce feelings of pleasure. These brain chemicals (also known as neurotransmitters) are part of the brain’s communication system. The nerve cells in your brain release these chemicals, which act as “messengers.” They carry messages between nerve cells. When you eat something delicious, a nerve cell releases a neurotransmitter called dopamine. This nerve cell is the one that is “sending” the message. The message has to be received for you to experience pleasure. What happens next is the dopamine attaches to another “receiving” nerve cell. Once the message has been received, any “extra” dopamine that remains in the space between the two cells (known as the synapse) is recycled or brought back into the “sending” nerve cell.
What do you feel when all of these messages are going back and forth in the nerve cells in your brain? When it involves the release of dopamine, the brain’s natural pleasure chemical, you feel great, and you want to repeat the behavior. Alcohol and most drugs that people become addicted to interfere with the brain’s communication system. Their chemical structure is so similar to some of our natural brain chemicals, like dopamine, that they can convey a “false” message to a nerve cell, causing it to release unusually large amounts of dopamine. They can also prevent extra dopamine from being recycled, so that it continues to send messages to other nerve cells. Dopamine starts flooding the brain’s reward system, and the system becomes overstimulated. When triggered by alcohol or another drug, the brain releases two to ten times more dopamine than it does when you eat something delicious or have another natural and pleasurable experience like listening to music or having sex (Di Chiara and Imperato 1988). The exaggerated sense of pleasure, or euphoria, that you experience when this happens leads to an intense desire to repeat the experience.
Our natural pleasure response involving dopamine was designed to promote survival. The experience of pleasure that we get from eating, intimacy, and other enjoyable activities is the reason that we repeat these acts. These acts are vital; without food and human contact we cannot stay healthy or live for very long. But the pleasure response that is triggered by repeated alcohol and drug use has the opposite effect—rather than promoting survival and well being, it causes emotional and physical suffering, a diminished ability to experience pleasure, and a diminished ability to carry out life-sustaining activities (such as working, eating, and taking care of yourself), while at the same time compelling a person to continue to drink or use.
As destructive as this cycle is, biologically it actually makes sense. Here’s what happens: with repeated drug or alcohol use, the brain’s production of dopamine becomes depleted, and with less dopamine available in the brain, using alcohol or drugs just doesn’t work as well to produce that intense euphoria or high. And neither does anything else, for that matter. When we don’t have enough dopamine in our brains, the things that used to bring us pleasure just don’t do the trick anymore; this loss of pleasure can lead to depression, hopelessness, and a lack of interest in the things that we once enjoyed.
When people are in this predicament, not only do they feel the need to drink or use drugs to try and bring their dopamine back to the way it used to be, but they need to use larger amounts of alcohol and drugs to trigger that same dopamine rush they experienced back when all of this started. This is known as tolerance. You may recall from chapter 1 that tolerance is one of the warning signs that a person is at risk of transitioning from social use of alcohol or drugs to addiction. You may also have heard the popular expression “chasing that first high.” That’s when you keep on trying, in vain, after becoming addicted to something, to get back to a high that is just like the first one you ever had on it. As you are now learning, the trouble is, once you build up tolerance, you just don’t have enough dopamine to get to that place anymore. That is why, when you cross that threshold and become addicted, the “chase” can never be satisfied.
In the longer term, addiction leads to other brain changes that make it hard to give up your use of alcohol and drugs. The parts of your brain that work together to enable you to control and plan rational behavior, such as the frontal lobe, can be damaged by excessive alcohol or drug use. At the same time, brain chemicals that influence your ability to learn can become depleted, causing problems with your ability to think and reason. When this happens, seeking out ways to get and use alcohol or drugs can come to resemble a habit that a person repeats without even realizing it. It becomes like a reflex, something you do automatically without thinking—especially when you’re in a place or with a person you associate with drinking or using. In fact, understanding how people, places, and things can be associated with drinking or using is going to be a very important part of overcoming your addiction.
How Addictive Behavior Is Learned
If you know a little bit about psychology, you have probably heard of Pavlov and his scientific experiments. Pavlov was interested in learned behavior, especially a process called associative learning, in which a pair of stimuli or experiences can become associated with one another. In his famous experiment using his dog, Pavlov found that if he rang a bell just before feeding his dog, and he did this over and over again, his dog could learn to anticipate or expect that the food was coming just upon hearing the bell ring. This became apparent to Pavlov when the dog began salivating every time he heard the bell, even before he could see or taste any food. The learned association between the sound of the bell and the experience of eating was so strong that the dog developed what is called a conditioned response to the bell. Salivating is a conditioned response that is designed to prepare the body to eat.
In the same way that Pavlov’s dog learned that the bell was a cue that signaled that food was coming, people can “learn” addictive behaviors. When you drink or use drugs frequently around certain people or in certain places, you learn to associate those people or places with the experience of being high or intoxicated. People and places become “cues” just like the bell in Pavlov’s experiments. These cues create an anticipation of drinking or using drugs and all of the feelings that go along with being intoxicated or high. That anticipation can create an intense urge or craving.
