The Disease Concept and Brain Chemistry of Alcoholism and Drug Addiction
is brought to you by,
National Institute on Chemical Dependency
People talk to each other by using words to convey a message. Some messages we send may request an action be performed from the person we are communicating to. Our brains communicate from one cell to the other via chemicals, and these are called neurotransmitters. When one cell communicates to another these chemicals may also require an action be taken or sensation produced, (like breathing, muscle contraction, body temperature regulation, and also feelings).
There are 5 main neurotransmitters affected by the disease of alcoholism and drug addiction. Two of these chemicals, dopamine and seratonin, have a profound affect upon the alcoholic and/or drug addict. These two neurotransmitters affect the addicted person by changing how they respond under stress, what moods are experienced, and also communicate feelings of pleasure and/or pain.
Dopamine, when depleted by alcohol and/or drug use, can leave a person with a high tolerance to pain and reduced level of pleasure one feels when doing an activity.
Seratonin depletion can lead to sensory deprivation, body temperature anomalies, and also depression.
These two chemicals, needed by the brain to convey feelings of health and wellness, can when affected by alcohol and drugs, lead to an inability to function in society.
In the above diagram you can see how the mechanism of brain chemistry functions. The cell on the left is communicating to the cell on the right via neurotransmitters like dopamine and seratonin. When there is a lack of serotonin in the synapse we experience this by having depression. In alcoholics and addicts this brain chemical depletion is common place.
The brain chemistry imbalance in alcoholics and addicts is one of permanent damage.
It’s like taking a cucumber and changing it into a pickle- you can’t go back once the change occurs. There is hope and help for this condition, and we will address this later.
Ask yourself this question, "Can you say how many seratonin molecules are in the synapse right now?" You can’t. If you have too few you could say that you have depression, and this is manifested by feeling sad. This is also evident by the fact that you may be isolative, have poor hygiene, and are apathetic.
If asked the same question again, but added the four other chemicals in imbalance you still would be unable to answer the question; however, if you had no symptoms you would think all is alright within you. Here is the catch, the alcoholic and addict have all this brain chemistry imbalance going on, and keeping in mind they can’t tell they have serious neurotransmitter depletion, they think all’s well. This is why the disease of alcoholism / drug addiction is a disease that tells you, you don’t have it.
For years the alcoholic and addict has been playing neurochemistry without a license, and damage has occurred. Sometimes the damage is severe, and sometimes it is minor. Some of the damage is irreversible, but even this can be dealt with effectively. The damage that is permanent is usually in the areas of thinking and acting. It is true that, once an alcoholic / addict, always an alcoholic / addict. This is said because of the altered brain chemistry. The good news is that this can be worked out through action taking steps.
Stress in sobriety produces the same brain chemistry reaction as when a person is drinking and/or taking addictive drugs; hence, the correlation between unresolved stress in recovery and relapse- it is the brain chemistry that can fuel a relapse.
So what is the answer to the brain chemistry imbalance problem? Are alcoholics and addicts doomed to a life of relapses? How can others help? Do I need to walk on eggshells around them? And what does the alcoholic and/or addict need to do to improve their chances at staying sober?
We will now discuss the road map to success.
The chemical imbalances can be addressed by seeing a medical professional. Sometimes a person may need to take an anti-depressant to correct the imbalance and start to get un-depressed. An important factor to consider is old drug seeking thoughts and behaviors. If a person states they have anxiety, it may not be in their best interest to seek medication for this condition. Many in early recovery experience what is known as PAWS, (Post Acute Withdrawal Symptoms). PAWS can be felt by a recovering person in many ways. These are described as mental confusion, lethargy, difficulty concentrating, memory loss, physical aches, unsteady gait, and anxiety to name a few. Anti-depressants are non-addicting, non-narcotic, and correct the brain chemistry imbalance.
Anti-anxiety medications are typically mood altering, addictive, and do not address or correct the problem. These types of medications only mask the real problem- that of not having the coping mechanisms to deal with life on life’s terms. If a person stays sober and works a good program of recovery, the signs and symptoms of PAWS will disappear without having to take narcotics, sedatives, and other mood altering chemicals.
Which brings us to the solution part of the problem. Utilizing resources, like 12-Step attendance, is an excellent way of attacking and finding a solution to the problem.
