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Addiction Is a Brain Disease
How the Brain Gets and Stays Addicted
Hardly a day goes by without some researcher, politician, or policymaker saying that, based on forty years of scientific research, addiction should be considered a chronic brain disease and treated like any other chronic disease. Patients should have more ready access to treatment, in line with what's offered for chronic illnesses like heart disease. While that is all well and good, is it true that brain disease is the same as other chronic diseases? What does having a brain disease really mean for people suffering from addiction, for their families and friends, and for their physicians? This is both a medical and a philosophical question, or to put it more accurately, this is where medicine and philosophy come together.
The Framework of Brain Disease
Nearly two thousand years ago, the Greek physician and philosopher Galen observed that people with brain disease behave differently than those suffering from diseases of other body organs. He saw that when disease affects the brain, not just one certain body part stops working properly, but the whole person is affected. While a diseased body organ can make you very sick, people still recognize you as the person you are. Brain disease, however, affects the whole person — your sense of being a person, your personality, and your personhood. You are no longer the person you once were, and you are not the person your family and your friends once knew. People don't recognize who the addicted person has become, and sometimes addicts don't even recognize themselves.
When leaders and policymakers say we should treat addiction the way we treat hypertension, diabetes, and heart diseases, they are mainly arguing that doctors should treat addicted patients in the same way as patients with other chronic diseases, and health insurance should provide similar coverage. As a matter of policy, this is fine. However, it misses the mark to regard diseases of addiction as similar to other diseases. Brain disease affects much more than the body. Our brains define us in symbolic, metaphysical, moral, and spiritual ways. The brain is the organ of relationships, and its disease affects our relationship with our family, society, and God, not to mention ourselves. It is what makes us who we are.
That is why I want to explain what drugs do to the brain, what happens to the brain on its way to becoming addicted and staying addicted, why people cannot just stop taking drugs when they want to, and why people take drugs to begin with. I want you to fully appreciate addiction as a brain disease.
That said, please remember that describing addiction as a "disease of the brain" is only a framework. A framework is not necessarily perfect or 100 percent accurate, and it doesn't have to be. We use frameworks to help us solve a problem in the most effective way, and I believe this framework for addiction does that. In time, as we understand addiction better, we may modify or even replace this framework, but only because a new framework works better at healing addiction.
Frameworks are most useful when they avoid any unnecessary, detrimental, or burdensome "baggage." Right now, the treatment of addiction is most often weighed down by the baggage of sin, blame, and faultfinding. While scientists describe and study addiction as a brain disease, as a society, which includes the medical profession, we still often treat people who suffer addiction as if they have sinned. But I believe we don't have to invoke guilt, shame, sin, or weakness of will in order to understand what happens in the brain or to treat drug addiction.
Say Hello to Your Brain
Let us begin by meeting our brain, or more accurately, our brains. Very simply, our brain is made up of three parts, which are really almost like three separate brains. The good news is that these three brains provide us with a good margin of safety in capacity, flexibility, and speed of thought. The bad news is that we have to keep the three brains running in harmony to work well, and most of the time the brains operate on their own, without our control or even awareness. We say we have an "integrated" brain when things run smoothly, but a lot can go wrong in a system like this — whether in one of the three brains or in the way they work together. But let's not get too far ahead of ourselves.
The first, oldest, and innermost of the three brains is our "reptilian" brain. This brain evolved along with the first lizards and crocodiles perhaps as long as three hundred million years ago. This primitive brain focuses on survival and has four basic functions: feeding, fighting, fleeing, and reproducing. Today, for us to have a smooth-running brain system, our main challenge is to let this survival brain do its job keeping us alive without dominating the other two brains, which arose later. Human lives are more complicated than those of crocs and lizards, and our reptilian brain needs to be kept under control.
Our second brain, the limbic brain, developed many millions of years later, along with the first mammals. The limbic brain focuses on memory and emotion. Its main job is to help us make connections and to keep us connected. It helps us bond and make lasting, meaningful relationships based on trust and love; it is the source of our happiness and our miseries. This brain determines our mood, whether we feel tough and cold or warm and fuzzy. Social mammals need emotion and memory; empathy and compassion, for ourselves and others, are necessary foundations of society, which requires individuals to balance self-interest against the welfare of others and the community. As we all know, this is not easy, but we use the limbic brain to negotiate this difficult terrain. And again, our main job is to let the limbic brain do its job without letting it get out of hand. Most emotional and behavioral problems, including addiction, have their roots in the limbic brain and its connections to — or the balance of power between it and — the reptilian brain and the cortical brain, which is our third brain.
