Part One: The Three C’s

For thousands of years, human cultures have used psychoactive substances for various purposes, including religious ceremonies, medicinal healing, to experience altered mind states, and for the pure pleasure it can produce.

In popular American culture, drug use is often glamorized – or even dramatized – as a way of providing maximum effect in television shows, films, and books. These stories shape our expectancies about what drugs will do to us (or for us) and how we understand the issue of addiction. Unfortunately, these portrayals do little to clarify the confusion about addiction, and they may worsen the stigma.

Going into this book, we ask you to keep an open mind. It is tempting to see addiction through the lens of our own experiences, and that is natural to do. However, many voices contribute to the concept of addiction, and they deserve to be heard as well. Because addiction is a complicated process, our understanding of it often requires us to challenge our existing views.

Below are some questions people often ask about addiction, which can aid your exploration of the topics in this book and help us seek answers:

While discussions about addiction have changed and will continue to evolve, one thing we know is that the core of addiction is the brain. Stated simply, “anyone with a brain can become an addict” (Kuhn, Swartzwelder, & Wilson, 2019). Certain people are more likely to develop an addiction, and people who are not necessarily addicted can still have significant problems with drugs of abuse. And relatively speaking, our understanding of the brain is in its infancy, particularly when it comes to mental health, compulsive behavior, and addiction.

Let’s start by looking at drug use on a continuum. On one end, we have abstinence or no use. Next to that we have use, followed by abuse, and finally addictive use.

|___________________|___________________|__________________|

Abstinence                     Use                                      Abuse                            Addictive Use

A person who is not using a certain drug will not have problems with it; that’s fairly simple to understand. This may include someone who never wanted to try a certain drug, who does not have access to it, or who previously used it but no longer does.

From there, we can look at use. This involves trying any particular drug, such as marijuana, alcohol, or cocaine. Notably, this can also include prescribed medication. Drug use can become habitual and problematic, but it does not always. Some people experiment with a drug and never use it again, or they use it infrequently and moderately enough that it does not interfere with their life. However, we should note that some users do not perceive the damage that has been caused by their drug use and fail to identify the consequences.

A more serious step would be drug abuse, and at this stage, the user has experienced problems related to their use. They are using more of the drug than intended or have engaged in problematic behavior while using or getting the drug. This could occur after just a single use of a drug, particularly if someone is unfamiliar with the effects of the drug. Think of a young person taking several shots of alcohol for the first time in their life and then trying to drive afterward. This could lead to catastrophic consequences.

Chronic use of a drug may also fall under the category of abuse, provided that it doesn’t meet the definition of addictive use. Note that there is no longer a diagnostic category called “abuse” in the newest version of the Diagnostic and Statistical Manual (DSM). Instead, there is simply the term Substance Use Disorder, and qualifiers to define the level of severity: Mild, Moderate, or Severe.

Finally, we have addictive use. An easy way to identify addictive use is by remembering the three Cs: Compulsion, Loss of Control, & Consequences. When a person’s use has all of these characteristics, it is an addiction. This also fits well with the definition written by the American Society of Addiction Medicine (ASAM), which can be found later in this chapter.

Let’s explain each of the three Cs a bit further:

Compulsion – this is an overwhelming urge to use the drug; an obsession is a repetitive and disruptive thought, and compulsion represents the behavior to act on the thought (as in obsessive-compulsive disorder)

Loss of Control – occurs when the person can no longer predict how much they will use and what will happen when they do use

Consequences – characterized by a person continuing to use despite consequences related to their use, such as financial, legal, social, interpersonal, emotional and spiritual (what we call the six “ALs”)

There is a significant discussion around the role of choice in addiction. One way to think of it is that addiction involves choices, but addiction itself is not a choice. As with other diseases and disorders, individual choice plays a role, as do genetics, home environment, and cultural norms. Addiction is a complex disorder because it involves perhaps the most complex entity in the universe, namely the human brain.