The first thing alcoholics and addicts must do is get out of the victim role. Once in recovery, the alcoholic and addict can’t blame their behavior on having a disease. Recovery from alcoholism and drug addiction is the sole responsibility of the person suffering with the disease. They must do what is necessary to stay sober. The family, friends, employers, etc. of the alcoholic and addict must never feel they need walk on eggshells. Being open, honest, and understanding, without enabling, is what is needed most from all who are in support of the individual who is in recovery.
If we have a leaking water pipe we fix it. If we have the flu we need time to heal- we can’t fix the flu. Stopping alcohol and drugs is the fix; however, the healing process takes a long time- there is no fix, just a recovery period which takes a lifetime of healing .
I have included a list of the minimums to working a healthy recovery program that, if followed, will keep a person sober.
1. Meetings (90 meetings in 90 days at the start and then regular attendance- at least three per week after that)
2. Sponsor (called every day)
3. Home Group
4. Working the Steps (with their sponsor)
5. Reading recovery literature
1. Prayer and Meditation
2. Service Work
3. Working with others
”When I started using this One Proven Method, I began to experience tremendous growth and positive changes in my own recovery.” Rev. Stephen J. Murray, MCRC, NICD Director See this link for more about our Director and Founder
NICD Web Sites: www.ni-cor.com and www.nicd.us
Before we get into what the One Proven Method is, allow me to share with you some staggering research results when using this Method:
Studies have shown by using this One Proven Method you will increase your chance of reaching your goals (career goals, financial goals, fitness goals, relationship goals) by as much as 82%! I read one study that said people who use this technique have more than 51% less colds, stronger immunity and half as many visits to their doctor. It is also proven that people who follow this method easily move through challenges and adversity and it helps them, more than anything else; keep focused on their reason for being.
Additional research revealed that addiction recovery, insomniacs, the panic-prone and depressed, cancer patients, and people trying to lose weight have All benefited through this One Proven Method.
Here is Doreene’s story
”One day, as I was driving down the freeway, I was struck by Divine inspiration with a brilliant idea for people to put into practice this One Proven Method. And, this method is far more effective than anything I had ever seen before. In my heart of hearts I knew I had to bring it to the world.
The idea was so profound, and at the time, I had the thought, this is so simple it must be out there. Yet, when I looked for it I could not find it anywhere. And, from this inspiration came the birth of a profoundly unique and life-changing tool called The 5 Year Journal.”
Unlike what you may be thinking, journaling takes only a few minuets a day, and you do not have to do it every day to have a lasting effect.
For as long as humans have had their own stories to tell we've been writing them down. We jot notes, make lists and write letters. And sometimes, when we need someone to talk to, a best friend, a confidante, a place to take our deepest secrets and our fears, or when we just want to record our thoughts, we write in journals.
The journal is communicating from the heart. It is a place we can go to protect our reminiscences and work through our difficult emotions. Our journal archives our growth and gives us perspective. Within the journal's safe pages, we can try out ideas and explore feelings. And since there's no right or wrong way to keep a journal, anyone can do it.
If your life is worth living, is not it worth recording?
The 5 Year Journal is beautiful hardcover book with place marker ribbon, 272 acid-free pages and over 100 motivational quotes. It includes an easy to follow how-to journal section, and work book sections.
This One Proven Method is for you, for someone who is new to recovery, recovered, and it is also a wonderful gift for family, friends, co-workers, anyone. NICD is in need of your support, so we may help more families to cope with the turmoil of addiction. By making a purchase 25% of each journal sold goes to www.nicd.us and www.ni-cor.com. Your purchase will help you, your loved ones, plus hundreds of others whose lives will be affected.
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Peggy McColl, Author of The 8 Proven Secrets to SMART Success and On Being a Dog with a Bone said this about The 5 Year Journal:
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Addiction is a Brain Disease
By ALAN I. LESHNER, MD
A core concept evolving with scientific advances over the past decade is that drug addiction is a brain disease that develops over time as a result of the initially voluntary behavior of using drugs. (Drugs include alcohol.)
The consequence is virtually uncontrollable compulsive drug craving, seeking, and use that interferes with, if not destroys, an individual’s functioning in the family and in society. This medical condition demands formal treatment.
