ADDICTION: What Is Addiction?

Summary

• People who are addicted cannot control their need for alcohol or other drugs, even in the face of negative health, social or legal consequences.
• The illness becomes harder to treat and the related health problems, such as organ disease, become worse.

Addiction is a chronic, but treatable, brain disorder. People who are addicted cannot control their need for alcohol or other drugs, even in the face of negative health, social or legal consequences. This lack of control is the result of alcohol- or drug-induced changes in the brain. Those changes, in turn, cause behavior changes.

The brains of addicted people “have been modified by the drug in such a way that absence of the drug makes a signal to their brain that is equivalent to the signal of when you are starving,” says National Institute on Drug Abuse Director Dr. Nora Volkow. It is “as if the individual was in a state of deprivation, where taking the drug is indispensable for survival. It’s as powerful as that.”

Addiction grows more serious over time. Substance use disorders travel along a continuum. This progression can be measured by the amount, frequency and context of a person’s substance use. As their illness deepens, addicted people need more alcohol or other drugs; they may use more often, and use in situations they never imagined when they first began to drink or take drugs. The illness becomes harder to treat and the related health problems, such as organ disease, become worse.

“This is not something that develops overnight for any individual,” says addiction expert Dr. Kathleen Brady. “Generally there’s a series of steps that individuals go through from experimentation and occasional use [to] the actual loss of control of use. And it really is that process that defines addiction.”

Symptoms of addiction include tolerance (development of resistance to the effects of alcohol or other drugs over time) and withdrawal, a painful or unpleasant physical response when the substance is withheld. Many people with this illness deny that they are addicted. They often emphasize that they enjoy drinking or taking other drugs.

People recovering from addiction can experience a lack of control and return to their substance use at some point in their recovery process. This faltering, common among people with most chronic disorders, is called relapse. To ordinary people, relapse is one of the most perplexing aspects of addiction. Millions of Americans who want to stop using addictive substances suffer tremendously, and relapses can be quite discouraging.

“It is devastating to me when I don’t get [recovery] right,” laments Brian, a Portland, Oregon, coffee shop owner who struggles with his cocaine addiction. “Man, I can’t even describe it. It’s just horrible. The guilt. The depression that comes with it because I screwed up again. It’s an indescribable feeling that’s just – man, it’s low, low, low.”

To appreciate the grips of addiction, imagine a person that “wants to stop doing something and they cannot, despite catastrophic consequences,” says Dr. Nora Volkow, director of the National Institute on Drug Abuse. “We’re not speaking of little consequences. These are catastrophic. And yet they cannot control their behavior.”

An addiction is an unhealthy relationship with drugs or alcohol in which you use more than you would like to use, and you continue to use despite negative consequences.

People use drugs or alcohol to escape, relax, or to reward themselves. But over time, drugs and alcohol make you believe that you can’t cope without them, or that you can’t enjoy life without using. The greatest damage is to your self-esteem.

What is the Medical Definition of Addiction?

An addiction must meet at least 3 of the following criteria. This is based on the criteria of the American Psychiatric Association (DSM-IV) and World Health Organization (ICD-10).(1)

1. Tolerance. Do you use more alcohol or drugs over time?
2. Withdrawal. Have you experienced physical or emotional withdrawal when you have stopped using? Have you experienced anxiety, irritability, shakes, sweats, nausea, or vomiting? Emotional withdrawal is just as significant as physical withdrawal.
3. Limited control. Do you sometimes drink or use drugs more than you would like? Do you sometimes drink to get drunk? Does one drink lead to more drinks sometimes? Do you ever regret how much you used the day before?
4. Negative consequences. Have you continued to use even though there have been negative consequences to your mood, self-esteem, health, job, or family?
5. Neglected or postponed activities. Have you ever put off or reduced social, recreational, work, or household activities because of your use?
6. Significant time or energy spent. Have you spent a significant amount of time obtaining, using, concealing, planning, or recovering from your use? Have you spend a lot of time thinking about using? Have you ever concealed or minimized your use? Have you ever thought of schemes to avoid getting caught?
7. Desire to cut down. Have you sometimes thought about cutting down or controlling your use? Have you ever made unsuccessful attempts to cut down or control your use?

How Common is Drug or Alcohol Addiction?

Approximately 10% of any population is addicted to drugs or alcohol. Addiction is more common than diabetes, which occurs in approximately 7% of the population.

Addiction crosses all socio-economic boundaries. 10% of teachers, 10% of plumbers, and 10% of CEOs have an addiction.

The terms alcohol addiction, alcoholism, and alcohol dependence are all equivalent. The same is true for the terms drug addiction and drug dependence. (Reference: www.AddictionsAndRecovery.org.)

How Does Addiction Feel?

