DEAR DOCTOR K:
My brother has struggled with addiction for years. I’ve told my husband that addiction is a disease, but he claims my brother is weak and lacks willpower. Is he right?
There is a lot of stigma and shame associated with addiction. But the truth is, people with substance-use disorders aren’t simply weak or immoral. It surely is true that people who try out illegal addictive drugs for recreational purposes are breaking the law. In my opinion, they also are doing something profoundly stupid. But they’re often teens, who tend to do a lot of stupid, impulsive things. Moreover, many people who become addicted to legal drugs were started on those drugs by their doctors.
The most important point is that addiction has a biological basis. Addiction impairs the brain in many important ways. I spoke to my colleague Dr. Michael Bierer, an internist at Harvard-affiliated Massachusetts General Hospital, about this topic. We discussed a recent review article in The New England Journal of Medicine about the “brain science” of addiction and its management.
Here are some of the highlights:
- An addicted person’s impaired ability to stop using drugs or alcohol has to do with deficits in the function of the prefrontal cortex. This is the part of the brain responsible for self-monitoring, delaying reward, and integrating messages from the intellect (reason) and libido (pleasure center).
- The prefrontal cortex is not fully developed in adolescents and is particularly vulnerable during this time. The earlier the brain is exposed to a drug, the greater the potential for damage. Adolescence is a time when caution and intervention may prove most valuable, but it’s also the time when it’s hardest to influence a person’s behavior.
- Once addiction sets in, which may be very early in experimenting with an addictive substance, the emotional response when a person is deprived of the drug is usually extreme negative emotion, a reaction that is “hard-wired” in the brain.
- In a particular setting, the strong association of learned environmental cues (for instance, seeing the corner where a person’s dealer can be found, or entering the doctor’s office for re-evaluation of chronic pain) intensifies the craving for the substance.
- What’s more, the brain releases a flood of intensely intoxicating brain chemicals, called neurotransmitters, during drug use. This is called the “reward pathway.” This makes the brain relatively insensitive to “normal” sources of pleasure, like a conversation with a good friend or a beautiful sunset. And it makes the brain focus all of its attention on obtaining the addicting substance.
This brain science is helping to shape treatment strategies. Medications such as methadone and buprenorphine can stabilize cravings. This gives the reasoning part of the brain a chance to get back in shape and kick in. Once cravings are under control, a person may be able to develop alternative sources of joy and reward in order to avoid the cues that set off cravings.