Emotions can become cues as well; when you drink or use drugs repeatedly when you are in a certain emotional state (for example, when you are angry, sad, or nervous), then the emotional state itself can become a conditioned cue. For these reasons, being around people, places, or things (such as emotions) that remind you of drinking or using can trigger powerful cravings that are so uncomfortable that drinking or using seems like the only choice. These cravings are your conditioned response to drug and alcohol cues.
When Pavlov’s dog salivated in response to the bell, it was like a reflex. When addiction takes hold, your reactions to alcohol or drug cues can become very automatic, much like reflexes. Our most basic reflexes are controlled by the lower, more primitive part of our brains, including the brainstem. Can you recall a time when you found yourself drinking or using and you couldn’t recall how you even decided or started to drink or use? If so, that is because the addicted part of your brain was driving your behavior.
We will continue to refer to your addicted brain throughout this workbook; this is the part of your brain that will tempt and drive you to fulfill your impulses. These impulses make you feel like you “need” to drink or use, especially when you encounter cues that trigger cravings. To overcome your addiction, you will need to learn to purposely retrain the more sophisticated, rational part of your brain, which involves your frontal lobe. As you work your way through the exercises in this book, this is exactly what you are going to learn to do!
We will also refer to your rational brain throughout the workbook, to highlight the ways in which the addicted and rational parts of your neurobiology will conflict, and help you train your rational brain to become stronger. The frontal lobe controls rational behaviors. These behaviors are the outcome of a decision process, the kind that involves considering the pros and cons of your actions and choosing between alternatives—just as Jody did when she had to decide whether to drink and smoke pot the night before an important meeting.
When you learn to use your rational brain to make decisions about drinking or using in recovery, you will tune in to your cravings so that you realize what is happening in your body and mind in that moment, have an internal dialogue about it, and then choose how to respond to it, rather than reacting to it automatically, like a reflex. Because of the way your brain has been affected by drug or alcohol use, your automatic, reflexive reaction will be to drink or use drugs in many situations. Learning to control that reflex is what recovery is all about. You will learn how to do this in chapters 3 through 10.
The following table summarizes some of the brain structures and chemicals that are affected by addiction, and how these brain changes influence behavior.
Brain Effects of Drugs and Alcohol: How They Affect Behavior
You might be wondering, If addiction is a brain disease, then how exactly does treatment fix that? Just as much of your addictive behavior has been learned, recovery-oriented behaviors are also learned. You can’t erase your brain’s memories of using drugs and alcohol in response to various conditioned cues—whether those cues are people, places, or things. Those cues will probably make you uncomfortable by triggering cravings for a while. But you can learn new responses to those cues, while you give your brain the time it needs to heal. The longer you are able to remain abstinent from alcohol or drugs, the greater your chances of successfully living without drinking or using in the long term. In part 2 of this workbook, you will learn three sets of therapeutic skills to help you achieve abstinence from alcohol or drugs: cognitive behavioral therapy, motivational techniques, and mindfulness strategies.
Cognitive behavioral therapy (CBT). CBT is a therapy approach that has been used very effectively to help people with a wide range of problems, including addictions of all kinds, mood and anxiety disorders, weight control, chronic pain management, and other mental and physical health conditions. When applied to changing addictive behaviors, CBT is also referred to as relapse prevention therapy. The techniques offered by CBT are based on the understanding of addictive behaviors as learned, conditioned responses to people, places, and things that have been associated with drinking and using. The goals of CBT are to help you (1) understand how your addictive behaviors were learned and conditioned; (2) identify the people, places, and things that have been conditioned to bring on cravings to use substances (in other words, your triggers); and (3) learn healthy coping responses to these triggers that enable you to remain abstinent from drug or alcohol use.
CBT is probably the most well studied form of psychotherapy for addictions. There have been literally dozens of clinical trials comparing CBT to other forms of addiction treatment, and the results consistently show that this approach effectively reduces drug and alcohol use for people with various types of addictions, including stimulant (Rawson et al. 2004), marijuana (Budney et al. 2006), alcohol (Annis and Davis 1989), and opioid addictions (Church et al 2001; McAuliffe 1990; Pollack et al. 2002; Stein et al. 2004).
Motivational techniques. If you’re like most people in recovery, since the day you first realized that you needed to do something about your addiction, your intention to quit drinking or using has been at times clear and strong, while at other times less certain, or even completely absent. This could vary from day to day, or even from hour to hour. It is simply a reflection of the ambivalence, or mixed feelings, that all of us have when we are going to make a difficult change. Motivational therapy techniques help you to figure out the source of your ambivalence and resolve it so that you can move your life forward and commit firmly to making changes (Miller, 1983).
Motivational therapy techniques help you to explore your own ideas about how recovery could change your life, so that you can come to your own conclusions about it and become the driver of your recovery plan. Studies show that this approach is helpful for motivating people with addictions to attend therapy (Hettema, Steele, and Miller 2005), and when you combine motivational techniques with CBT, they are especially useful for helping you to quit using alcohol and drugs (Glasner-Edwards et al. 2013; Rohsenow et al. 2004). In chapter 3, you will complete motivational exercises to help you resolve ambivalence you might have about quitting drinking or using, and strengthen your commitment to your recovery.
