Understanding Addiction and Recovery
By Thomas G. Beley, PhD, LCSW
Neurobiology, Behavior, and Addiction
The addictive disorders have probably been one of the most confusing and elusive disorders to treat over the years. There is no other disorder that has created more confusion or controversy, or for that matter, debate as to what needs to be done for someone suffering from addiction. However, in recent years there is a continuing emergence of research in the field of the neurosciences that is gradually shedding light on how to treat this life threatening illness.
The fact of the matter is that we all have the genetic make up to become an addict whether it is with alcohol, drugs, food, or some other compulsive habit. Yes, all of us. However, the big question remains as to why do some of us become addicted and others don’t. How is it that someone is able to put down their drug of choice or obsessive habit and move on with the rest of their life while another person continues to spiral out of control? And, probably an even more relevant and practical question to ask is just how is that some individuals suffering from an addictive disorder are able to engage in a successful recovery process while others are doomed to repeated relapses and increased suffering. The answers continue to evolve; however, research has been able to shed some light on some of these often asked questions. One of the answers appears to revolve around a person’s behavior and neurobiology.
In order to grasp a basic understanding of the addictive process and the recovery process, it is necessary, first, to take a closer look at how our mind, body, and behaviors work together. Although genetics do play a role in the addictive process, there are a number of other influences that are just as important to understand. One of those influences is that of understanding the relationship of neurobiology and behavior. Understanding the role of the mind, body, and one’s behavior in the addictive process can provide extremely vital information in understanding the ingredients of a successful recovery.
Pain and Discomfort
Research has shown that the pain sensors in our body outnumber the pleasure sensors by a ratio of ten to one. Our body does not like any type of pain or discomfort whatsoever. In essence, our body is hardwired to avoid any pain or discomfort at any cost. As a result of this hardwiring, our body, or more succinctly our brain, has the ability to offset this discomfort and pain through a series of biochemical processes that produces a number of neurotransmitters that are intended to give us a sense of pleasure and well being. Remember that tedious, boring day at work. Well, that daydream about the wonderful experience you may have had about the night before or those thoughts of what you might be doing after work produced enough neurotransmitters of well-being in the brain to take the edge off, sort to speak, in order to get through the rest of the day and to accomplish the tasks at hand. In essence, the mind and the body work together in creating a harmonious balance. If the brain senses an imbalance of the presence of too much pain in the body, it is ready to produce enough neurotransmitters of well-being to try and off-set that pain. A good example of this is the so called “runners high.” It has long been documented that long distance runners and marathon runners will experience euphoria after a period of time as a result of the production of endorphins and other neurotransmitters of well-being in the brain. Although this mind-body connection seems to make sense, the question still remains as to how all of this is related to addiction and recovery.
The problem appears to arise when the brain begins to produce too much of these neurotransmitters of well being. Although there are a number of neurotransmitters that have been implicated in the addictive process, dopamine seems to be one that has received special attention. Dopamine is one of those neurotransmitters that give a person an intense feeling of well being and pleasure. Although these neurotransmitters are a natural function of the brain to offset discomfort, it is a person’s behavior that can also manipulate our body’s dopamine production. For instance, food can raise dopamine levels by as much as 25%. The term “comfort food” takes on a whole new meaning. How many times have you reached for that piece of chocolate in times of stress for a sense of relief? Sex increases our dopamine levels by as much as 50% which may account for a growing preoccupation with sexuality and pornography. Internet pornography is one of the fastest growing addictions in our society today. In essence, any behavior that a person engages in that produces pleasure is also producing dopamine as well as other neurotransmitters of well-being in our body.
Feeling Good May Not Be So Good!
So, what is the problem with feeling good? The problem does not lie with the sensations of feeling good. Everybody needs to feel good. In fact feeling good is the driving force of human motivation. We need to feel good. The problem lies with what the excessive amounts of dopamine that are being produced in our brain in one’s quest to feel good that can be a problem. Research has shown that excessive amounts of dopamine in the brain actually impair the orbital frontal cortex, the thinking part of our brain, to where our judgment becomes impaired. Think of the times that you had ever taken a risk in your life. In many of those instances, not all of course, you were feeling very confident and secure in your decision. In essence, you felt great about making that decision. How many times after taking that risk, you said to yourself, “What was I thinking?” or “I don’t know what happen. I wasn’t thinking.” In fact, you probably weren’t. It was likely the dopamine affecting your judgment. Not that the impairment is necessarily all that noticeable at first, particularly if we are eating that piece of chocolate or slice of pizza to feel a bit of comfort. The fact remains there is some degree of impairment due to the flow of dopamine to the thinking part of the brain.
