Addiction is all around us. Whether you are a family member of a loved one who is using, an employer, a pastor, or simply someone who is concerned about the state of affairs in our world, you are keenly aware that addiction (or substance use disorders) profoundly affects our society and families. The National Institute on Drug Abuse (NIDA) estimates that as much as 10% of our population is struggling with or at least affected by a substance use disorder. Personally, I think the percentage is much higher than that.
However, what I would like to address here is the nature of addiction as a disease, because there is a lot of bias, preconceptions, and misinformation out there about what addiction is and is not. It’s important for us to sort through some of these ideas to find the truth about this powerful disease.
Let me just say at this point that if you are a family member of someone who is using alcohol or drugs, then I understand that you are tired of having to deal with the lies, frustrations, manipulations, mistrust, disappointment, and fear that accompanies active addiction. And, I want to say that this information is critical for your well-being, because you have a gnawing question at the heart of your emotions: is this a choice?
Let’s look at how to answer this question.
First, we have to understand that a disease is actually something that is very straightforward: a disease is when an organ or a system in the body gets a defect, and then that causes symptoms. While active use of alcohol or drugs will affect every organ and system within the body, the one organ that is most profoundly affected is the brain.
The Disease Model
The most widely accepted and utilized model of addiction is that it is a disease. The Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute on Drug Abuse (NIDA), and the National Institutes of Health (NIH) all consider addiction to be a disease. Again, a disease is a process that occurs in the body when a bodily organ or system gets a defect, which causes symptoms. Addiction is a disease that has clearly defined signs and symptoms, a progression, and recovery. Addiction is a disease that is:
Primary – Addiction is not a secondary symptom of another disease process in the body. While every organ and system is affected by drug use, the primary organ that is affected is the brain and once the disease has set itself up in the body, just like cancer, it is primary. So, for example, while a young person may start drinking or using drugs because of “low self-esteem,” addiction is not simply a low self-esteem issue.
Chronic – Addiction, like cancer, is not a disease that is considered “curable.” It is a life-long disease and the person can relapse. So, like other diseases, someone who is in recovery is considered in remission.
Progressive – With drug/alcohol use, physical and emotional symptoms are describable and worsen in intensity and consequences if not treated.
Fatal – The person will die from the disease or complications of the disease if left untreated. However, the good news is that this is a highly “treatable” disease.
The Disease Process
While use of drugs/alcohol affects all bodily systems it is essentially a disease of the brain. Addiction radically affects brain chemistry, primarily by altering neurotransmitter levels, and how the brain perceives pleasure. The main neurotransmitter that is affected is dopamine.
The use of drugs/alcohol affects all parts of the brain but the two areas most radically affected are the prefrontal cortex and the mid-brain. The prefrontal cortex is located in our forehead area and is the part of the brain where logic and choice occurs; where emotional attachment, abstract thinking, rational decision-making, and inhibition occur. But this isn’t where drugs start to work. Drugs begin their work in the mid-brain area, in the Limbic System, on a very basic level.
The neural circuitry in the mid-brain/Limbic System is our survival circuitry. Eating, nurturing children, memory, sexual activity, defense, all take place in the mid-brain. This is what ensures the survival of our species. Here’s where it all goes wrong: on the level of survival.
Drugs act on our neural circuitry, affecting the dopamine delivery systems within the neurons themselves. For example, cocaine sets up a barrier in the synaptic gap, stopping the reuptake of excess dopamine, thereby flooding the circuit with extra dopamine. This creates the pleasurable sensations. Different drugs have different dopamine “curves” (e.g. how quickly the dopamine elevates and how long it is elevated) which provide the different sensations for different drugs.
When the mid-brain gets affected, it also affects the prefrontal cortex. The “Pleasure Pathway” that goes from the mid-brain to the prefrontal cortex carries the message that an experience is pleasurable and that we should repeat it to ensure survival. The neurotransmitter dopamine acts as a learning trigger. Think of the pleasure of holding and nurturing a baby. We will repeat it because it feels good; and the child survives.
The prefrontal cortex then will send glutamate (another neurotransmitter) back down to the Limbic System and through the structures of our brain that have to do with memory. This ensures that we remember the experience and will repeat it. So, we remember that good feeling of nurturing a baby and so the repetition is ensured.
All drugs have in common the ability to release dopamine into the pleasure centers of the brain. Unfortunately, when we use drugs, the mid-brain releases a “blast” of dopamine through the neurons in the pathway to the prefrontal cortex, not simply stating, this is good we should do this again, but, because of the massive amount of dopamine that hits the prefrontal cortex, it says, we have to do this again. The prefrontal cortex, because of the overwhelming release of dopamine, then releases the neurotransmitter glutamate back down through the pathway to the mid-brain sending an order to “go get/do this again.”
This activity makes such a significant impact that the rational part of the brain, the prefrontal cortex, is overwhelmed by the surge of dopamine. It then mistakenly classifies drinking and drug use alongside the survival behaviors, like eating, reproduction, or taking care of one’s children. But, the surge of dopamine is so strong that the brain is “hijacked” to such a degree that when the disease of addiction is active, the craving for alcohol or drugs will supersede all other survival instincts.
So, the prefrontal cortex is radically impacted by the flood of dopamine. These abnormal releases of dopamine damage the mechanism of the “top-down” control of the prefrontal cortex. The ability to think rationally and logically becomes compromised. The ability to choose disappears.
Also, the release of glutamate will lock an experience into memory, which will then become a trigger to use in the future. While the addict can reduce the effects of the damage through recovery, the connection of the drug to survival will always remain. This is why a person is considered “in remission” from addiction rather than “cured” because of the experience being locked into the Limbic System. But, as the brain heals from the impact of the drugs, the ability to choose and think rationally begins to return.
Again, the good news is that this is a highly “treatable” disease with lots of good recovery for literally millions of people. For this recovery to be possible, and for the brain to begin to heal, it is essential that a person stop using, get into some type of treatment or counseling program, and begin to take responsibility for their actions. Even though they may struggle with continuing (but lessening) influence of the damaged processes in their brain for a time, with the help of a treatment program, counseling, their family, friends, pastor, coworkers, and sponsor, they can begin the road to healing and recovery. So, on a positive note, treating addiction as a disease, rather than offering an excuse, normalizes the process, offers hope to the sufferer and their loved ones, and gives responsibility to the addict for their recovery!