I Have a Brain Disease

Addiction is a term no longer in favor by medical professionals. The preferred wording nowadays is “substance use disorder,” or SUD. Our very own government has differing views of this. NIDA, The National Institute on Drug Abuse, defines addiction as a chronic, often relapsing brain disease that causes compulsive drug seeking and use, despite harmful consequences.[1] But SAMSHA, the Substance Abuse and Mental Health Services Administration, states that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), no longer uses the terms substance abuse and substance dependence, let alone addiction.[2] Instead, it refers to SUDs, which are defined as mild, moderate, or severe, determined by the number of diagnostic criteria met by an individual. These disorders occur when the recurrent use of alcohol and/or drugs causes health problems, disability, and failure to meet major responsibilities. According to the DSM-5, a diagnosis of SUD is based on evidence of loss of control, social impairment, and risky use, at times combined with: craving, tolerance and withdrawal.[3]

Whatever you call it, there is much agreement that it is a brain disease, which, left untreated, is often progressive, incurable and fatal. But with treatment, addiction is manageable. The symptoms of addiction, which may include criminal acts, can be eliminated if the addict works at recovery.

It has been scientifically proven, using scans of the brain, that drug use changes the brain.[4] Abuse changes the brain. Trauma, both physical and psychological, can change the brain. And being in recovery changes the brain, too. Studies have been undertaken with people behaving kindly to others, and not only does good behavior change the brain of the actor and the receiver, it changes the brain of the observer of the act of kindness.[5]

Because addiction is a disease of the brain, it is a disease of the thinking. The brain’s function, in addition to its autonomous role of running the body, is to problem-solve, analyze sensory data, perform memory functions, learn new information, form thoughts and make decisions. Most of these higher brain functions occur in the frontal cortex, where reasoning takes place. This is the part of the brain that reminds us to follow the rules and take responsibility for ourselves. Brain functioning here diminishes under the influence of alcohol or drugs.

But addiction takes place in the deeper, primitive part of the brain, the limbic system.[6] This is the survival center of the human being. The survival instincts are eat, drink, fight or flight, and mate. It is believed by many that in addiction, the substance or behavior moves to the top of the survival list. In a twisted hierarchy of needs, the addict must satisfy his addiction before any other need is met. Addiction becomes a matter of survival. The laboratory rat presses the lever to get more cocaine instead of food and water. The addict thinks, “Sure, I’m going to pay the rent and change the oil in the car. But first, I need to get high, have a drink, pull this lever,” you get the picture.

In active addiction, the addict no longer has a choice: The addict must use. The survival system in the brain has become dysfunctional.

Now, given the above information, how can an addict decide that he needs treatment? I suppose a message could get through from the frontal cortex, “Hey, wake up, this is not good. We are losing our job, nearing divorce and financial ruin, and that ticket has turned into a warrant for our arrest.” Under the influence, the addict answers, “Sure, I’ll take care of that later.” Not under the influence, the addict replies, “Yes, that’s true, but first…”

Therefore, it is an amazing action when any addict breaks this cycle and seeks out treatment of his own accord. This is why “hitting bottom” is a dangerous myth. For some, the bottom continues to get lower and lower until irreversible tragedy or death result.

I’ve heard professionals refer to a patient or potential patient, “Oh, he’s just not ready to stop.” Using the brain disease model, how can an addict decide on his own to quit or, once he has quit, to stay quit? The disease, which is primary, has taken over the addict’s ability to think rationally. How can an addict in the throes of addiction decide, “Hey, I need to change this”?

When I worked in the recovery profession, I encountered individuals to whom every opportunity was extended, and the addict failed to take any action in their own best interest. A colleague likened this to a dog that has been caged for so long that, when the cage door is opened, the dog just sits there.

One way to repair the damaged thinking of an addict is by helping them learn how to practice new behaviors and think new thoughts. In this way, the brain again becomes changed, and the seeking of the substance is no longer primary. This is one aim of treatment, to aid the addict to learn coping skills and learn to function without the use of substances.