Drugs of Abuse
Now when it comes to drugs of abuse, it becomes a totally different story. Drugs of abuse begin to set a whole new standard for pleasure at least initially. Marijuana increases our dopamine levels by as much as a 150%; cocaine by as much as 300%; and the grand daddy of them all, “crack” cocaine and methamphetamines (crystal meth), by as much as 1100%. It is no wonder that people have become dependent on these substances for a source of pleasure. The payoff is rapid and effective. What we are talking about now is a tidal wave of dopamine flooding the thinking part of the brain to where the thinking part of the brain begins to lose all sense of judgment, sound decision making, and control. Literally, this tidal wave of dopamine begins a process of breaking down the control functions in our brain to the point a person is not able to determine when enough is enough. In all actuality, it is at this point, the brain begins to focus on more not nearly being enough.
The Addictive Process
The addictive process potentially starts when the brain gets that intense feeling of pleasure from the influx of dopamine neurotransmitters. Whether it is from a substance, like chocolate or cocaine, or even from a behavior such as gambling or exercise, or for that matter the adulation that one might get from the success of a job well done, the brain senses this increase in dopamine and begins to regulate and compensate for this new found source of pleasure. In essence, the brain begins to cut back on the natural production of dopamine that the person may have been experiencing previously from other areas of their life such as family, friends, and hobbies. The problem begins when that new source of pleasure begins to wear off. Let’s take for example the person who comes home from a stressed out day from work. That person may have a glass wine to “take the edge off.” On face value there appears to be nothing wrong with this. In fact, it is estimated that there are tens of millions of Americans that do this every day. Even the American Medication Association has stated that one glass of wine per day for women and two glasses of wine for men has potential health benefits. What they didn’t tell you is that if this glass of wine is the only source of pleasure for a person the likelihood of that person developing an addictive disorder increases greatly regardless of genetics. Furthermore, this same process works exactly the same with people who may be getting intense pleasure with other outlets such as exercise, work, or some other compulsive activity such as gambling, having extramarital affairs or internet pornography.
The nature of the problem begins if this activity and source of relief is a person’s sole source of stress relief or dopamine for the person. The key factor here is the person is relying, or becoming dependent upon, only one source of dopamine to deal with their discomfort. It is at this point that the addictive process works in a relatively simple manner. Let’s say that a person develops a dependency on certain behaviors to relieve stress such as having that glass of wine after a difficult day at work, or going to the gym, or shopping for that special new outfit, etc. Again, on face value, there doesn’t appear to be anything wrong with this. The problem occurs when this behavioral “quick fix” begins to wear off. Once that pleasure wears off, what is the person left with? Remember that the mind and body have already been in a process of compensating for this new source of dopamine. When the “quick fix” wears off, the person is left with a diminished capacity of natural dopamine which renders previous sources of pleasure seriously lacking. Past behaviors and activities that once produced a modicum of pleasure, just doesn’t simply feel as good. However, a more important element that evolves is the fact that the person is more aware of their pain sensors and discomfort. Since it is inherent for all humans to avoid pain and discomfort, the tendency is for the mind and body to work in simpatico in trying to get the relief to quiet these pain sensors. Research has demonstrated that there is a vertical integration that takes place in the brain whereby the communication that is constantly taking place between the higher executive functions of the brain and the lower more primitive instinctual parts of our brain becomes impaired. As a result, one part of the brain senses the pain and discomfort and another part of the brain is letting us know how to effectively relieve that discomfort. Unfortunately, the mind and the body have already established a fast and effective fool proof way of relieving pain and discomfort. A person’s pattern of behavior has a tendency to become engrained in certain neuronal pathways of the brain. In a way, a person develops a “knee jerk” response to the pain. So one piece of chocolate becomes two, one cocktail leads to two cocktails, smoking a joint after work to relax leads to smoking a joint before work to relax, and the cycle deepens and becomes more engrained in both the mind and the body.