- We now know in great detail the brain mechanisms through which drugs acutely modify mood, memory, perception, and emotional states.
- Using drugs repeatedly over time changes brain structure and function in fundamental and long-lasting ways that can persist long after the individual stops using them.
- Addiction comes about through an array of neuro-adaptive changes and the lying down and strengthening of new memory connections in various circuits in the brain.
The High jacked Brain
We do not yet know all the relevant mechanisms, but the evidence suggests that those long-lasting brain changes are responsible for the distortions of cognitive and emotional
functioning that characterize addicts, particularly including the compulsion to use drugs that is the essence of addiction.
It is as if drugs have high jacked the brain’s natural motivational control circuits, resulting in drug use becoming the sole, or at least the top, motivational priority for the individual.
Thus, the majority of the biomedical community now considers addiction, in its essence, to be a brain disease:
This brain-based view of addiction has generated substantial controversy, particularly among people who seem able to think only in polarized ways.
- Many people erroneously still believe that biological and behavioral explanations are alternative or competing ways to understand phenomena, when if fact they are complementary and integrative.
Modern science has taught that it is much too simplistic to set biology in opposition to behavior or to pit willpower against brain chemistry.
- Addiction involves inseparable biological and behavioral components. It is the quintessential bio-behavioral disorder.
Many people also erroneously still believe that drug addiction is simply a failure of will or of strength of character. Research contradicts that position.
Responsible For Our Recovery
However, the recognition that addiction is a brain disease does not mean that the addict is simply a hapless victim. Addiction begins with the voluntary behavior of using drugs, and addicts must participate in and take some significant responsibility for their recovery.
- Thus, having this brain disease does not absolve the addict of responsibility for his or her behavior.
But it does explain why an addict cannot simply stop using drugs by sheer force of will alone.
The Essence of Addiction
The entire concept of addiction has suffered greatly from imprecision and misconception. In fact, if it were possible, it would be best to start all over with some new, more neutral term.
The confusion comes about in part because of a now archaic distinction between whether specific drugs are “physically” or “psychologically”addicting.
The distinction historically revolved around whether or not dramatic physical withdrawal symptoms occur when an individual stops taking a drug; what we in the field now call “physical dependence.”
- However, 20 years of scientific research has taught that focusing on this physical versus psychological distinction is off the mark and a distraction from the real issues.
From both clinical and policy perspectives, it actually does not matter very much what physical withdrawal symptoms occur.
- Physical dependence is not that important, because even the dramatic withdrawal symptoms of heroin and alcohol addiction can now be easily managed with appropriate medications.
- Even more important, many of the most dangerous and addicting drugs, including methamphetamine and crack cocaine, do not produce very severe physical dependence symptoms upon withdrawal.
What really matters most is whether or not a drug causes what we now know to be the essence of addiction, namely
- The uncontrollable, compulsive drug craving, seeking, and use, even in the face of negative health and social consequences.
This is the crux of how the Institute of Medicine, the American Psychiatric Association, and the American Medical Association define addiction and how we all should use the term.
It is really only this compulsive quality of addiction that matters in the long run to the addict and to his or her family and that should matter to society as a whole.
Thus, the majority of the biomedical community now considers addiction, in its essence, to be a brain disease:
- A condition caused by persistent changes in brain structure and function.
This results in compulsive craving that overwhelms all other motivations and is the root cause of the massive health and social problems associated with drug addiction.
The Definition of Addiction
In updating our national discourse on drug abuse, we should keep in mind this simple definition:
- Addiction is a brain disease expressed in the form of compulsive behavior.
Both developing and recovering from it depend on biology, behavior, and social context.
It is also important to correct the common misimpression that drug use, abuse and addiction are points on a single continuum along which on slides back and forth over time, moving from user to addict, then back to occasional user, then back to addict.
Clinical observation and more formal research studies support the view that, once addicted, the individual has moved into a different state of being.
- It is as if a threshold has been crossed.
Very few people appear able to successfully return to occasional use after having been truly addicted.
The Altered Brain - A Chronic Illness
Unfortunately, we do not yet have a clear biological or behavioral marker of that transition from voluntary drug use to addiction.