An addictive substance feels good because it stimulates the pleasure center of the brain through neurotransmitters such as dopamine and GABA. If you have a genetic predisposition, addictive substances don’t just feel good. They feel so good that you will want to chase after them.

This is where addiction comes in. If you have a genetic predisposition, addictive substances feel so good that you are willing to suffer negative consequences in order to get more and to continue to feel the high.

Addictive substances feel different inside an addict’s brain than they do to a non-addict. This is why the two sides have difficulty understanding each other. In someone who is not addicted, drugs and alcohol only produce a mild high. Therefore a non-addict cannot understand why the addict would go to such lengths, when it is clearly destroying their life.

Denial is a big part of addiction. Because addictive substances feel good, an addict will initially deny that they have a problem. In the long-run addiction isolates you from the people and activities and that mean the most to you.

The Cost of Addiction

The dollars and cents cost of addiction is mind boggling. At least twice as many people die from alcoholism in the US every year as die from motor vehicle accidents.(2)

Alcohol intoxication is associated with 40-50% of traffic fatalities, 25-35% of nonfatal motor vehicle injuries, and 64% of fires. Alcohol is present in nearly 50% of homicides, either in the victim or the perpetrator.(3)

Alcohol intoxication is involved in 31% of fatal injuries, and 23% of completed suicides.(4)

One study found that 86 % of homicide offenders, 37 % of assault offenders, and 57 % of men and 27 % of women involved in marital violence were drinking at the time of their offense.(5)

The Consequences of Addiction

People only stop using drugs and alcohol when they have suffered enough negative consequences. When you’ve suffered enough pain and enough regret you are ready to stop.

You are ready to stop when the two sides of addiction collide. On the one hand, addiction feels so good that you want to use more. On the other hand, addiction leads to negative consequences. After a while, something has got to give.

You don’t have to hit rock bottom. The purpose of websites like this is to show you the potential negative consequences of addiction so that you will be ready to quit before you’ve lost everything. You can imagine what it would be like to hit rock bottom. And that can help motivate you.

The most important consequences of addiction are social, emotional, and psychological. People usually think of the physical and economic consequences of addiction. “I don’t have a serious addiction because my health is fine, and I haven’t lost my job.” But those are very late stage consequences.

As far as work is concerned that’s usually the last thing to suffer. You need your work in order to pay your bills, so that you can continue your addiction. When your work begins to suffer, you’ve slipped from being a functioning addict to a non-functioning addict.

The damage addiction does to your relationships and self-esteem is far deeper and takes longer to repair. You’ve hurt friends and family. You’ve disappointed yourself. You’ve traded important things in your life so that you could make more time to use. You’ve lived a double life. You’ve seen the hurt in your family’s eyes, and the disappointment in your children’s faces. Those are the consequences that can motivate you to begin recovery.

Here are three tests to help you decide if you have an addiction.

The CAGE Test for Alcohol Addiction

This simple test is surprisingly accurate. Answer yes or no to each question.

1. Have you ever felt you should Cut down on your drinking?
2. Have you ever been Annoyed when people have commented on your drinking?
3. Have you ever felt Guilty or badly about your drinking?
4. Have you ever had an Eye opener first thing in the morning to steady your nerves or get rid of a hangover?

Your score:
Score one point for each yes answer.(2)

If you scored 1, there is an 80% chance you’re addicted to alcohol.
If you scored 2, there is an 89% chance you’re addicted to alcohol.
If you scored 3, there is a 99% chance you’re addicted to alcohol.
If you scored 4, there is a 100% chance you’re addicted to alcohol.

The Modified CAGE Test for All Addictions

Most self-test questionnaires apply to alcohol addiction, but can be easily adapted to any addiction.

1. Have you ever felt you should Cut down your use of drugs?
2. Have you ever been Annoyed when people have commented on your use?
3. Have you ever felt Guilty or badly about your use?
4. Have you ever used drugs to Ease withdrawal symptoms, or to avoid feeling low after using?

The AUDIT Test for Alcohol Addiction (Alcoholism)

To correctly answer some of these questions you need to know the definition of a drink. For this test one drink is:
One can of beer (12 oz or approx 330 ml of 5% alcohol), or
One glass of wine (5 oz or approx 140 ml of 12% alcohol), or
One shot of liquor (1.5 oz or approx 40 ml of 40% alcohol).