Some people are uncomfortable with the disease concept of addiction because they believe it removes responsibility from the using person. However, addictions specialists use the disease concept to remove the burden and guilt associated with the consequences of addictive use, while empowering the individual to take healthy steps toward recovery. While other models may emerge in the future to describe addictive use, the brain disease model holds several advantages.

For one, it is destigmatizing and takes away blame. It also suggests an important role for treatment, whether that be through the use of medications, formal therapy, support groups, or other positive lifestyle changes. And finally, the disease concept opens up the need for further research to better understand the illness and develop improved ways of recovering from it.

It is crucial that a person identifies a problem and takes responsibility for their recovery. However, no benefit has been found from forcing people to accept a certain label, like the terms “addict” and “alcoholic.” Because of the long-standing stigma in the fields of addiction and mental health, people struggling with these issues often minimize or hide their problems and refuse to seek help. Therefore, it is vital to make treatment and recovery accessible to all without putting unnecessary barriers in the way.

As you explore this chapter, you will learn to define addiction, recognize its impact on society, compare United States drug-using norms to those of other countries, and identify addiction as a dysfunctional relationship between user and substance.

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Article: ASAM Definition of Addiction Offers Support for Long Term Treatment and Recovery Approaches

by David Kerr

The American Society of Addiction Medicine (ASAM) has recently created a definition of addiction.  The essential long-term treatment and recovery needs of the addict are supported by this recent ASAM definition.

The definition of addiction offered by ASAM is as follows:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, and craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

This definition describes physical attributes that appear to relate to the very wiring of the human brain.  After reading both the short and long term definitions recently published by ASAM, it is clear to me why addicts have such a difficult time stopping their drug and/or alcohol use.  It is equally clear why relapse may be frequent.  The brain of a substance abuser is hard-wired for addiction and if changes are to occur to reverse this, the re-wiring will likely take a long time. Knowing this, it is easy to see why long term treatment and recovery approaches appear to be more durable than the short-term acute care approaches.

A logical assumption can be made that it took years to wire the addictive brain chemistry and any approach to restore normalcy in this chemistry or to re-wire the brain will also probably take years. This is why the Alcoholics Anonymous (AA) approach has had success and is why long-term treatment, recovery, and supportive care are likely to be more durable.

How Addiction Hijacks the Brain

Published by Harvard Health Publishing, Harvard Medical School

Desire initiates the process, but learning sustains it.

The word “addiction” is derived from a Latin term for “enslaved by” or “bound to.” Anyone who has struggled to overcome an addiction — or has tried to help someone else to do so — understands why.

Addiction exerts a long and powerful influence on the brain that manifests in three distinct ways: craving for the object of addiction, loss of control over its use, and continuing involvement with it despite adverse consequences. While overcoming addiction is possible, the process is often long, slow, and complicated. It took years for researchers and policymakers to arrive at this understanding.

In the 1930s, when researchers first began to investigate what caused addictive behavior, they believed that people who developed addictions were somehow morally flawed or lacking in willpower. Overcoming addiction, they thought, involved punishing miscreants or, alternately, encouraging them to muster the will to break a habit.

The scientific consensus has changed since then. Today we recognize addiction as a chronic disease that changes both brain structure and function. Just as cardiovascular disease damages the heart and diabetes impairs the pancreas, addiction hijacks the brain. Recovery from addiction involves willpower, certainly, but it is not enough to “just say no” — as the 1980s slogan suggested. Instead, people typically use multiple strategies — including psychotherapy, medication, and self-care — as they try to break the grip of an addiction.

Another shift in thinking about addiction has occurred as well. For many years, experts believed that only alcohol and powerful drugs could cause addiction. Neuroimaging technologies and more recent research, however, have shown that certain pleasurable activities, such as gambling, shopping, and sex, can also co-opt the brain. Although the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) describes multiple addictions, each tied to a specific substance or activity, consensus is emerging that these may represent multiple expressions of a common underlying brain process.

