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Medical and public health professionals have gained a more sophisticated understanding of how substance abuse changes the chemistry of the brain as more research is conducted on the science behind addiction and recovery.
The neurological evidence shows that vulnerability to addiction to certain drugs and alcohol is in part a genetic disease known as substance use disorder, experts say.
About 15% of the U.S. population is believed to be predisposed to develop an addiction from substance abuse on a sustained basis. For some, drugs and alcohol rewire part of the circuitry of the brain in a way that can severely impact cognitive ability. It can drive the cravings and the compulsion to use and drink that consumes a person, even among those who can make sound decisions in other areas of their life.
“There are brain changes that go on with any drug that activates neuroreceptors in the brain that the body will respond to,” said Kenneth Leonard, director of Clinical and Research Institute on Addictions at University at Buffalo. “If that happens regularly for long periods of time the brain will change structurally to try to minimize that impact. Then when the drug is no longer there the brain says, ‘Hey what happened? You’ve changed conditions dramatically on me.’”
The heightened understanding of addiction has helped shift public perception about the problem stemming from a moral failing or character flaw. It’s also fueling efforts to offer treatment options rather than law enforcement punishment to those who spiral out of control.
“There’s still plenty of stigma,” said Leonard. “There are still plenty of people who think all you need is willpower to overcome an opioid addiction. In most instances that’s just not the case.”
As much as biochemical research has advanced, so has the understanding of how social and behavioral factors influence an addict’s ability to stay sober. It all adds up to an extremely complicated condition for health professionals to address, one that requires a treatment plan carefully tailored to individual needs.
“You don’t cure addiction — you manage it,” said Caleb Banta-Green, principal research scientist at University of Washington’s Alcohol and Drug Abuse Institute. “You manage it actively with counseling. You need to create a new life and a new way of interacting with people in a way that is healthy for you.”
Scientists say there are myriad factors that affect the severity of a person’s response to drug and alcohol abuse.
People who start using alcohol at a young age often have a different response than those who wait until their later teens or early 20s. The rate of a person’s metabolism also makes a difference in the way a body processes alcohol. The faster a person’s engine runs, the faster the brain says “more” to stimulants. People who were exposed to trauma, stress and instability early in life have often have a more extreme response than others to alcohol and drugs.
“Exposure early on can turn on genes that would not be turned on if you had waited until later,” said John Kelly, director of the Recovery Research Institute at Massachusetts General Hospital and a professor of psychiatry at Harvard Medical School.
Researchers are studying the brains of addicts in an effort to have an “early warning system” for people, he said. “The challenge is that it’s complex. We’re talking about configurations of 80-100 genes.”
As the genetic picture is slowly coming together, there is also increased documentation of the importance of an individual’s family and friends in providing support networks to keep addicts in long-term sobriety. Kelly calls it “remission.”
Studies also show that substance use disorder is frequently a response to trauma and pain for people who reach for the numbing effect of mind-altering substances. Banta-Green and other researchers emphasize the need for counseling and support systems to help addicts in recovery handle ups and downs without self-medicating.
“A big part of recovery is people learning positive coping tools for dealing with physical and emotional pain,” Banta-Green said. “So many people use so many substances to deal with bad feelings. We have to recognize that trauma is a major driver of a lot of addiction problems.”
And those problems often go hand in hand with depression and other mental illnesses. For some, the urge to drink and use is reinforced by having a powerful emotional response to the high.
“Some find it to be a very profound experience — the missing link for them that is almost like a spiritual experience,” Leonard says. “For those people there is a powerful reinforcing value that they get from alcohol.”
Researchers are also increasingly focused on how brain chemistry changes for people in long-term recovery.
The first year of recovery is the hardest for addicts to stay sober, experts say. One-third of those who make it through the first year will relapse in year two.
“It takes a long time for the central nervous system to recalibrate and for lifestyles to change,” Kelly said.
After four to five years of sobriety, however, Kelly says most people in recovery are no more likely to have a relapse than those in the general population are of developing a chronic alcohol or drug problem — about 15%.
Banta-Green cited the breakthroughs in medical treatments for opioid addiction as a good catalyst for radically changing the public health approach to treating addiction.
A number of different drugs have been shown to help ease the withdrawal pains and dramatically lower the chance of death in opioid addicts. Banta-Green hopes to see those drugs made available free to users who request them as a first step toward a comprehensive treatment plan.
Banta-Green cites the results of a pilot program in Seattle where anti-opioid drugs were offered to users at the site of a needle exchange program. The response was overwhelmingly positive. Studies in the U.S. have shown that the use of anti-opioid medications such as buprenorphine have cut death rates from overdoses by 40%-60%. France has made such medications widely available in recent years and seen the mortality rate drop by nearly 80%, Banta-Green said.
In Seattle, “people started lining up earlier to get free treatment medications,” Banta-Green said. “If you think outside the box and act like you want customers, they will show up.”
Moreover, the cost of giving away drugs can’t be more than the toll taken by addiction-related issues on hospitals, law enforcement, criminal justice and the social fabric of neighborhoods.
“Untreated addiction is very expensive,” he said. “Instead of saying, ‘Here’s all the reasons why we have to do this the same old way,’ how about we make it easier to access treatment than it is to access illicit drugs.”