1. How often do you have a drink containing alcohol?
Never (score 0) 
Monthly or Less (score 1) 
2-4 times a month (score 2) 
2-3 times a week (score 3) 
4 or more times a week (score 4)

2. How many alcoholic drinks do you have on a typical day when you are drinking?
1 or 2 (0) 
3 or 4 (1) 
5 or 6 (2) 
7-9 (3) 
10 or more (4)

3. How often do you have 6 or more drinks on one occasion?
Never (0) 
Less than monthly (1) 
Monthly (2) 
Weekly (3) 
Daily or almost daily (4)

4. How often during the past year have you found that you drank more or for a longer time than you intended?
Never (0) 
Less than monthly (1) 
Monthly (2) 
Weekly (3) 
Daily or almost daily (4)

5. How often during the past year have you failed to do what was normally expected of you because of your drinking?
Never (0) 
Less than monthly (1) 
Monthly (2) 
Weekly (3) 
Daily or almost daily (4)

6. How often during the past year have you had a drink in the morning to get yourself going after a heavy drinking session?
Never (0) 
Less than monthly (1) 
Monthly (2) 
Weekly (3) 
Daily or almost daily (4)

7. How often during the past year have you felt guilty or remorseful after drinking?
Never (0) 
Less than monthly (1) 
Monthly (2) 
Weekly (3) 
Daily or almost daily (4)

8. How often during the past year have you been unable to remember what happened the night before because of your drinking?
Never (0) 
Less than monthly (1) 
Monthly (2) 
Weekly (3) 
Daily or almost daily (4)

9. Have you or anyone else been injured as a result of your drinking?
No (0) 
Yes, but not in the past year (2) 
Yes, during the past year (4)

10. Has a relative, friend, doctor, or health care worker been concerned about your drinking, or suggested that you cut down?
No (0) 
Yes, but not in the past year (2) 
Yes, during the past year (4)

Your score:
If you scored 8-10 or more, you are probably addicted to alcohol.

It may seem like the AUDIT questionnaire is an easy test to fail. If you applied this test to other aspects of your life you will almost certainly come up as being addicted to something. For example, most people watch too much television, or eat too much of their favorite food. But those are so-called “soft addictions”, and the AUDIT questionnaire was not designed to assess them. It is extremely reliable when it comes to assessing alcohol addiction.

The AUDIT (Alcohol Use Disorders Identification Test) was developed by the World Health Organization (WHO). The test correctly classifies 95% of people into either alcoholics or non-alcoholics. It was tested on 2000 people before being published.(1)

When Is Someone Addicted?

The American Psychiatric Association says that a person is dependent if their pattern of substance use leads to clinically significant impairment or distress shown by three or more of the following in a 12-month period:

1. Tolerance as defined by any of the following:

• a need for markedly increased amounts of the substance to achieve intoxication or desired effect
• markedly diminished effect with continued use of the same amount of the substance

2. Withdrawal, as manifested by either of the following:

• the characteristic withdrawal symptom of the substance
• the same or a closely related substance is taken to relieve or avoid withdrawal symptoms

3. The substance is often taken in larger amounts or over a longer period than was intended (loss of control)

4. There is a persistent desire or unsuccessful efforts to cut down or control substance use (loss of control)

5. A great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects (preoccupation)

6. Important social, occupational or recreational activities are given up or reduced because of substance use (continuation despite adverse consequences)

7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (adverse consequences)

Addiction and the Brain

Scientists now know that addiction is the result of key changes in the brain.

For example, all drugs of abuse affect the dopamine pathway in the brain. Dopamine is a kind of neurotransmitter – a chemical produced by nerve cells that process and transmit information in the brain. The dopamine neurotransmitter’s job is to produce feelings of pleasure so this pathway is commonly known as the “pleasure pathway.”

“What happens when people develop a substance use disorder is that they tax the ability of their dopamine system to keep up,” says Dr. Kathleen Brady, an addiction researcher at the Medical University of South Carolina. “The amount of dopamine we have in our brain is limited by the substances that the brain uses to make dopamine. And if we release it too often, we get into a situation where the brain has less dopamine. What that means is that an individual who has depleted their dopamine source in their brain has a difficult time feeling pleasure from even the normal events that would make someone happy – a mother seeing her child, or having a good meal.”

The dopamine pathway is not the only part of the brain affected by addiction. Alcohol and drugs can profoundly affect different neurological circuits. Prolonged excessive alcohol use, for example, is believed to cause cause pervasive alterations in the brain’s stressand stressand anti-stress systems. These changes, in and of themselves, may lead to additional compulsive drinking.

Drugs of abuse affect the parts of the brain that control pleasure, motivation, emotion, and memory, these changes can lead to the disease of drug addiction. Using drugs repeatedly over time changes brain structure and function in fundamental and long-lasting ways that can persist long after a person stops using them. Different types of drugs affect the brain in different ways, altering different aspects of the brain chemistry. However, with prolonged abstinence, some of the brain changes caused by specific drugs (e.g., methamphetamine) may be reversible, which is one reason why treatment is essential.

A Chronic ConditionAddiction can be effectively treated and managed through lifestyle changes and, in some cases, the use of medication.Stop! Go! A Rogue System in the BrainOur brain controls our decisionmaking, letting us know when to go forward with an action and when to stop. Scientists have learned which parts of the brain send these messages.Abuse vs. DependenceThe difference between abuse and dependence is not always clear to the general public, but medical professionals use a set of criteria to distinguish between these two categories of problem use.