From liking to wanting

Nobody starts out intending to develop an addiction, but many people get caught in its snare. According to the latest government statistics, nearly 23 million Americans — almost one in 10 — are addicted to alcohol or other drugs. More than two-thirds of people with addiction abuse alcohol. The top three drugs causing addiction are marijuana, opioid (narcotic) pain relievers, and cocaine.

Genetic vulnerability contributes to the risk of developing an addiction. Twin and adoption studies show that about 40% to 60% of susceptibility to addiction is hereditary. But behavior plays a key role, especially when it comes to reinforcing a habit.

Pleasure principle. The brain registers all pleasures in the same way, whether they originate with a psychoactive drug, a monetary reward, a sexual encounter, or a satisfying meal. In the brain, pleasure has a distinct signature: the release of the neurotransmitter dopamine in the nucleus accumbens, a cluster of nerve cells lying underneath the cerebral cortex (see illustration). Dopamine release in the nucleus accumbens is so consistently tied with pleasure that neuroscientists refer to the region as the brain’s pleasure center.

All drugs of abuse, from nicotine to heroin, cause a particularly powerful surge of dopamine in the nucleus accumbens. The likelihood that the use of a drug or participation in a rewarding activity will lead to addiction is directly linked to the speed with which it promotes dopamine release, the intensity of that release, and the reliability of that release. Even taking the same drug through different methods of administration can influence how likely it is to lead to addiction. Smoking a drug or injecting it intravenously, as opposed to swallowing it as a pill, for example, generally produces a faster, stronger dopamine signal and is more likely to lead to drug misuse.

Learning process. Scientists once believed that the experience of pleasure alone was enough to prompt people to continue seeking an addictive substance or activity. But more recent research suggests that the situation is more complicated. Dopamine not only contributes to the experience of pleasure, but also plays a role in learning and memory — two key elements in the transition from liking something to becoming addicted to it.

According to the current theory about addiction, dopamine interacts with another neurotransmitter, glutamate, to take over the brain’s system of reward-related learning. This system has an important role in sustaining life because it links activities needed for human survival (such as eating and sex) with pleasure and reward. The reward circuit in the brain includes areas involved with motivation and memory as well as with pleasure. Addictive substances and behaviors stimulate the same circuit — and then overload it.

Repeated exposure to an addictive substance or behavior causes nerve cells in the nucleus accumbens and the prefrontal cortex (the area of the brain involved in planning and executing tasks) to communicate in a way that couples liking something with wanting it, in turn driving us to go after it. That is, this process motivates us to take action to seek out the source of pleasure.

Tolerance and compulsion. Over time, the brain adapts in a way that actually makes the sought-after substance or activity less pleasurable.

In nature, rewards usually come only with time and effort. Addictive drugs and behaviors provide a shortcut, flooding the brain with dopamine and other neurotransmitters. Our brains do not have an easy way to withstand the onslaught.

Addictive drugs, for example, can release two to 10 times the amount of dopamine that natural rewards do, and they do it more quickly and more reliably. In a person who becomes addicted, brain receptors become overwhelmed. The brain responds by producing less dopamine or eliminating dopamine receptors — an adaptation similar to turning the volume down on a loudspeaker when noise becomes too loud.

As a result of these adaptations, dopamine has less impact on the brain’s reward center. People who develop an addiction typically find that, in time, the desired substance no longer gives them as much pleasure. They have to take more of it to obtain the same dopamine “high” because their brains have adapted — an effect known as tolerance.

At this point, compulsion takes over. The pleasure associated with an addictive drug or behavior subsides — and yet the memory of the desired effect and the need to recreate it (the wanting) persists. It’s as though the normal machinery of motivation is no longer functioning.

The learning process mentioned earlier also comes into play. The hippocampus and the amygdala store information about environmental cues associated with the desired substance, so that it can be located again. These memories help create a conditioned response — intense craving — whenever the person encounters those environmental cues.