Drugs and Alcohol Are Not the Problem, They Have Been the Solution
In most instances, genetics notwithstanding, people stumble into the addictive process. Although some may be more genetically predisposed and arrive at a much faster pace given their genetic makeup, the process of addiction remains pretty much the same for all humans. One of the interesting phenomena’s in our culture is the preoccupation and fascination that our youth has with experimenting with substances. Although it can be argued that our society has glamorized the use of drugs, alcohol, nicotine, and other behaviors, this argument doesn’t necessarily hold true completely since this seemingly has been an aged old phenomena. The National Institute of Health estimates that approximately 85% of all adolescents are experimenting with drugs and alcohol. These statistics have not changed for the past twenty years. The question is no longer whether my kid is drinking or drugging, the more accurate question maybe whether my kid is going to weather the storm and not get trapped in the engrained patterns of neuronal activation in the brain that promotes the behaviors that lead to the gene activation of a person propensity toward addiction.
One of the answers to the phenomena appears to go back to the pain sensors that we all have. As previously stated, humans are hard wired to avoid pain and to experience pleasure. Undeniably, adolescence is without question an extremely turbulent time for an individual. Given even an ideal living situation, an adolescent still has to struggle with hormonal changes, changes in brain development, the struggle with independence, the desire to establish a sexual identity, just to name a few, which all contribute to a great deal of stress which in turn triggers a person’s pain sensors and level of discomfort. Now we add in certain external influences such as divorce, blended families, economic relocation, poverty, peer group pressure, a lack of education, trauma, and a general need to fit in and now the pain sensors are not only exposed but are conceivably being rubbed raw. This is usually the time that a person begins to experiment with substances. And the start of this use is usually not directly associated with the discomfort the person may be experiencing. Typically the introduction of drug and alcohol use is innocent by itself. It usually starts with curiosity or what the person has been exposed to via the peer group or family. However, the result of this innocent curiosity renders an immediate effect. The adolescent feels good and in some instances euphoric. The person finds an instant solution to their discomfort. Although some would argue that their first experience with drugs and alcohol was not necessarily a pleasant one, the pleasure the person derived from fitting in or being a part of a peer group was undeniable. In either case, the person found a way to feel good. The person found a dopamine source that was immediate and effective. As a result, the person begins neglecting parts of their life, as well as their own personal development, in favor of “feeling good.” The potential end result of this process is that the person begins to avoid or cut off more stable natural sources of pleasure that come from life goals, relationships, family and career, just to name a few, in lieu of something that can give them immediate and spontaneous gratification.
This process would also seem to explain why some people develop an addictive disorder later in life. Some would argue that adolescence is not the only turbulent and stressful time in one’s life. Some would say that as we get older, life presents itself with a whole new set of challenges and complications that has the potential of creating even more stress and discomfort. For some, latter life can bring a well experienced past of how to deal with pain and discomfort making that person even more prone to continuing their addictive behaviors. For others, latter life can also allow for more financial stability, at least initially, indulging in activities, behaviors, and/or in substances that create that same “feel good” experience. However, it also opens the door for a person to neglect those challenges that can ultimately give a person a better quality life style.
The Pre-Recovery Process
The recovery process doesn’t start when the person stops drinking, drugging or engaging in their addictive behaviors. It doesn’t even start when that person enters into a treatment program or begins attending 12 step meetings. Nor does it start when a person has admitted to themselves and another that their life has become unmanageable and out of control due to their drinking and drugging and are in need of help. At best, this needs to be considered pre-recovery. This is the time when a person is only “thinking about recovery,” and those words need to be used loosely considering the state of a person’s neurochemistry in the orbital frontal cortex of the brain. In reality, the person simply is sick and tired of being sick and tired. The person is tired of suffering, tired of feeling the pain since their drug of choice has long since stopped working, and feeling the impending doom of their past decisions and choices. When a person makes a conscious decision to stop their addiction, this is not a change, this is a thought. True recovery begins when the person is willing and able to begin to take steps and actions towards making behavioral changes in their respective lifestyle as it relates to relationships, friends, family, career, health, and spirituality.