A Chronic Condition

Summary

• Like hypertension or diabetes, addiction is a lifelong illness.
• Biological and behavioral factors influence addiction, as they do other chronic conditions.
• Addiction can be effectively treated and managed through lifestyle changes and, in some cases, the use of medication.

For hundreds of years, people have considered addiction to be a problem of willpower or of moral failing. Now we know that addiction is a disorder much like other chronic illnesses that involve behavior and lifestyle. Some of these illnesses begin with voluntary behaviors, such as poor nutrition or failure to exercise. But then, biological changes occur in the body to make the illness a chronic condition.

Most people who have chronic conditions, even those who are working hard to stay on top of their illness, sometimes eat poorly or do other things that they know aren’t healthy. They backslide, or relapse, at some point.

Other diseases like this include:

• hypertension (high blood pressure)
• adult onset (type 2) diabetes
• atherosclerosis (hardening of the arteries)

These diseases are similar because they are:

• chronic
• influenced by biological and behavioral factors
• incurable, but can be effectively treated and managed

But in all of these illnesses, as in addiction, medications can be helpful, as can lifestyle changes, for getting better.

Summary

1. Like hypertension or diabetes, addiction is a lifelong illness.
2. Biological and behavioral factors influence addiction, as they do other chronic conditions.
3. Addiction can be effectively treated and managed through lifestyle changes and, in some cases, the use of medication.

For hundreds of years, people have considered addiction to be a problem of willpower or of moral failing. Now we know that addiction is a disorder much like other chronic illnesses that involve behavior and lifestyle. Some of these illnesses begin with voluntary behaviors, such as poor nutrition or failure to exercise. But then, biological changes occur in the body to make the illness a chronic condition.

Most people who have chronic conditions, even those who are working hard to stay on top of their illness, sometimes eat poorly or do other things that they know aren’t healthy. They backslide, or relapse, at some point.

Other diseases like this include:

1. hypertension (high blood pressure)
2. adult onset (type 2) diabetes
3. atherosclerosis (hardening of the arteries)

These diseases are similar because they are:

• chronic
• influenced by biological and behavioral factors
• incurable, but can be effectively treated and managed

But in all of these illnesses, as in addiction, medications can be helpful, as can lifestyle changes, for getting better.

Stop! Go! A Rogue System in the Brain

Summary

1. Drug abuse damages a person’s ability to make decisions.
2. Healthy people have interacting systems in their brain that signal when to take action (go) and when to refrain (stop).
3. A leading addiction researcher says that when someone is addicted, it’s as if the “go” system is “running off on its own” instead of interacting with the “stop” system.

Our brain controls our decisionmaking, letting us know when to go forward with an action and when to stop. Scientists have learned which parts of the brain send these messages. And they know that for addicted people, these “stop” and “go” systems are impaired.

The brain’s reward, or “go” system, is basic to all humans. Called the mesolimbic dopamine system, it evolved to help us pursue things necessary for survival such as food or sex. Conversely, the brain’s frontal lobes or “stop” system evolved to help us weigh the consequences of our impulses. For example, this system will help keep us from driving through a red light when we’re in a hurry, because the brain will tell us that doing so would be both dangerous and illegal. In this case, the “stop” system sends a message that the consequences of doing what the “go” system wants are too negative.

“When things are working right, the ‘go’ circuitry and the ‘stop’ circuitry really are interconnected and are really talking to each other to help you weigh the consequences of a decision and decide when to go or not to go,” says Dr. Anna Rose Childress, a psychology researcher at the University of Pennsylvania. “It’s not that they’re separable. They’re interactive. They’re interlinked at all times.” That means that even when you are in a great hurry and risk missing an appointment, you still do not run the red light. “Go” and “stop” have communicated with each other, and “stop” has prevailed.

With Childress’s addicted patients, however, “it is as though [the systems] have become functionally disconnected. It is as though the ‘go’ system is sort of running off on its own, is a rogue system now, and is not interacting in a regular, seamless, integrated way with the ‘stop’ system.”

When an addicted person, even one who is working to recover, gets certain signs, or triggers, such as conflict with a companion, the “go” system overwhelms the part of the brain that’s telling them, “Stop! This is a very bad idea!” The trigger can be something essential to the addicted person’s life: one recovered writer realized that his addiction was partly triggered by the deadline pressure of his chosen profession as a journalist, and was prompted to start a new career; other recovering people often move from their old neighborhoods to be away from triggers. But a trigger can also be something as subtle as a scent that reminds a person of the place where they used to buy drugs.