Medication also works in early recovery, to quiet noisy neurotransmitters that are screeching for more of their substance. Back in the 1980s, The Program was where my fellow opiate addicts went to get the daily juice. Those of us who were lucky enough to be eligible for methadone maintenance were not going to get dope sick that day. But many of us were afraid to get on methadone, because we were already hooked on one substance, and word was that methadone got in your bones, and to kick methadone was agony. If you weren’t on the juice, though, you could still go to The Program to get high. If dealers weren’t selling dope in the parking lot, there would always be someone there who knew where to cop. Nobody went to The Program to get clean back then. They only went to get well; to stave off dope sickness.

When I entered my first treatment center, I was given Klonipin and Ativan, benzodiazepines (like Valium) to kick with. If someone wanted to get off opiates, that’s how it was done in those days. They sent us to 12-Step meetings, where complete abstinence was preached and practiced. It was, they said, the only way to get clean and stay clean. In my own recovery, I’ve discovered that to be true for me. I’ve tried less-than-complete abstinence, and the personal devastation was astounding, enough to lead me to embrace, for me, total abstinence from all mind-altering chemicals.

Thirty years later, some things have changed. The concept of harm reduction has taken root and is now a public health philosophy that seeks to lessen the impact of drug abuse on society. The sensational “War on Drugs” was lost some time ago. Marijuana is legal in a few states, and medically controlled in others. A completely drug-free society is an unobtainable and ridiculous illusion. Alcohol is the nation’s most widely-used drug, and the societal costs from harms done by alcohol abuse are astronomical.[7]

The cost of drug addiction is high. It takes its toll on individuals, families, and communities. Drug overdose is one of the leading causes of accidental death in America, surpassing traffic fatalities.[8] Many opiate addicts who detox, by any method, return to using. Medication-assisted treatment has been studied extensively, often by government-funded groups. The research has demonstrated that MAT is successful in reducing drug use as well as crime, death, and disease.[9] MAT, which include the medications Suboxone and Methadone, has been proven to be an effective treatment for heroin addiction. MAT is effective in reducing the spread of HIV and AIDS. Criminal behavior is lesssened because methadone patients reduce or stop buying and using illegal drugs.

Many studies have shown that MAT is cost-effective. One study reports that MAT costs an average about $4,000 per patient per year.[10] [11]Because of the reduction in criminal behavior, the lessening of health-care costs and the increase in social productivity, cost-benefit analyses indicate savings of $4 to $5 for every $1 spent on MAT. Incarceration costs $20,000 to $60,000 and more per year. MAT is often provided by government-funded agencies at many clinic locations. Clients are medically screened and receive counseling and education in addition to medication. They may also pay monthly fees, on a sliding scale.

We as a society cannot give up. We have to not only open the door to the cage of addiction, sometimes we have to lead the addict out. Whether by complete abstinence, education, MAT or another way, recovery is possible. Instead of punishing and incarcerating people who have SUDS, we need to offer treatment, demonstrate positive regard, teach new behaviors and coping skills, and help the addict on the road to recovery.

[1] http://www.drugabuse.gov/publications/drugfacts/understanding-drug-abuse-addiction

[2] http://www.samhsa.gov/disorders/substance-use

[3] http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.pdf

[4] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851068/

[5] http://greatergood.berkeley.edu/article/item/kindness_makes_you_happy_and_happiness_makes_you_kind

[6] http://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/preface

[7] http://www.cdc.gov/features/alcoholconsumption/

[8] http://www.cdc.gov/drugoverdose/data/overdose.html

[9] https://store.samhsa.gov/shin/content/SMA09-4443/SMA09-4443.pdf

[10] https://www.niatx.net/PDF/NIATx-MAT-Toolkit.pdf

[11] http://lac.org/resources/substance-use-resources/medication-assisted-treatment-resources/case-for-eliminating-barriers-to-medication-assisted-treatment-of-heroin-and-opioid-addiction/#_ftn12