The Recovery Process
A test question that can be posed to a person who is in recovery is whether they believe they have control over a future relapse. If the person answers yes, then they have potentially failed a crucial part of the of the recovery process. Why? The answer lies in the fact that addiction is an illness. The person doesn’t have any more control over a relapse (getting sick again) than a person does over getting the flu. However, does a person have control over strengthening their immune system in order to prevent oneself from getting the flu? Definitely! What can a person do? The list is virtually endless, flu shots, washing one’s hands, vitamins, staying away from people who are sick, even chicken soup. Let’s pose the same question with recovery. Can a person do something for their recovery in order to prevent a relapse? Absolutely! And, again the list is virtually endless, attending 12-step meetings, working the steps, therapy, exercise, obtaining a sponsor, staying away from other people who are “sick,” engaging in health oriented activities.
Often when a person is asked the question of what they are going to do to avoid drinking or drugging or preventing a relapse, it is not uncommon to hear the words, “I am not going to pick up” or “I’m never going to drink again.” Although this is a good position to take, it is a little bit like a person saying “I am not going to get the flu again.” Needless to say, this is not very realistic and more importantly it is not enough considering the neurochemistry of the mind and body. The key ingredient here is for a person to begin to take action and begin to make behavioral changes in key areas of their life. It is the behavioral changes that can inoculate the person against a relapse by increasing the dopamine and other neurotransmitters of well-being in the brain.
Healing the Mind, Body, and Spirit
A person in treatment once said to me, “Why are you on my case all the time. I am not doing anything wrong.” I said to the person, “You are absolutely right. You aren’t doing anything wrong. But, again, you aren’t doing anything right for your recovery either.”
In order to effectively assist a person to develop an effective recovery plan, it is important to first develop a plan of action as it relates to mind, body, and spirit. In other words, what is it that the person is going to do on a daily basis to protect themselves against the disease? What behavioral activities or actions is that person going to do for their mind, for their body, and for their spirit each day? The importance of these planned activities is that it creates a number of protective therapeutic measures for that person.
To begin with, these planned activities provide a necessary structure that has been missing in a person’s life. Since the thinking part of the brain is still not working at its optimum level, the person is less prone to their attention deficits, which is extremely common in the early part of recovery, as well as falling back into old patterns of behavior. As many of the 12 step programs espouse, “Keep it simple.” By keeping it simple, a person can easily monitor whether they did that planned activity or not. As is often the case, relapse occurs well before a person begins using again. It usually begins when the person stops doing the things that were effective for them. When a person stops doing that daily activity, there is a good chance that person is beginning the process of relapse.
New Sources of Dopamine
Individuals in the early part of recovery are also going to experience a great deal of pain and discomfort. This discomfort, as previously mentioned, has been the result of the massive amounts of dopamine and pleasure the person has been used to getting. The brain in the early part of recovery is not too different than a very hungry 10 year old child who hasn’t eaten all day long. At the end of the day, the child is offered to choose between a big bowl of green beans and a big bowl of ice cream to satisfy their hunger. Which one are they going to choose?
Research has demonstrated that the use of substances leaves the natural dopamine resources of a person depleted. Studies have shown that these dopamine receptors can remain depleted for as much as two years as is the case with individual’s addicted to “crack” cocaine and methamphetamines. Although other studies have suggested that the increased functioning of dopamine receptors can be brought back on line in the brain much quicker via behavioral stimulation and change, a sense of well-being may take a little time to evolve.
One of the interesting paradoxes in the recovery process is that the new source of dopamine may very well come from the old sources of pain and discomfort, namely our relationship systems. As previously mentioned, a lot of one’s pain and discomfort comes from one’s life experiences as it relates to, not only to personal experiences, but also to one’s interpersonal relationships, family relationships, social relationships, professional relationships, as well as our health and spiritual make-up. However, it also needs to be realized that it is these same areas that have the potential to provide a person with an unlimited source of well being and pleasure. The development of these areas has the potential to be the new dopamine source.
The problem that occurs is, often, these areas have been seriously neglected because of the addictive behaviors over the years or, in the case of people who have been addicted since their early teens, these areas have never really been developed at all. However, it is all of these areas of a person’s life that has the unlimited potential to increase self-esteem, provide a natural network of support, and to provide a person with a real an on-going sense of belonging, nurturing, and love. As a result, a person newly into recovery has a mountain of work ahead them. As a person once said to me when they came into treatment, “I came into treatment because my life was miserable and unmanageable. Now that I am clean and sober, I realize that my life is even more miserable than I thought but I know it can be more manageable. There is a light at the end of the tunnel. I know what I need to work on in order to get better.”