Cravings contribute not only to addiction but to relapse after a hard-won sobriety. A person addicted to heroin may be in danger of relapse when he sees a hypodermic needle, for example, while another person might start to drink again after seeing a bottle of whiskey. Conditioned learning helps explain why people who develop an addiction risk relapse even after years of abstinence.

The long road to recovery

Because addiction is learned and stored in the brain as memory, recovery is a slow and hesitant process in which the influence of those memories diminishes.

About 40% to 60% of people with a drug addiction experience at least one relapse after an initial recovery. While this may seem discouraging, the relapse rate is similar to that in other chronic diseases, such as high blood pressure and asthma, where 50% to 70% of people each year experience a recurrence of symptoms significant enough to require medical intervention.

Fortunately, a number of effective treatments exist for addiction, usually combining self-help strategies, psychotherapy, and rehabilitation. For some types of addictions, medication may also help.

The precise plan varies based on the nature of the addiction, but all treatments are aimed at helping people to unlearn their addictions while adopting healthier coping strategies — truly a brain-based recovery program.

Chapter One, Part One Quiz

Part Two: The Costs of Addiction

Next, we will explore the costs of addiction to American society, while also turning an eye toward the cultural norms around drug use. In this section, keep in mind the ways that your culture influences certain behaviors, including whether you try a certain drug and which drugs are more acceptable than others.

This section includes a video from the former head of the Office of National Drug Control Policy, Michael Botinelli, as well as an excellent article from the National Institute on Drug Abuse that describes the science of addiction. There is also a slideshow that explores the societal costs of addiction and concludes by telling the Tale of 10 Beers, a metaphorical party that represents alcohol consumption among Americans.

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In this TED Talk, Michael Botticelli, the former Director of the Office of National Drug Control Policy, discusses why we should treat addiction as a disease.

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This pamphlet, produced by the National Institute on Drug Abuse, explains the effects of addiction on the brain and why it changes people’s behavior.

Drugs, Brains, and Behavior – The Science of Addiction

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Part Two Quiz

Part Three: Our Relationship with Drugs of Abuse

In the final part of Chapter 1, we examine how each person has an individual relationship with drugs of abuse. These relationships are influenced by our genetics, our environment, and our life decisions. Pay particular attention to how Gabor Mate describes addiction in his captivating video, “The Power of Addiction.”

After that, there is an article and a slideshow that both describe the ways in which addiction can be viewed through the lens of relationships. Although dysfunctional, the relationship with addiction can become just as important as any other meaningful connection. The process of coming back from the relationship of addiction requires a grieving process and new, healthy relationships.

Finally, notice how addiction subtly hijacks the brain over time by overloading our primitive “go” system and impairing our rational “stop” system to create the central struggle of addictive behavior.

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Addiction, Heartbreak, and the Healing Power of Relationships

Relationships take on a multitude of forms, from friends united by common interests and shared experiences, to family members bound by genetics and loyalty. Our relationships are built around intimacy, connection, spirituality, and emotion. Some relationships last a lifetime, while others carry us through a particularly difficult stage of life. When they end, most relationships leave an individual in some manner of pain and grieving. Often, people do not want the relationship to end when it does. In this sense, perhaps no relationship is more powerful or hard to part with than the relationship of addiction.

For over half a century, the addictions field has worked to erase the stigma of addiction by reframing the problem not as one of morality or inadequate willpower, but rather as a complex illness marked by specific characteristics (DuPont, 2000; Kinney, 2012). Research now strongly supports the notion of addiction as a brain disease involving physiological changes in two key regions: the reward circuit in the limbic system, and the prefrontal cortex (National Institute on Drug Abuse, 2010; Inaba & Cohen, 2011). In the simplest terms, the human brain can be broken into two parts. The first is the “old brain,” responsible for our physical drives, raw emotions, and survival and pleasure instincts. The second is the “new brain” where higher-order planning, rational thinking, and judgment happen (Inaba & Cohen, 2011). The process of addiction hijacks both regions.

