Something that has been controversial (and to some extent still is) within the mental health community is whether addiction is a disease or a choice. There has been a wealth of research over recent years that has really pointed in the direction that addiction is an actual disease. I have been wanting to write about this for a while, and something happened recently that makes this feel like an apt time to do so.
A few weeks ago the United States surgeon general publicly asserted his position that addiction is a disease and not a moral failing.
We know now that addiction is a disease because it makes actual physical changes in the brain that make addicts prone to addictive behaviors. Much like how someone with diabetes cannot simply choose to not need insulin, an addict cannot simply choose to stop being an addict without having negative, often terrible, side effects. The diabetic can follow a strict regimen of diet, exercise, and medication and experience a significant reduction in symptoms. Similarly, the addict can do things to better his/her condition but cannot simply make their addiction disappear at will. If you’ve ever known an addict you might have thought “why can’t he/she just stop?” This is why.
Addiction hijacks the brain’s natural hierarchy of needs. We are wired to value/prioritize things that are more important to our survival over things that are not. In this way, eating is much more important to the brain than say watching a movie, for example. So naturally, when deprived of both movie watching and food, the brain will urge us to eat, but not so much to go see a movie. Addiction takes over this hierarchy and places the substance of abuse above all else. This results in a situation, much like breathing, in that you can choose to hold your breath for a long time, but eventually your brain will implore you to breath, and you will give in. This is how a person in the throws of addiction experiences cravings.
Some people think of addiction as being a choice rather than a disease because diseases like diabetes make actual physical changes in the way the body functions, and thereby alters the person’s health. We now know that addiction makes physiological changes to the brain. This part gets a little complicated.
All pleasurable experiences, no matter what they are; sex, drugs, eating cookies, whatever, give you that pleasurable experience by releasing a neurotransmitter called dopamine into key areas of the brain. The difference between say eating an apple and eating a cookie is essentially the amount of dopamine available to special receptors in these areas that pick up dopamine. Think of it as if dopamine is the key, and the receptors are the locks that unleash pleasure. When you eat an apple a few locks are unlocked. When you eat a cookie, more locks are unlocked. If you take heroin, or whatever your drug of choice is, just about all of the locks are unlocked. This is where the physical change comes in. Human beings are amazing homeostasis machines. The brain generally will do whatever it can to maintain homeostasis. So, when you take heroin and the brain becomes flooded with dopamine, over time the brain’s response is to reduce the actual number of dopamine receptors in the pleasure areas of the brain. This means that regularly pleasurable things like cookies, sex, reading a book, etc., are no longer able to stimulate the brain in a way that produces feelings of pleasure. In this way, addiction is a disease of the brain’s ability to experience pleasure.
I think it helps to think of it like this: imagine you’re standing over a board with a couple dozen randomly spaced holes that are slightly bigger than a dime. When you eat a cookie you drop a hand full of dimes and a couple get through the holes. When you take a drug of abuse it’s the equivalent of dropping a bucket full of dimes, and hundreds of them getting through the holes. Too many are getting through, so to compensate you plug some of the holes. Now a handful of dimes doesn’t really get anything through, but a bucket gets a good amount. At some point you get rid of the bucket and go back to using a handful of dimes (because using a bucket to pour dimes is clearly addictive behavior). Now you have a horribly slim chance of getting any dimes through the board because there are so few holes now. This is how addiction works in the pleasure centers of the brain. After extended use of an intoxicant, the brain adapts in a way that makes a person dependent on the drug. Over time, while abstaining from drug use, the brain can heal from this. However, studies have shown that the brain somehow remembers being addicted, and if a person in recovery uses again after a long period of abstinence, the brain is more quick to make these changes than in a person who was never an addict. For more on the neurochemistry of addiction, check out this video:
When I was in grad school I heard an amazing lecture by Dr. Kevin McCauley, who has been very influential in growing the disease model of addiction. I really wanted to share that lecture with you, but I was unable to find it. The following is another good lecture of his. It talks about the specifics of why addiction is a disease. If you want to learn more you should really listen to it sometime. He does a good job explaining everything, so you can listen to it without seeing his slides.
For more on addiction and substance abuse, check out my other blog posts on the subject:
If you or someone you love is suffering with addiction, therapy can really help. Think about giving me a call sometime. We can talk about whats going on and how I might be able to help you.