The Disease of Addiction

By Cheri Sinnott, LCSW

Editor's Note: This blog continues along the theme of the last few: substance abuse. However, our focus now shifts to the science and disease of addiction. There is still a lingering old-school mentality about drug addiction being a choice, and that really couldn't be further from the truth. The consequences of that mentality mean that we may not be providing the empathy or level of care that we should be. This blog talks about how drugs affect the brain and helps dispel the many myths of addiction. We are really excited to bring this to you so we can break down the rest of those barriers!

Substance abuse and addiction is a factor in many social problems, including work productivity, relationship issues, crime, child abuse, violence, homelessness, and additional health concerns. One in four Americans will have an alcohol or other drug problem at some point in their lives, according to The National Center on Addiction and Substance Abuse (CASA) at Columbia University. The organization notes that “Addiction is America’s number one health care and health cost problem. Approximately 30 percent of our federal and state health care spending is attributable to this disease. Across all government spending, the total financial cost is nearly $500 billion annually.”

The personal and societal consequences of addiction include fatal accidents, violence, theft and other criminal behavior, health problems, employment issues, and relationship problems. Specific examples of these consequences of addiction noted by CASA and the Centers for Disease Control and Prevention (CDC) include:

Alcohol and other drug abuse is involved in most violent and property crimes, with 80 percent of the nation’s adult inmates and of juvenile arrestees either committing their offenses while high, stealing to buy drugs, violating alcohol or drug laws, having a history of substance abuse/addiction, or sharing some mix of these characteristics.
70 percent of abused and neglected children have alcohol and/or drug abusing parents.
80,000 deaths per year in the U.S. are caused by drinking.
90 percent of homeless have alcohol problems; 60 percent abuse other drugs.
Almost a quarter of a trillion dollars of the nation’s yearly health care bill is attributable to substance abuse and addiction.

Information on nationwide substance use and abuse is gathered annually in the National Survey on Drug Use and Health, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), and in the Monitoring the Future study funded by the National Institute on Drug Abuse. Some results from the 2010 data indicate that:

Daily marijuana use increased among 8th, 10th, and 12th graders from 2009 to 2010. Among 12th graders, use was at its highest point since the early 1980s, at 6.1 percent.
Annual rates of hallucinogen use remained unchanged from 2009 to 2010, although significant increases were reported by 12th graders for annual (2.6 percent) and past-month (0.8 percent) use of LSD.
Prescription and over-the-counter (OTC) medications accounted for most of the top drugs abused by 12th graders.
Past-year use of inhalants remained steady from 2009 to 2010, with 8 percent of 8th graders reporting past-year use.
Current cocaine use gradually declined between 2003 and 2010, with a steady decline for current, annual, and lifetime prevalence of cocaine and crack abuse, from peak-year use in 1999.
An estimated 30.2 million people (12.0 percent) aged 12 or older reported driving under the influence of alcohol at least once in the past year.

Addiction is a chronic disease that alters the brain. The National Institute on Drug Abuse (NIDA) refers to addiction as a chronic relapsing brain disease. Other chronic relapsing diseases include diabetes, asthma, and heart disease. The current medical model view of addiction as a complex brain disease does not place blame on the individual, as did the moral model which identified addiction as a moral weakness, character defect, and spiritual deficit. NIDA’s publication Drugs, Brains, and Behavior: The Science of Addiction explains that addiction is a brain disease because it changes the structure of the brain and how it works. Neurotransmitters, the chemicals that transmit information (deliver messages) between neurons in the brain, are impacted by drugs. Dopamine is the neurotransmitter that informs the brain when pleasurable activities have taken place, such as eating or sex. This is a natural reward system in the brain to ensure that these life-sustaining activities will repeat themselves. Most drugs cause the brain to release unnatural amounts of dopamine, producing euphoric effects and reinforcing the behavior. With continued use of the drug,"…the brain adjusts to the overwhelming surges in dopamine (and other neurotransmitters) by producing less dopamine or by reducing the number of receptors that can receive signals. As a result, dopamine's impact on the reward circuit of a drug abuser's brain can become abnormally low, and the ability to experience any pleasure is reduced. This is why the abuser eventually feels flat, lifeless, and depressed, and is unable to enjoy things that previously brought them pleasure. Now, they need to take drugs just to try and bring their dopamine function back up to normal. And, they must take larger amounts of the drug than they first did to create the dopamine high - an effect known as tolerance.”

As this cycle continues, the inhibition and behavioral control systems in the brain are altered; the brain’s mechanisms for self-control and good decision-making become damaged. Due to changes in these areas of the brain, good judgment is inhibited while the brain sends intense signals to take the drugs. This leads individuals to compulsively take the drugs, despite the negative personal consequences. Another NIDA publication, Addiction Science: From Molecules to Managed Care, also explains how drug use changes the brain. It includes sample brain images of individuals who are substance abusers, and compares them with brain images of normal control subjects.