The largest and most recent arrival, our cortical brain, is our thinking and decision-making brain. This makes us who we are as a species and as individuals. We depend on the cortical brain for our intelligence, our intuition, our creativity, and our appreciation of art and music and all things beautiful. It is the chief executive officer of our three-brain system. In many respects our cortical brain is still under construction; we are not sure where it will take us, but it is not an exaggeration to say that the survival of our human race depends on it. So far it has produced the fantastic scientific and technological innovations that have given us the comforts of modern life, but it has also given us the capacity to destroy ourselves and this planet we call home.
The harmonious working of our three-part brain gives rise to something more than the sum of its parts: a sense of self-awareness. Our minds are capable of observing our own thoughts, so that we can consciously direct, exercise, and improve ourselves. This sense of self — of self-consciousness — makes it possible to wonder about andsearch for the meaning of life, such as when we ask, "Who am I? Why am I here? What is the meaning of all this?" However, the exact relationship between our self-aware mind and our physical brain is unclear. Although the mind needs the brain in order to express itself, that doesn't mean the mind is the product of the brain. A good analogy is TV: The programs we watch are not produced by the television set, although we need the set to view them. Where the mind comes from and where it resides remains one big mystery.
In any case, using this greatly simplified model of our brain, we can discuss the disease of addiction. Many things can go wrong with each of our three brains individually, but more often the problem is that one brain has too much or too little power relative to the others.
How the Brain Becomes Addicted
At the simplest physical level, the brain functions using a combination of electricity and chemistry. Electric circuits give the brain its speed, but at the cellular level, the brain works chemically. It is one big chemical machine.
In the story of addiction, the main protagonist — usually a hero, but here a villain — is the chemical dopamine. Dopamine is the motivational or "feel-good" chemical, which is released in our limbic brain by such rewarding experiences as food, sex, and drugs. Dopamine also helps release the "cuddling" hormone oxytocin, which makes us want to repeat these experiences. Different levels of dopamine are released by different stimuli. For instance, during an average day in a normal, nonaddicted brain, the dopamine number hangs around 100. With a good meal, the dopamine level might rise to 150. With sex or morphine, it might rise to 200; with cigarettes, 225; with cocaine, 350; and with methamphetamines, 1,000. Wow! As you can see, drugs of abuse often produce dopamine surges that are many times higher than the surges produced by such natural rewards as food and sex, which is why drugs are so much more powerful and so much more destructive. Addiction starts as a problem of dopamine numbers in the reward circuitry of our limbic brain.
However, beyond making us feel good, dopamine is involved in a special type of learning known as conditioning or reward-driven learning. Because of dopamine, the context of the drug-use experience — the good times — adds value and strength to the drug memory. This added strength is what we call "salience." This "value-added" salient memory now has more power, holds a higher priority, and commands in us a stronger desire to seek the experience again, so we are driven to act in anticipation of the reward. In this way, the brain becomes addicted from a combination of repeated drug exposure and repeated reward-driven learning, both of which depend on the action of dopamine.
How does this relate to our three brains? Drugs activate and strengthen the "pleasure" response in the limbic brain, while weakening the fear response to potential harm in the reptilian brain and also reducing the inhibition exerted by the cortical brain — or the cortex, which governs decision making and executive functioning. The reduced cortical inhibition makes risky behaviors seem more rewarding and the harmful consequences less relevant, so that using drugs and its consequences become increasingly normal.
This becomes a negative spiral. Desire for the drug experience increases as it is repeated, and eventually this drives the reward circuitry completely out of control so that it takes over the entire brain system. In other words, our reward circuitry runs amok and cuts itself off, disconnecting itself from the control of the rational cortical brain and perhaps also the self-protective reptilian brain. That, in a nutshell, is how the brain acquires the disease of addiction. An addicted person might continue to function in society, to varying degrees of success, but their mind becomes obsessed with thinking about drugs, dreaming of drugs, remembering drug experiences, and using drugs. Once someone is addicted, this takeover of the mind continues despite the increasingly serious consequences of drug use.