When that trigger surfaces, Childress says, “instead of being able to say, ‘What? Wait a minute. Think about what happened last week. You lost your job. You almost lost your life,’ the ‘stop’ system doesn’t seem to get into the picture at all. It’s all about ‘go.'”

Abuse vs. Dependence

Summary

1. Medical professionals follow certain criteria to determine if a person abuses alcohol or drugs.
2. These established criteria also can mark whether the substance abuse has progressed to dependence.
3. Alcohol and drug dependence cause people to suffer from withdrawal symptoms when they stop using the substance. Dependence also causes major behavioral changes, such as overwhelming preoccupation with drug or alcohol use.

Some people who start as casual drinkers or drug users will stay that way. But others will become substance abusers or dependent, feeling that they need a drug to feel alive. The difference between abuse and dependence is not always clear to the general public, but medical professionals use a set of criteria to distinguish between these two categories of problem use.

The essential feature of abuse is a pattern of substance use that causes someone to experience harmful consequences. Clinicians diagnose substance abuse if, in a twelve-month period, a person is in one or more of the following situations related to drug use:

1. Failure to meet obligations, such as missing work or school
2. Engaging in reckless activities, such as driving while intoxicated
3. Encountering legal troubles, such as getting arrested
4. Continuing to use despite personal problems, such as a fight with a partner

Dependence is more severe. Medical professionals will look for three or more criteria from a set that includes two physiological factors and five behavioral patterns, again, over a twelve-month period. Tolerance and withdrawal alone are not enough to indicate dependence. And not all behavioral signs occur with every substance.

The physiological factors are:

• Tolerance, in which a person needs more of a drug to achieve intoxication
• Withdrawal, in which they experience mental or physical symptoms after stopping drug use

The behavioral patterns are:

• Being unable to stop once using starts
• Exceeding self-imposed limits
• Curtailing time spent on other activities
• Spending excessive time using or getting drugs

Taking a drug despite deteriorating health

Addiction and the Brain’s Pleasure Pathway: Beyond Willpower

Summary

1. Addiction can develop despite a person’s best intentions and in spite of their strength of character.
2. Repeated drug use disrupts complex but well balanced systems in the human brain.
3. Many people are addicted to more than one substance, complicating their efforts to recover.

The human brain is an extraordinarily complex and fine-tuned communications network containing billions of specialized cells (neurons) that give origin to our thoughts, emotions, perceptions and drives. Often, a drug is taken the first time by choice to feel pleasure or to relieve depression or stress. But this notion of choice is short-lived. Why? Because repeated drug use disrupts well-balanced systems in the human brain in ways that persist, eventually replacing a person’s normal needs and desires with a one-track mission to seek and use drugs. At this point, normal desires and motives will have a hard time competing with the desire to take a drug.

How Does the Brain Become Addicted?

Typically it happens like this:

1. A person takes a drug of abuse, be it marijuana or cocaine or even alcohol, activating the same brain circuits as do behaviors linked to survival, such as eating, bonding and sex. The drug causes a surge in levels of a brain chemical called dopamine, which results in feelings of pleasure. The brain remembers this pleasure and wants it repeated.
2. Just as food is linked to survival in day-to-day living, drugs begin to take on the same significance for the addict. The need to obtain and take drugs becomes more important than any other need, including truly vital behaviors like eating. The addict no longer seeks the drug for pleasure, but for relieving distress.
3. Eventually, the drive to seek and use the drug is all that matters, despite devastating consequences.
4. Finally, control and choice and everything that once held value in a person’s life, such as family, job and community, are lost to the disease of addiction.

What brain changes are responsible for such a dramatic shift?

Research on addiction is helping us find out just how drugs change the way the brain works. These changes include the following:

• Reduced dopamine activity. We depend on our brain’s ability to release dopamine in order to experience pleasure and to motivate our responses to the natural rewards of everyday life, such as the sight or smell of food. Drugs produce very large and rapid dopamine surges and the brain responds by reducing normal dopamine activity. Eventually, the disrupted dopamine system renders the addict incapable of feeling any pleasure even from the drugs they seek to feed their addiction.
• Altered brain regions that control decisionmaking and judgment. Drugs of abuse affect the regions of the brain that help us control our desires and emotions. The resulting lack of control leads addicted people to compulsively pursue drugs, even when the drugs have lost their power to reward.

The disease of addiction can develop in people despite their best intentions or strength of character. Drug addiction is insidious because it affects the very brain areas that people need to “think straight,” apply good judgment and make good decisions for their lives. No one wants to grow up to be a drug addict, after all.

Co-occurring Addictions: Compounding Complexities

It is not unusual for an addicted person to be addicted to alcohol, nicotine and illicit drugs at the same time. Addiction to multiple substances raises the level of individual suffering and magnifies the associated costs to society. No matter what the addictive substance, they all have at least one thing in common – they disrupt the brain’s reward pathway, the route to pleasure.