However, a body of scientific evidence is rapidly developing that points to an array of cellular and molecular changes in specific brain circuits. Moreover, many of these brain changes are common to all chemical addictions, and some also are typical of other compulsive behaviors such as pathological overeating.
- Addiction should be understood as a chronic recurring illness.
- Although some addicts do gain full control over their drug use after a single treatment episode, many have relapses.
The complexity of this brain disease is not atypical, because virtually no brain diseases are simply biological in nature and expression. All, including stroke, Alzheimer's disease, schizophrenia, and clinical depression, include some behavioral and social aspects.
What may make addiction seem unique among brain diseases, however, is that it does begin with a clearly voluntary behavior- the initial decision to use drugs. Moreover, not everyone who ever uses drugs goes on to become addicted.
- Individuals differ substantially in how easily and quickly they become addicted and in their preferences for particular substances.
Consistent with the bio-behavioral nature of addiction, these individual differences result from a combination of environmental and biological, particularly genetic, factors.
In fact, estimates are that between 50 and 70 percent of the variability in susceptibility to becoming addicted can be accounted for by genetic factors. Although genetic characteristics may predispose individuals to be more or less susceptible to becoming addicted, genes do not doom one to become an addict.
- Over time the addict loses substantial control over his or her initially voluntary behavior, and it becomes compulsive. For many people these behaviors are truly uncontrollable, just like the behavioral expression of any other brain disease.
Schizophrenics cannot control their hallucinations and delusions. Parkinson’s patients cannot control their trembling. Clinically depressed patients cannot voluntarily control their moods.
Thus, once one is addicted, the characteristics of the illness- and the treatment approaches- are not that different from most other brain diseases. No mater how one develops an illness, once one has it, one is in the diseased state and needs treatment.
Addictive behaviors do have special characteristics related to the social contexts in which they originate.
- All of the environmental cues surrounding initial drug use and development of the addiction actually become “conditioned” to that drug use and are thus critical to the development and expression of addiction.
Environmental cues are paired in time with an individual’s initial drug use experiences and, through classical conditioning, take on conditioned stimulus properties.
- When those cues are present at a later time, they elicit anticipation of a drug experience and thus generate tremendous drug craving.
Cue-induced craving is one of the most frequent causes of drug use relapses, even after long periods of abstinence, independently of whether drugs are available.
The salience of environmental or contextual cues helps explain why reentry to one’s community can be so difficult for addicts leaving the controlled environments of treatment or correctional settings and why aftercare is so essential to successful recovery.
- The person who became addicted in the home environment is constantly exposed to the cues conditioned to his or her initial drug use, such as the neighborhood where he or she hung out, drug-using buddies, or the lamppost where he or she bought drugs.
- Simple exposure to those cues automatically triggers craving and can lead rapidly to relapses.
This is one reason why someone who apparently overcame drug cravings while in prison or residential treatment could quickly revert to drug use upon returning home.
In fact, one of the major goals of drug addiction treatment is to teach addicts how to deal with the cravings caused by inevitable exposure to these conditioned cues.
It is no wonder addicts cannot simply quit on their own.
They have an illness that requires biomedical treatment.
- People often assume that because addiction begins with a voluntary behavior and is expressed in the form of excess behavior, people should just be able to quit by force of will alone.
- However, it is essential to understand when dealing with addicts that we are dealing with individuals whose brains have been altered by drug use.
They need drug addiction treatment.
We know that, contrary to common belief, very few addicts actually do just stop on their own.
Observing that there are very few heroin addicts in their 50s or 60s, people frequently ask what happened to those who were heroin addicts 30 years ago, assuming that they must have quit on their own.
- However, longitudinal studies find that only a very small fraction actually quit on their own. The rest have either been successfully treated, are currently in maintenance treatment, or (for about half) are dead.
Consider the example of smoking cigarettes: Various studies have found that between 3 and 7 percent of people who try to quit on their own each year actually succeed.
Science has at last convinced the public that depression is not just a lot of sadness; that depressed individuals are in a different brain state and thus require treatment to get their symptoms under control. It is time to recognize that this is also the case for addicts.
The Role of Personal Responsibility
The role of personal responsibility is undiminished but clarified.
Does having a brain disease mean that people who are addicted no longer have any responsibility for their behavior or that they are simply victims of their own genetics and brain chemistry? Of course not.