Once the cortical brain is overridden, a person loses their inhibitory control. Thus, addiction is like losing the brakes in your car. Normally, your little sedan has pretty good brakes, but under the influence of drugs, your brake pedal will fail just as you pick up speed going down a very steep slope. An old Japanese proverb puts it this way:
First the man takes a drink,
This process is the same no matter which drug leads to addiction. Underlying all addictions is the same brain mechanism, which results in very similar behavioral manifestations and often common destructive consequences. That said, different drugs are obviously experienced differently. In general, drugs affect the brain in one of four ways. Stimulants like tobacco and cocaine enhance brain activity by "kicking it up a notch," whereas depressants such as sedatives, benzodiazepines, and alcohol suppress brain activity. Psychedelics and hallucinogens completely muddle the brain's working processes. Finally, opioids have a unique way of affecting the brain. They are primarily prescribed to kill pain, but it is more correct to say they reduce suffering. Opioids don't actually eliminate pain, but the person feels like nothing much matters. This is why the ancient Greeks called opioids the "medicine of the gods": The gods on Mount Olympus were far removed from and did not much care about mortal troubles.
Of course, people become addicted to things besides drugs. They can become addicted to food, sex, porn, gambling, video games, the internet, and so on. Whatever the cause, the core feature is the extreme takeover of all life activities by the addictive behavior. The addictive experience becomes the predominant driving force in the person's daily life — everything is wrapped up in it, and everything is ruined by it. Addiction is a disease of extremes, and anything done to extreme takes over everything else and becomes a dominating fact of life.
Why Do People Take Drugs?
We have discussed how the brain works, how drugs affect the brain, how the brain becomes addicted, and how it stays addicted — as it learns and incorporates drug experiences into memory and as its reward circuitry overwhelms rational inhibitions. Now let's ask perhaps the most important question of all: Why do people take drugs in the first place?
Alan Leshner, former director of the National Institute on Drug Abuse, puts it simply: "People take drugs to feel good or to feel better." In other words, people take drugs because they like how the drugs make them feel. Since we all want to feel good, and we all want to feel better when we do not feel good, what's wrong with that?
Nothing, really. There's nothing wrong with wanting to feel good and be happy. After all, America's founding fathers put the pursuit of happiness, along with life and liberty, into the Declaration of Independence as one of our inalienable rights. What's the big fuss if people take drugs in pursuit of happiness?
Well, a few things. One is that the "good time" from drugs can become addicting, and being addicted is not a happy place. An addict doesn't do drugs to "pursue happiness," but out of compulsion. Further, and more importantly, the "happiness" people feel on drugs isn't the "happiness" that the founding fathers were talking about. The "happiness" referred to in the Declaration of Independence is related to "virtue." It's the kind of happiness you experience by becoming the person you want to be and by engaging in meaningful, productive activities that help others. In other words, the founding fathers meant the satisfaction of a successful life, feeling good from having done good, not pursuing personal pleasure for its own sake.
These two types of happiness are entirely different. They have different names, involve different brain mechanisms, and have very different effects on our health. Pleasure for its own sake — "having a good time" without any other meaning or purpose and benefiting only oneself — is called "hedonia." This type of happiness creates a physiological response that is similar to when the body is under stress: Excitement is accompanied by increases in blood pressure and respiration, by increases in blood sugar and stress hormones, and by a decrease in immune responses. Which is to say, as with stress, too much of this kind of happiness can make you sick — which is the price you pay for the good time.
The other kind of happiness — feeling good from personal satisfaction and from helping others and one's community through meaningful actions — is called "eudemonia." The physiological responses that accompany this feeling are the opposite of hedonia's: Blood pressure, respiration, blood sugar, and stress hormones all decrease, and immune-response hormones increase — in other words, you get healthier.
You may not be surprised to learn that these two types of happiness involve different parts of our brain. Hedonia, or personal pleasure, is antithetical to reflection; as we've discussed, the limbic brain's reward centers overwhelm the rational cortical brain — the part of our brain that makes us uniquely human. On the other hand, eudemonia emerges from self-reflection and self-awareness, and it requires the highest level of cortical brain function. In a way, with eudemonia we feel good about precisely what makes us uniquely human — like being a good worker, a good friend, or a good parent. That is what feeling good about yourself is all about.
Excerpted from "Mastering the Addicted Brain"
Copyright © 2017 Walter Ling, MD.