What is the best way to treat people who are addicted to more than one drug?

• Medications. In some cases, medications developed for one addiction have proven useful for another. For example, naltrexone, which can help former heroin users remain abstinent by blocking the “high” associated with heroin, has been found to be effective in treating alcoholism.
• Behavioral therapy or other psychotherapy. Behavioral therapies do not need to be specific to one drug and can be adapted to address use of multiple or different drugs. It is the disease of addiction that the therapy addresses.
• Combined medications and behavioral therapy. Research shows that this combination, when available, works best.
• Multipronged approach. Treatment for multiple addictions should be delivered at the same time. This is especially true because there are always triggers, such as trauma, depression, or exposure to one drug or another, that can put the recovering addict at risk for relapse. In addition, treatment must consider all aspects of a person – their age, gender, life experiences – in order to best treat their drug addiction. Although the type of treatment may differ, it should always strive to address the entire person through a multipronged approach that tackles all co-occurring conditions at once.

Relapse: Part of Addiction as a Chronic Disease

Despite the availability of many forms of effective treatment for addiction, the problem of relapse remains the major challenge to achieving sustained recovery. People trying to recover from drug abuse and addiction are often doing so with altered brains, strong drug-related memories and diminished impulse control. Accompanied by intense drug cravings, these brain changes can leave people vulnerable to relapse even after years of being abstinent. Relapse happens at rates similar to the relapse rates for other well-known chronic medical illnesses like diabetes, hypertension and asthma.

How is relapse to drug abuse similar to what happens with other chronic diseases?

• Just as an asthma attack can be triggered by smoke, or a person with diabetes can have a reaction if they eat too much sugar, a drug addict can be triggered to return to drug abuse.
• With other chronic diseases, relapse serves as a signal for returning to treatment. The same response is just as necessary with drug addiction.
• As a chronic, recurring illness, addiction may require repeated treatments until abstinence is achieved. Like other diseases, drug addiction can be effectively treated and managed, leading to a healthy and productive life.

To achieve long-term recovery, treatment must address specific, individual patient needs and must take the whole person into account. For it is not enough simply to get a person off drugs; rather, the many changes that have occurred – physical, social, psychological – must also be addressed to help people stay off drugs, for good.


 
Repeated drug exposure changes brain function. Positron emission tomography (PET) images are illustrated showing similar brain changes in dopamine receptors resulting from addiction to different substances – cocaine, methamphetamine, alcohol, or heroin. The striatum (which contains the reward and motor circuitry) shows up as bright red and yellow in the controls (in the left column), indicating numerous dopamine D2 receptors. Conversely, the brains of addicted individuals (in the right column) show a less intense signal, indicating lower levels of dopamine D2 receptors.

Let’s Talk About Craving

Summary

Brain imaging research is revealing that the signals, or cues, that may spark an addicted person’s desire to take drugs can be incredibly subtle or quick. Expanded knowledge about craving helps scientists develop new medical treatments for addiction.

Cravings – powerful desires – are part of the human condition. Our brains are “hard-wired” to appreciate and to pursue natural rewards such as food and sex because of their critical survival value.

Drugs used by addicted people activate the same circuits that motivate food and sexual behavior. Signals, called cues, can be sights, sounds, smell or thoughts. Cues activate the brain’s powerful “go!” circuit creating cravings. The cravings for alcohol and other drugs can be even stronger than those for food or sex.

Managing the cravings associated with food, sex and drugs is the responsibility of the brain’s inhibitory “stop!” circuitry. Research suggests that some people have better “stop!” systems or better “brakes,” than others. Individuals with weaker “brakes,” may have much greater difficulty managing cravings, putting them at increased risk for addiction, and/or for relapse. Exposure to some drugs may actually weaken the brain’s braking system.

Cravings may have their beginnings outside conscious awareness. Recent brain imaging research shows that drug and sexual cues as brief as 33 milliseconds can activate the brain “go!” circuit even though the person is not conscious of the cues.

In addition to cue-induced craving, desire can also be fueled by:

• a small sample of the drug/food/rewarding activity (the “salty peanut” effect: “just a little” often leads to much more!)
• the wish to avoid negative effects (such as drug withdrawal, or negative moods, etc.). Many people with addictions have a co-occurring mood disorder (anxiety or depression). These moods can themselves become triggers for food or drug craving, increasing the risk of relapse.

Hope Through Research

You can get help with managing craving, and there is much ongoing research aimed at the development of more effective anti-craving interventions (for food, drugs, sex, gambling, etc.).

Both anti-craving medications and anti-craving behavioral strategies may be helpful to inhibit or “stop!” drug craving. Many of these medications have been well-studied; others are in the early stages of testing. New anti-craving interventions may be available in a location close to you. Research treatments are usually available at no cost (as they are supported by research grants), and they may offer a new treatment option that is not yet available in the community.