A cascade of neurotransmitters activated by substance use initiates the relationship between user and substance. The drug plays the role of activating the old brain’s reward system, which happens each time the user engages in the behavior (Kuhn, Swartzwelder, & Wilson, 2008; Inaba & Cohen, 2011). This relationship is unique because it is more reliable and predictable than most human relationships. Drugs are so effective at delivering their promised high that the individual comes to count on the pleasurable feeling with near 100% certainty. Future events, from celebrations to loss of a loved one, cue the brain to seek more of the drug.

According to the National Institute on Drug Abuse, the old brain becomes altered in such a way that it interprets the need for a drug as being equally or even more important than the need for food and sex (2010). Further exacerbating the problem is a change happening in the new brain, where the brakes should be applied to this runaway train. However, the prefrontal cortex also adapts to the drug and begins taking a backseat to the old brain’s drives. The ability to make sound, rational decisions is significantly impaired (National Institute on Drug Abuse, 2010). Thus, the brain is in a state of having a brick on the gas pedal and a malfunctioning brake line.

Understanding addiction as an intimate bond between an individual and a behavior helps counselors to conceptualize exactly what happens when a person cannot simply choose to change. As dysfunctional as the relationship becomes, the way out seems nearly impossible to the person suffering from addiction. A search for a logical explanation to this phenomenon yields confusion for friends, family, and for the user. The question of why certain people become addicted is as complicated as the brain itself, and there is no simple or complete answer. Genetics clearly play a central role, but environment, culture, access to substances, and personal choices are important as well (Kinney, 2012).

While some clients and counselors may find it important to flesh out the exact underpinnings of one’s addiction, more critical in the short term is finding ways to terminate the old relationship and begin the path toward change. Thus, the treatment for the relationship of addiction is new, healthy connections. These may come in the form of a positive client-counselor relationship, a sponsor, sober peers, healthy family members, a higher power, or a change in environment.

With abstinence, the brain begins to re-wire over time, although drug cravings are inevitable and notoriously difficult to fend off (Marlatt & Donovan, 2007; Kuhn, Swartzwelder, & Wilson, 2008). This is one area where counselors can make an important impact, helping clients to anticipate and avoid high-risk situations, or practice new coping skills. Clients who relapse and use the drug again have not committed a shameful act. Marlatt and Donovan (2007) warn that clients who view relapse as a failure will be more likely to repeat the unhealthy behavior and ultimately renew the harmful relationship. Instead, counselors and clients alike can use the experience as a learning tool.

While many factors co-occur with substance use, including trauma, mental illness, and medical concerns, counselors need to remember to treat addiction as a primary disorder (National Institute on Drug Abuse, 2010; Kinney, 2012). Addiction should not be viewed simply as the symptom of an underlying mental health issue. Treatment needs to center on the addiction. In many cases, especially with long-term use of alcohol, benzodiazepines, or opiates, a period of detoxification is necessary. Following that, a referral to a level of treatment appropriate to the client’s situation should be made, which may include meeting with a licensed counselor. If a client’s substance use disorder is beyond the scope of your training, make sure to provide ample resources. Referrals to treatment programs that accept various forms of payment should be made available. One good resource is SAMHSA’s free online treatment finder. Counselors can also provide information on local mutual help meetings, such as 12-Step groups and SMART Recovery.

When working with clients with addictions, remember that there is a physiological change that has taken place. Healing can and will happen, but expect it to take time and be patient with the process. Focus on ways to end the unhealthy, life-draining relationship of addiction, no matter how heartbreaking the loss may be. Shift the client into healthy, life-giving relationships that invoke passion, which is the opposite of addiction.

Written by Jason Florin and originally published in the Illinois Counseling Association’s newsletter, Contact.

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Part Three Quiz