Excerpted by permission of New World Library.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of ContentsIntroduction
1. Addiction Is a Brain Disease: How the Brain Gets and Stays Addicted
2. Getting Off and Staying Off Drugs: Detoxification and Relapse Prevention
3. Preparing for a New Life: Physical Health
4. Emotional Health
5. Living Responsibly
6. Connections: Living Among Family and Friends
7. Being a Member of the Community
8. A Balanced Life
What People are Saying About This
“Dr. Ling, one of the world’s foremost experts on addiction, explains addiction in a way that non-scientists can understand, and he dispels the pervasive myth that this disease can’t be treated. . . . If you or a loved one is suffering addiction or if you want to understand a disease that’s devastating our families, communities, and nation this book is indispensable.” David Sheff, author of Beautiful Boy: A Father’s Journey through His Son’s Addiction and Clean: Overcoming Addiction and Ending America’s Greatest Tragedy “In this seemingly simple book, Dr. Ling reminds the reader that stopping drug and alcohol use is only the first, and in some ways the easiest, step in treating addiction, with the real and joyful work beginning as a new way of living unfolds.” Peggy Compton, RN, PhD, FAAN, Associate Professor, van Ameringen Endowed Chair, Department of Family and Community Health, University of Pennsylvania School of Nursing“This beautifully written book by a prominent figure in addiction medicine provides a useful perspective for individuals whose pleasure-seeking, feel-better use of opiates has led to addiction. The book could also have been titled Getting to Know Walter Ling: Neurologist, Psychiatrist, Practitioner, Philosopher, Family Man. His wit and wisdom contribute to the appeal of his message for an even wider audience of interested readers.” C. James Klett, PhD “Like Dr. Ling himself, [ Mastering the Addicted Brain ] is filled with compassion, wisdom, and funny stories. Most of all, it provides a road map for how to lead a happy, balanced, and meaningful life. Addicts, their friends and family, and anyone who has struggled with difficult problems will benefit from reading this book.” Sandra D. Comer, PhD, Professor of Neurobiology, Department of Psychiatry, Columbia University and New York State Psychiatric Institute“There are very few entertaining and easy-to-read books about addiction that are scientifically accurate and also contain gems of ancient wisdom. Dr. Ling has provided the latter in this wonderful little handbook that contains all the essentials of recovery and a wonderful first chapter for everyone who has ever known someone struggling with this most difficult disease.” Jeanne L. Obert, MFT, MSM, cofounder and board chair, Matrix Institute on Addictions “An amazing amount of information is packed into this very readable little book. Walter Ling is one of the pioneers in the field of addiction, and anyone who is affected by addiction can learn from the wisdom of this master.” Richard A. Rawson, PhD, Research Professor, Vermont Center on Behavior and Health“ Mastering the Addicted Brain is the perfect guide to support clinicians. It provides practical, evidence-based guidance along with an easy-to-understand conceptualization of how addiction occurs. It’s useful for those who have an addiction as well as the family and friends of those who need support in their recovery. Highly recommended.” Robert Ali, Associate Professor of Pharmacology, University of Adelaide School of Medicine“With this short, easy-to-read summary of his research findings and clinical wisdom, Dr. Ling has opened the door for clinicians, educators, and affected families to understand and ultimately ‘master’ addiction. There are not yet cures for addictions, but this book shows how it is possible indeed expectable to overcome drug cravings and relapses and to develop a rewarding life in recovery.” A. Thomas McLellan, addiction researcher and founder of Treatment Research Institute“This book is delightful and easy to read, yet conveys a profound understanding of what addiction is and what it takes to overcome addiction. It is full of useful insights, thoughtful exercises, and sound advice to guide individuals along the difficult road to recovery. This book will be helpful to patients and their families as well as professionals in the addiction field.” Kathleen Brady, MD, PhD, former president, American Academy of Addiction Psychiatry“Dr. Walter Ling’s Mastering the Addicted Brain makes the very complicated and complex information on the disease of addiction simple and direct. He explains with profound clarity the difference between getting addicted and staying addicted and getting sober and staying sober. . . . In well-laid-out steps and exercises, Dr. Ling offers guidance, support, and a simple plan for long-term recovery.” Kristina Wandzilak, CAS, CIP, author of The Lost Years: Surviving a Mother and Daughter’s Worst Nightmare and founder of Full Circle Intervention and Full Circle Addiction and Recovery Services“This is a very valuable book for those afflicted by addictions, for their family and friends, and for the interested general public.” Professor Sir John Strang, National Addiction Centre, King’s College London