FIVE THINGS TO DO ABOUT CRAVING

When you have an episode of craving:

• 1. Try to view the craving in a matter-of-fact way. Having a craving does not mean that you are unmotivated – or that you are doomed to relapse.
• 2. Learning about your craving triggers, and how to manage them, will be an important part of your recovery in addiction.
• 3. Try anti-craving behavioral strategies, such as the 5-minute contract (making a contract with yourself not to act on the desire for the next five minutes, and then engaging in a distracting activity in the meantime.) Many urges are short-lived – you will find they are weaker if you can “surf through” the first few minutes.
• 4. Call upon the guidance of a trained treatment professional may be needed for successfully implementing any of a number of well-described behavioral techniques that can be helpful in managing cravings. Treatment manuals detail these strategies.
• 5. Consider an anti-craving medication. Craving can erupt quickly and feel overwhelming, making it difficult to put to use behavioral anti-craving strategies, even well-learned ones. 
An anti-craving medication may give you a better chance to use the tools you have learned. Some FDA-approved medications for alcohol and heroin addiction may have a beneficial effect on cue-triggered craving; medications for cue-induced cigarette craving and cue-induced cocaine/methamphetamine craving are the focus of many ongoing research studies. Several medications are already under study or in the research phase which may work for more than one type of craving, offering “one-stop-shopping.” Anna Rose Childress, Ph.D., is a research associate professor in the Department of Psychiatry at the University of Pennsylvania School of Medicine. She directs the Brain-Behavioral Vulnerabilities Division at the Center for the Study of Addictions, where she has conducted federally-funded research projects for more than two decades. Dr. Childress tests potential new medications with potential impact on both substance and non-substance addictions. Her addiction research has focused on the motivation for drug use/relapse, with an emphasis on understanding and treating the profound craving states elicited by heroin, cocaine and nicotine drug cues. Her early work characterized the subjective and physiological responses to drug cues, developing behavioral anticraving strategies.

Why Do Some People Become Addicted?

For two decades, researchers have been struggling to identify the biological and environmental risk factors that can lead to addiction to alcohol and other drugs. These factors form a complex mélange in which the influences combine to bring about addiction and to make its treatment challenging. But scientists know more about addiction now than they did even 10 years ago, and have learned much about how the risk factors work together.

The widely recognized risk factors include:

• Genes: Genetics play a significant role: having parents with alcoholism, for instance, makes you four times more likely than other children to become alcoholics. More than 60 percent of alcoholics have family histories of alcoholism.
• Mental illness: Many addicted people also suffer from mental health disorders, especially anxiety, depression or mood illnesses.
• Early use of drugs: The earlier a person begins to use drugs the more likely they are to progress to more serious abuse.
• Social environment: People who live, work or go to school in an environment in which the use of alcohol and other drugs is common – such as a workplace in which people see heavy drinking as an important way to bond with coworkers – are more likely to abuse drugs.
• Childhood trauma: Scientists know that abuse or neglect of children, persistent conflict in the family, sexual abuse and other traumatic childhood experiences can shape a child’s brain chemistry and subsequent vulnerability to addiction.

“The kids most likely to get addicted are the ones who also have other problems,” says Dr. Mark Willenbring, who directs the Division of Treatment and Recovery Research of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Forty percent of people who start drinking before they are 15 years old develop alcoholism. Addiction is at the end of a spectrum of substance use problems; for most people, though not all, addiction arrives after other phases of drinking or drugging go uninterrupted. That’s why it is so important to treat substance use problems in their earliest stages. Although genetic researchers are trying to identify the genes that confer vulnerability to alcoholism, this task is difficult because the illness is thought to be related to many different genes, each of which contributes only a portion of the vulnerability.

Stress and AddictionScience shows that stress and addiction are so closely intertwined that to recover, people with addictions must learn new ways of coping with stress.Co-occurring DisordersA significant portion of people with addictions also suffer from other mental health illnesses, called co-occurring disorders. Without comprehensive treatment, people with co-occurring disorders are far less likely to recover from their addictions.

What Is Relapse?

Relapse is a cardinal feature of addiction, and one of the most painful.

Most people who struggle with addiction will have one or more relapses – the return to drug use after a drug-free period – during their ongoing attempts to recover. This can be extremely frustrating for patients and for families, as they have already experienced great pain.

What leads to relapse?

Multiple – and often interactive – factors can increase the likelihood of relapse. These are some of the commonly cited precursors:

• drug-related “reminder” cues (sights, sounds, smells, drug thoughts or drug dreams) tightly linked to use of the preferred drug(s) can trigger craving and drug seeking
• negative mood states or stress
• positive mood states or celebrations
• sampling the drug itself, even in very small amounts

The motivation to seek a drug, once triggered, can feel overwhelming and sometimes leads to very poor decisionmaking: the user will pursue the drug, despite potentially disastrous future negative consequences (and many past negative consequences).