Mindfulness-based relapse prevention. Mindfulness, one of the most well-studied forms of meditation practice, is a tool that has been recently introduced to the world of addiction treatment. Originally part of Buddhist meditation practice, mindfulness was adapted more than thirty years ago for use in a stress reduction program that was developed by Jon Kabat-Zinn (1982). Since that time, mindfulness has been used effectively to help with a range of psychological problems, including depression, anxiety, grief, and stress in individuals with serious medical problems. Mindfulness meditation, which you will learn about and practice in chapter 7, focuses on two core skills that can help you in your recovery: (1) learning how to be present in the moment, using awareness of your breath as a tool; and (2) learning to accept your experience just as it is, without judging yourself for it or trying to change it. As you will learn in chapter 7, these skills can be helpful to get you through a craving or to cope with another unpleasant emotion without turning to alcohol or drugs.
Medication is an option in the treatment of alcohol and certain drug addictions; and for some (for example, opioid addiction), it’s crucial, as highlighted by a recent quote in Time magazine by one of the leaders in the field of drug addiction treatment, Dr. Richard Rawson. Discussing use of the medication buprenorphine (which you will learn more about below) as a means of preventing opioid overdose deaths, which have increased in recent years, Rawson states, “Failure to encourage patients to use these medications is unconscionable. It’s comparable to conducting coronary bypass surgery and failing to prescribe aspirin, lipid, and blood pressure medications as part of a discharge plan” (Time, Feb 2, 2014).
Combining medication with behavioral therapy techniques can be a very effective way of treating addiction. The techniques in this workbook are compatible with the use of medication, which may also help you to achieve a long enough period of time without relapsing that you can engage more fully in the psychological skills–building process. Most of the medications for addictions work in one of three ways: (1) by minimizing the intense cravings that often stand in the way of successfully quitting drug or alcohol use; (2) by blocking or preventing the “high” or “rush” that you experience when you use alcohol or drugs, making substance use less appealing; or (3) by substituting for or “replacing” the drug that you are addicted to, keeping a steady level of a similar chemical in the system. Although historically the idea of using a medication or “drug” to treat a “drug problem” has been controversial, as addiction has become better understood as a chronic illness requiring ongoing treatment, much like diabetes and heart disease (McLellan et al. 2000), medications for addiction have been demonstrated scientifically to save lives, reduce deaths by overdose, improve overall quality of life, and enable people with addictions to flourish as productive members of society.
The table that follows summarizes the available medications that are approved by the Food and Drug Administration (FDA) and currently used, most successfully in combination with behavioral therapies. There are a few additional medications that are not FDA-approved but have been studied in clinical trials and show promise for the treatment of addictions; these include Topamax, Zofran, Seroquel, and baclofen. For more information on medications that can be used to treat addiction, you can visit the website of the National Institute on Drug Abuse: http://www.drugabuse.gov.
FDA-Approved Medications Used to Treat Addiction
As strong as the evidence is that addiction has damaging effects on the brain, scientific studies have shown that the brain has a remarkable potential for recovery. In one study, using brain imaging techniques, the researchers studied images of the brains of people who were addicted to methamphetamine, looking at changes in the images repeatedly over fourteen months of recovery and comparing them to healthy individuals who had never used drugs. They found that, over time, the brain’s potential to make dopamine, which was quite compromised at the beginning of the study, gradually recovered among those who remained abstinent from drugs (Volkow et al. 2001).
Even more recently, a group of scientists completed a similar brain imaging study, except that this study was designed to find out whether behavioral therapy for addiction could produce changes in brain activity in areas of the brain that are thought to be damaged by addiction. The researchers found that individuals who received cognitive behavioral therapy to treat their addictions showed improvement from the start to end of treatment on a test of impulse control and other cognitive abilities. They also showed changes in brain areas that control rational decision-making and “self-control,” or the ability to control your responses to your impulses (DeVito et al. 2012).
What does this mean for me? you might be wondering. It means that, with the right therapeutic skills in place, such as those you will learn in this workbook, not only can you learn to control your behavior as it relates to drug and alcohol use, and recover your ability to make healthy decisions, but you can experience pleasure again from ordinary, naturally enjoyable experiences. When drugs and alcohol take hold and you lose control, it is easy to feel hopeless, especially when the depression sets in. The great news about these scientific studies is that they show that your life can return to normal if you receive treatment using the techniques we are focusing on in this workbook, and are able to remain abstinent from drugs and alcohol.
By now, you have a deeper understanding of how addiction affects the brain. Many of your addictive behaviors can be explained by the neurobiological changes you have endured from your drug or alcohol use. In this chapter, you learned how rational decision-making is affected by chronic drinking and drug use. We reviewed how addictive behaviors are learned, and how they can become automatic. The therapy techniques you will learn in the chapters that follow can help you to learn new responses to the cues that previously triggered alcohol or drug use. By “relearning” how to respond to these cues in a healthy way without drinking or using, you are strengthening your rational brain, while disengaging from your addicted brain. This will allow you to heal and rebuild your ability to make rational choices. In the next chapter, we will begin working on strengthening your motivation for recovery.