The HBO® Addiction Project website provides information and related videos on Addiction and the Brain and Addiction and the Brain’s Pleasure Pathway. In the supplemental film What is Addiction? Dr. Nora Volkow, Director of NIDA, notes that addiction is a “disease of the brain that translates into abnormal behavior.” She explains that addicted individuals can’t regulate their own behavior, because the area of the brain that allows free choice isn’t working properly. They become wrapped up in the drug and neglect other things. Regarding dopamine, which produces the sensation of pleasure, Dr. Volkow shares that “The brain evolved a natural reward system to learn those behaviors that are necessary for survival. Drugs activate the same reward systems, but in a faster more efficient way. The hijacked brain becomes dependent on drugs because natural rewards are no longer producing normal levels of dopamine or pleasure.” The individuals enter a state of deprivation, and they feel as if the drug is necessary for survival. This is why it becomes a priority. Due to the physical changes that occur in the brain, they don’t feel “normal” without it; they need the drug to feel “normal.” Through brain imaging, Dr. Volkow demonstrates how drugs affect the brain and compares addicted brains with non-addicted brains. She is able to point out the areas of addicted brains that have reduced dopamine activity, as well as the altered brain regions that control decision making and judgment.

Adolescence is typically a time when individuals naturally display poor decision making and judgment, due to frontal lobes that are not yet fully developed. Researchers have found that teenagers are more susceptible to addiction when they engage in drug use, due to differences in how their brains respond when anticipating rewards. A 2011 national study from CASA indicates that ninety percent of Americans who meet the medical criteria for addiction started smoking, drinking, or using other drugs before the age of 18. The study, Adolescent Substance Use: America’s #1 Public Health Problem notes that “adolescence is the critical period for the initiation of substance use and its consequences” and that “1 in 4 Americans who began using any addictive substance before age 18 are addicted, compared to 1 in 25 Americans who started using at age 21 or older.” The CASA report highlights the fact that “addiction is a disease with adolescent origins. The underdeveloped teen brain makes it likelier that teens will take risks, including using addictive substances that interfere with brain development, impair judgment and heighten their risk of addiction.”

What are some of the reasons people begin to use drugs in the first place?

To feel good – Most drugs, initially, induce a sense of pleasurable feelings. These feelings range from power and self confidence to relaxation and satisfaction, depending on the substance. Many addicts describe a sense of having a big empty hole within themselves, and using the drug in order to fill the hole.
To feel better – Many individuals use drugs in order to obtain relief from anxiety, stress, or depression. Some people begin using drugs in order to sleep better.
To perform better – Many substances provide a boost to physical or intellectual performance.
Peer pressure – When a peer group is using drugs, many individuals, especially adolescents, succumb to the peer pressure to participate.

There are several factors that help to predict whether or not an individual is at risk for substance abuse or addiction. NIDA shares that “Risk for addiction is influenced by a combination of factors that include individual biology, social environment, and age or stage of development.” Some examples of risk and protective factors include:

There are many opportunities for prevention related to these risk and protective factors. For example, in the domain of family, note that parental monitoring and support creates a protective factor. With this in mind, CASA introduced Family Day - A Day to Eat Dinner with Your Children(TM) in 2001 to remind parents that Dinner Makes a Difference. Family Day, celebrated annually on the fourth Monday in September, is “a national movement that informs parents that the engagement fostered during frequent family dinners is an effective tool to help keep America’s kids substance free.”

Despite the wealth of information available, there are still many misconceptions and misperceptions related to substance abuse and the individuals who suffer from the disease of addiction. Some of the myths and facts of addiction, provided by Whatcom County, Washington include:

MYTH: Addiction is a willpower problem. People can stop, if they really want to.

FACT: A person may start out as an occasional drug user, and that is a voluntary decision. But as time passes, continued use of the addictive drug changes the person’s brain, and that person goes from being a voluntary drug user to being a compulsive drug user.

MYTH: Addicts are bad, crazy, or stupid. These people just have a character flaw.

FACT: Addiction is a brain disease. Evolving research shows 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.

MYTH: People have to want treatment in order for it to be effective.

FACT: People who are forced into treatment do recover. 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.

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

FACT: Addiction is a brain disease that can be treated by changing brain function, through several types of treatment. New brain scan studies are showing that behavioral treatments, counseling, and medications work similarly in changing brain function. New medications are being developed to help patients who have already become abstinent to further curb their craving for addicting drug and alcohol. These medications reduce the chances of relapse and enhance the effectiveness of existing therapies. Relapse rates are similar for drug addiction and other chronic illnesses.

MYTH: Addicts who continue to abuse alcohol and other drugs after treatment are hopeless.

FACT: Addiction is a chronic disorder; occasional relapse does not mean failure. Risk for relapse is especially high when individuals return to family and environmental situations that initially led them to abuse substances. Recovery is a long process and frequently requires multiple treatment attempts before complete and consistent sobriety can be achieved.

MYTH: Addicts need to reach rock bottom before they can accept help.

FACT: There is no evidence that this is true. Early intervention in the addictive process can reduce the toll the disease will take on the individual’s life.

The Robert Wood Johnson Foundation's "Silent Treatment: Addiction in America" project maintains an archive of stories of individuals who have battled substance abuse and addiction. A cautionary tale from a child prodigy of substance abuse is written by a 23 year old college sophomore who was a star athlete in high school, but ended up addicted to a variety of drugs and cycling through multiple treatment centers before achieving sobriety. The story From girl to woman: ‘I couldn’t count on myself. I couldn’t count on my emotions’ is written by a woman who grew up in an alcoholic household with an abusive father. Additional stories portray a variety of experiences.

*This article is an excerpt from the book Introduction to Social Work: Macro, Mezzo, Micro Perspectives by Cheri Sinnott, LCSW, National Social Science Press

About the Author

Cheri Sinnott, LCSW, is the author of Introduction to Social Work: Macro, Mezzo, Micro Perspectives. She has been an Adjunct Instructor at College of Lake County for ten years. She is also the Director of the Illinois Service Resource Center (www.isrc.us) and maintains a private practice.

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