Individuals have different brain circuitry

Brain-imaging is helping us to understand the paradox of the decision to pursue a drug reward despite such consequences. For example, very recent imaging research shows that visual drug cues as short as 33 milliseconds can activate the ancient reward (“go”) circuitry, and that this process does not require conscious processing – it can begin outside awareness.

By the time the motivation does reach awareness, and is recognized and labeled, the reward circuit has a strong head start. This head start means the frontal brain regions may be less effective. This area of the brain is responsible for weighing the consequences of a decision and for helping to “stop” or inhibit the impulses toward drug reward.

Imaging research also shows that some individuals have less effective “stop” circuitry. For these people, the job of managing the powerful impulses toward drug reward may be even more difficult.

When it comes to the vulnerability to relapse, and to addiction itself, we are not all created equal. We differ both in our brain response to drug rewards and in our ability to manage the powerful impulses toward drug reward.

Hope through research

Relapse is a long-term vulnerability, but intensive ongoing research is targeting the problem. The tools of brain imaging and genetics promise to help us understand our vulnerabilities – and our strengths – to help us realize more effective relapse prevention. Many different clinical research trials are underway, and new antirelapse interventions (behavioral or medication-based) may be available in a location close to you.

Old Ideas

Since so much of our scientific understanding of addiction is relatively new, and since so much about drug and alcohol use is tied up in belief systems, it’s not surprising that myths about this disease abound.

“There are two main misconceptions that really drive me crazy when it comes to addictions,” says Dr. Kathleen Brady, a professor at the Medical University of South Carolina. “One of them is this whole idea that an individual needs to reach rock bottom before they can get any help. That is absolutely wrong. There is no evidence that that’s true. In fact, quite the contrary. The earlier in the addiction process that you can intervene and get someone help, the more they have to live for. The more they have to get better for.”

The other big myth, says Dr. Nora Volkow, director of the federal government’s National Institute on Drug Abuse, is that you have to want to be treated in order to get better. Even as an internationally respected researcher, she once believed that to be true, Volkow says, but she knows now that people who are forced into treatment do recover. Addicted people may be pushed to enter a treatment program by an employer, a companion or the criminal justice system. Employers may threaten to fire a person unless treated; a spouse may threaten to leave the relationship, or the court may offer treatment in lieu of prison. (In this case, people convicted of nonviolent, drug-related crimes may go through specialized alternative courts, called drug courts, in which they can reduce their sentence or avoid jail altogether by getting intensive addiction treatment.) In fact, research has shown that the outcomes for those who are legally mandated to enter treatment can be as good as the outcomes for those who entered treatment voluntarily.

Myths of Addiction

1. Addicts are bad, crazy, or stupid.

Evolving research is demonstrating that addicts are not bad people who need to get good, crazy people who need to get sane, or stupid people who need education. Addicts have a brain disease that goes beyond their use of drugs.

2. Addiction is a willpower problem.

This is an old belief, probably based upon wanting to blame addicts for using drugs to excess. This myth is reinforced by the observation that most treatments for alcoholism and addiction are behavioral (talk) therapies, which are perceived to build self-control. But addiction occurs in an area of the brain called the mesolimbic dopamine system that is not under conscious control.

3. Addicts should be punished, not treated, for using drugs.

Science is demonstrating that addicts have a brain disease that causes them to have impaired control over their use of drugs. Addicts need treatment for their neurochemically driven brain pathology.

4. People addicted to one drug are addicted to all drugs.

While this sometimes occurs, most people who are dependent on a drug may be dependent on one or two drugs, but not all. This is probably due to how each drug “matches up” with the person’s brain chemistry.

5. Addicts cannot be treated with medications.

Actually, addicts are medically detoxified in hospitals, when appropriate, all the time. But can they be treated with medications after detox? New pharmacotherapies (medicines) are being developed to help patients who have already become abstinent to further curb their craving for addicting drugs. These medications reduce the chances of relapse and enhance the effectiveness of existing behavioral (talk) therapies.

6. Addiction is treated behaviorally, so it must be a behavioral problem.

New brain scan studies are showing that behavioral treatments (i.e., psychotherapy) and medications work similarly in changing brain function. So addiction is a brain disease that can be treated by changing brain function, through several types of treatments.

7. Alcoholics can stop drinking simply by attending AA meetings, so they can’t have a brain disease.

The key word here is “simply.” For most people, AA is a tough, lifelong working of the Twelve Steps. On the basis of research, we know that this support system of people with a common experience is one of the active ingredients of recovery in AA. AA doesn’t work for everyone, even for many people who truly want to stop drinking.