Addiction begins with the voluntary behavior of drug use, and although genetic characteristics may predispose individuals to be more or less susceptible to becoming addicted, genes do not doom one to become an addict.
This is one major reason why efforts to prevent drug use are so vital to any comprehensive strategy to deal with the nation’s drug problems. Initial drug use is a voluntary, and therefore preventable, behavior.
Moreover, as with any illness, behavior becomes a critical part of recovery. At a minimum, one must comply with the treatment regimen, which is harder that it sounds.
- Treatment compliance is the biggest cause of relapses for all chronic illnesses, including asthma, diabetes, hypertension, and addiction.
- Moreover, treatment compliance rates are no worse for addiction than for these other illnesses, ranging from 30 to 50 percent.
Thus, for drug addiction as well as for other chronic diseases, the individual’s motivation and behavior are clearly important parts of success in treatment and recovery.
Alcohol/ Drug Treatment Programs
Maintaining this comprehensive bio-behavioral understanding of addiction also speaks to what needs to be provided in drug treatment programs.
- Again, we must be careful not to pit biology against behavior.
The National Institute on Drug Abuse’s recently published Principles of Effective Drug Addiction Treatment provides a detailed discussion of how we must treat all aspects of the individual, not just the biological component or the behavioral component.
As with other brain diseases such as schizophrenia and depression, the data show that the best drug addiction treatment approaches attend to the entire individual, combining the use of medications, behavioral therapies, and attention to necessary social services and rehabilitation.
- These might include such services as family therapy to enable the patient to return to successful family life, mental health services, education and vocational training, and housing services.
That does not mean, of course, that all individuals need all components of treatment and all rehabilitation services. Another principle of effective addiction treatment is that the array of services included in an individual's treatment plan must be matched to his or her particular set of needs. Moreover, since those needs will surely change over the course of recovery, the array of services provided will need to be continually reassessed and adjusted.
We believe holistic approaches ranging from brain wave biofeedback to yoga and acupunture are an important part of the "array of services" to which he refers.
J. D. Berke and S. E. Hyman, "Addiction, Dopamine, and the Molecular Mechanisms of Memory," Neuron 25 (2000): 515~532 (http://www.neuron.org/cgi/content/full/25/3/515/).
H. Garavan, J. Pankiewicz, A. Bloom, J. K. Cho, L. Sperry, T. J. Ross, B. J. Salmeron, R. Risinger, D. Kelley, and E. A. Stein, "Cue-Induced Cocaine Craving: Neuroanatomical Specificity for Drug Users and Drug Stimuli," American Journal of Psychiatry 157 (2000): 1789~1798 (http://ajp.psychiatryonline.org/cgi/content/full/157/11/1789).
A. I. Leshner, "Science-Based Views of Drug Addiction and Its Treatment," Journal of the American Medical Association 282 (1999): 1314~1316
A. T. McLellan, D. C. Lewis, C. P. O'Brien, and H. D. Kleber, "Drug Dependence, a Chronic Medical Illness," Journal of the American Medical Association 284 (2000): 1689~1695 (http://jama.ama-assn.org/issues/v284n13/rfull/jsc00024.html).
National Institute on Drug Abuse, Principles of Drug Addiction Treatment: A Research-Based Guide (National Institutes of Health, Bethesda, MD, July 2000) (http://18.104.22.168/PODAT/PODATindex.html).
National Institute on Drug Abuse, Preventing Drug Use Among Children and Adolescents: A Research-Based Guide (National Institutes of Health, Bethesda, MD, March 1997) (http://22.214.171.124/Prevention/Prevopen.html).
E. J. Nestler, "Genes and Addiction," Nature Genetics 26 (2000): 277~281 (http://www.nature.com/cgi-taf/DynaPage.taf?file=/ng/journal/v26/n3/full/ng1100_277.html).
Physician Leadership on National Drug Policy, position paper on drug policy (PLNDP Program Office, Brown University, Center for Alcohol and Addiction Studies, Providence, R.I.: January 2000) (http://center.butler.brown.edu/plndp/Resources/resources.html).
F. S. Taxman and J. A. Bouffard, "The Importance of Systems in Improving Offender Outcomes: New Frontiers in Treatment Integrity," Justice Research and Policy 2 (2000): 37~58.