Years of scientific study have taught us that addiction is a chronic brain disease. But compared to medical and technological breakthroughs for other chronic diseases, such as type 2 diabetes, advances in drug and alcohol treatment haven’t kept pace. Despite a wide range of recovery options, relapse rates remain high. Across the globe, the number of alcohol and drug addicts continues to rise every year.
There is an urgent need to improve treatment as well as increase access to quality care. To achieve these goals, we need to understand how the latest scientific evidence challenges long-standing beliefs about addiction and how we treat it.
Under normal circumstances, our bodies react to naturally occurring stimuli, such as eating and sex, by sending pleasure signals to our brains. Our brains have evolved to interpret eating and sex as pleasurable pursuits because they have ensured the survival of our species. When we engage in activities like these, dopamine, a neurotransmitter, is released into the nucleus accumbens (commonly called our brain’s pleasure center) and voila! We feel good. Similarly, addictive substances cause pleasure by flooding the nucleus accumbens with dopamine. But addictive drugs typically release 2 to 10 times more dopamine than their naturally occurring counterparts.
Armed with these understandings, most in the scientific and medical communities concluded that the release of dopamine into our brain’s pathways was entirely, or at least largely, responsible for the reinforcing effects of drugs. The so-called dopamine hypothesis explained how the pleasure caused by drugs led to repetition of behaviors that prompted feelings of euphoria, satisfaction, and pleasure.
If dopamine is the primary driver of addiction, then anyone who uses drugs should become addicted, and all addictive drugs should be interchangeable. But science is showing that neither is the case. In fact, less than 10% of people who use alcohol and other drugs become addicted, and addictive substances are not interchangeable. For example, nicotine isn’t a substitute for heroin, marijuana doesn't take the place of cocaine, and alcohol is not a replacement for amphetamines. Thus pleasure can’t be the sole cause of addiction.
Thanks to quantum leaps in brain imaging technology, experts at the forefront of the science of addiction recognize that alcohol and other drugs, over time, cause physical changes in different parts of the brain. For instance, drugs affect brain regions that influence learning, memory, feelings, and mood. New studies continually show that it’s these changes that cause addicts to become obsessed with their drug of choice.
Although drug use begins with the activation of the brain’s dopamine pleasure pathway, it also alters other parts of the brain. Together, these often result in addiction. Thus, activation of the brain’s pleasure center is the primary starting point of addiction. But once a person takes drugs habitually, their use affects other brain regions. And these areas have little to do with the rewarding influence of drugs.
So how do we use this information to improve how we treat addicts? First, we must reevaluate past approaches. For instance, many healthcare professionals believed that controlling dopamine levels in addicts could decrease, or even cure, addiction. But more than 20 years of research have repeatedly shown that treatments primarily focused on dopamine levels aren’t effective. Although controlling dopamine levels addresses how addiction starts, it doesn’t tackle the reasons behind long-term drug abuse. So the question becomes what treatment approaches can provide the best possible outcome for the most people?
Herein lies the intersection between tried and true 12-Step principles and scientifically and medically based approaches. We now understand that addiction cannot be reduced merely to dopamine dependence. In fact, 12-Step programs, such as Alcoholics Anonymous, are effective precisely because they address the changes that take place in other areas of the brain that influence addiction.
Both groups — the 12-Steppers and the scientific community — need to learn from one another to provide the best of both worlds in treatment. Twelve-Steppers shouldn’t disregard scientific advances that change how we treat addiction, but the scientific community shouldn’t underestimate the importance of the Steps in remedying memory deficits and rebuilding a connection to the community through empathy and service.
When the strengths of both 12-Step and the scientific and medical communities merge, addicts have treatment options that can provide faster, longer-lasting recovery.
David Sack, M.D., is board certified in Addiction Medicine and Addiction Psychiatry. As CEO of Elements Behavioral Health he oversees a number of addiction treatment centers. He served as a senior clinical scientist at the National Institute of Mental Health (NIMH) where his research interests included affective disorders, seasonal and circadian rhythms,and neuroendocrinology. You can follow Dr. Sack on Twitter.