Is Addiction a Disease? Yes, and it is the only disease that you have to convince someone that they have. The only one. I get asked by residents and their families this question often, and because of this I wanted to break it down and explain what exactly happens in the brain once addiction hijacks it.
A normal pleasurable event begins with a stimulus. For example, a visit with your granny gives you a warm experience of joy. Her smile, her eyes, or her calling you by your nickname all set in motion a series of events in your brain that creates a ‘pleasure construct’. We have several of these pleasure constructs, triggered by a fond memory, shopping, food, a favorite sports team, etc. Once activated, these produce a normal release of dopamine in the midbrain. Drugs, however, initiate a massive release of dopamine into the midbrain, way more than the brain was ever intended to handle.
The midbrain sends signals to the rest of the brain that this drug is great and floods the pleasure circuit with dopamine. This is where those who are genetically predisposed to addiction get set apart. In about 10% of the population, sometimes quickly and sometimes over longer periods of time something critical occurs: addiction.
What is Dopamine?
Dopamine is the pleasure neurotransmitter. When we experience something pleasurable the midbrain releases dopamine that tells the brain “this is good, and I like it.” This is also called the pleasure circuit.
What is Glutamate?
Glutamate is the memory neurotransmitter. Once the midbrain releases dopamine (“this is good and I want it”), then the prefrontal cortex releases glutamate to say, “remember this and go get it.”
When this balance works properly then we enjoy life appropriately. However, addiction wrecks this balance.
What is the midbrain?
The midbrain is one of the more primal areas of the brain. Think back to our Neanderthal ancestors. It’s reflexive and sub-conscious. It is part of the survival matrix, telling us to eat, fight, flee, and procreate. The process of reward, pleasure, and emotional processing starts here but also involves many other areas. In addiction, the midbrain hyper-prioritizes the drug. In its primal way, with its massive releases of dopamine, the midbrain says to the rest of the brain that the drug is now more important than anything else, including food, health, family, sex, God, etc. The drug becomes the primary focus of the brain.
What is the prefrontal cortex?
The prefrontal cortex is a rather recent development in the brain, appearing in primates about half a million years ago. This is the area of the brain that humanizes us in the highest sense. It is where wisdom originates; it is also responsible for decision making, anticipating consequences, our ability to love others, and even have spiritual experiences.
In a normal functioning brain, the prefrontal cortex executes choices and serves as a governor to more primal drives. Therefore, we do not seek to have sex, eat, or fight all of the time. The midbrain serves its purpose of providing survival drives and indicating when an experience is pleasurable. However, it is the prefrontal cortex that has the final decision-making power as to how these drives are fulfilled.
In addiction, this balance is destroyed. The midbrain takes over and overrides the critical thinking areas of the prefrontal cortex. This disconnect explains the destructive, tragic and often incomprehensible behavior of addicts and alcoholics. Addiction breaks down every area of brain functioning and processing. The ability to think is tragically compromised. Even the addict often struggles to comprehend the chaos.
…so why don’t they choose to stop?
The answer is uncomfortable and disturbing, but undeniably true: they have lost the ability to choose freely. They are at the mercy of a primal brain drive that is saying the drug is the most important thing in life.
This explanation is not an excuse. It is simply an explanation of what is happening and is also why the necessity of entering treatment is vital, where freedom to choose can once again be restored.
Almost everyone, at some point in their life, has taken a drink of alcohol. There is nothing wrong or harmful with that slight dopamine surge, at least initially. A person genetically predisposed to addiction, however, experiences the surge, and that pleasurable sensation gets locked in by other areas of the brain in ways that do not occur in the non-addict. The misguided power of the midbrain surges through the entire pleasure circuitry of the brain and drugs and alcohol become the dominant drive.
Their brain has become wired for drugs or alcohol. It has built a pleasure construct around the use of alcohol. The prefrontal cortex has memorized sights, sounds, and smells into this warped pleasure construct, paving the way for triggers in the future.
This is an unconscious brain drive that takes over the life of the addict.
What began as a disorder of pleasure ends in a catastrophically impaired ability to choose. Note what came first. The tragically bad choices are the result of underlying brain dysfunctions. The brain is diseased and broken, at some very fundamental levels.
Addiction has wrecked the freedom of choice.
What is craving?
Craving describes both the physical compulsion to use and the mental obsession about using. The addict’s life revolves around drugs. Even when they are functioning in a fairly normal way, i.e. taking care of normal daily tasks, they are still thinking about drugs. This obsession may take the form of longing and planning for the next high, or even wrestling with the desire to not use. It’s all a form of craving.
The craving in addiction is much more severe, overwhelming, and debilitating. Imagine not eating for three days and then trying not to think about food. At that point, your midbrain would be screaming for food! The addict has the same obsession with their drug, every day, because the midbrain has declared the drug to be #1.
What is denial?
Denial is often the most maddening part of addiction to the outsider. Everyone around the addict sees the toxic behavior and consequences. The addict often does not see it that way at all, or, if they do, only fleetingly and through a haze. Denial is why the addict is usually the last person to recognize the depth and seriousness of a problem.
Again, this is a reflection of what is happening in the brain. The pleasure circuitry of the brain is desperately trying to protect its unobstructed access to the drug. Addicts often appear to have a relationship with their drug of choice, as if it is their best friend. Essentially that is what their brains are telling them.
What is pleasure blindness?
Pleasure blindness is the inability to enjoy formerly pleasurable experiences. Addicts can get to the point where they feel depressed and utterly numb to ordinary and important pleasures; like family, hobbies, art, music, and beauty in nature.
This is an outward reflection of the twisted inner chemistry of the addicted brain. In a normal brain, typical dopamine surges, such as enjoying family time, “reach” the pleasure set-point and register as enjoyable events. However, repeated dopamine floods from drinking or using drugs raise the set-point so impossibly high that only the drug provides any sense of fleeting pleasure. Ironically, in later addiction no amount of alcohol or drugs brings pleasure. The addict then begins to use or drink in a desperate attempt to feel normal or simply to feel nothing.
So again, we can see how lower brain dysfunctions have compromised the higher functions of choice. The prefrontal cortex, that executive part of the brain that polishes our humanity, has been set aside.
Do you still believe that addiction is not a disease?
Addiction is a combined genetic and stress-induced defect in the midbrain and prefrontal cortex dopamine/glutamate reward-learning system, resulting in symptoms of decreased functioning, namely:
- Loss of control
- Persistent use of the drug/behavior despite negative consequences
Understanding the devastating effects of addiction on the brain should help you understand why “choice” alone is inadequate. In fact, you can take away alcohol from the alcoholic and all you’ll have is an angry, irritable, unhappy alcoholic. He will still crave alcohol, and that is truly a miserable experience. Treatment gets to the underlying brain dysfunctions. It helps the alcoholic manage stress. The normal pleasure circuitry comes back “online.” True freedom of choice can be restored.