Definition: Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry.
- Addiction involves craving for something intensely, loss of control over its use, and continuing involvement with it despite adverse consequences.
- Addiction changes the brain, first by changing the way it registers pleasure and then by corrupting other normal drives such as learning and motivation.
- Although breaking an addiction can be challenging, it can be done. Recovery from addiction is best achieved through a combination of self-management, mutual support, and professional care provided by trained and certified professionals.
What Causes a Person to Become Addicted?
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 a standard U.S. diagnostic manual (the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition or DSM-V) 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.
Nobody starts out intending to develop an addiction, but many people get caught in its snare. Consider 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 3 drugs causing addiction are marijuana, opioid (narcotic) pain relievers, and cocaine
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. This happens as the brain goes through a series of changes, beginning with recognition of pleasure and ending with a drive toward compulsive behavior.
Pleasure and Reward
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.
The Brain’s Reward Center
Addictive drugs provide a shortcut to the brain’s reward system by flooding the nucleus accumbens with dopamine.
The hippocampus lays down memories of this rapid sense of satisfaction, and the amygdala creates a conditioned response to certain stimuli.
The 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 the process which motivates us to take action to seek out the source of pleasure.
Do You Have an Addiction?
Determining whether you have an addiction isn’t completely straightforward. Admitting it isn’t easy, largely because of the stigma and shame associated with addiction but acknowledging the problem is the first step toward recovery.
A “yes” answer to any of the following three questions suggests you might have a problem with addiction and should—at the very least—consult a health care provider for further evaluation and guidance:
- Do you use more of the substance or engage in the behavior more often than in the past?
- Do you have withdrawal symptoms when you don’t have the substance or engage in the behavior?
- Have you ever lied to anyone about your use of the substance or extent of your behavior?
Development of Tolerance
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 2 to 10 times the amount of dopamine that natural rewards do, and they do it quicker 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.
Compulsion Takes Over
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.
Persistent risk and/or recurrence of relapse, after periods of abstinence, is another fundamental feature of addiction.
This can be triggered by exposure to rewarding substances and behaviors, by exposure to environmental cues to use, and by exposure to emotional stressors that trigger heightened activity in brain stress circuits.
Recovery is Possible
It is not enough to “just say no”; as the 1980s slogan suggested. Instead, you can protect (and heal) yourself from addiction by saying “yes” to other things. Cultivate diverse interests that provide meaning to your life. Understand that your problems usually are transient, and perhaps most importantly, acknowledge that life is not always supposed to be pleasurable.
In some cases of addiction, medication management can improve treatment outcomes. In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results. Chronic disease management is important for minimization of episodes of relapse and their impact. Treatment of addiction saves lives.
Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction. As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery.