Why the addiction-brain connection has to be part of the addiction treatment picture

Dr. Dodes recent article, apparently trying to blow up the myth of addiction as a neurophysiological disorder, sounded persuasive, although its underpinning was oversimplified and it’s understanding of the brain-science involved in addiction, and other associated mental health disorders, was lacking. Hopefully, by presenting a more complete picture of the evidence for a brain-aspect to addiction, I can un-bias the discussion somewhat. I, for one, don’t believe that neuroscience will ever be the only factor important in addiction – an individual’s environment, social influences, and other factors will always end up playing important parts as well – still, I think that to dismiss all of the evidence for biological factors at play in the development of addiction is foolhardy. Especially when there’s so much of it that was glossed over in Dr. Dodes’ introduction.

Pleasure center activation is only part of the picture in addiction

Firstly, supporters of the notion that addiction is, at least partly, an outcome of specific brain function point not only to pleasure center activation, but also to a whole host of findings showing genetic variability that is either protective from, or a risk factor for, dependence on drugs and likely also behavioral addiction like eating disorders, compulsive gambling, and maybe sex addiction as well (you can start out looking up ALDH2-2 variability and alcoholism and cocaine addiction, DRD4 and stimulant addiction, and many more).

While it is true that all those who consume addictive substance activate the brain similarly, there are considerable differences in the specific of that activation in reaction to drugs. Some release more dopamine while others have more “active” versions of specific important receptors; neurotransmitter recycling is quick in some, but not all, and drug metabolism is different in different individuals in ways that have been shown to be important not just for addiction risk, but also for the probability of treatment success. Just look at the nicotine and CPY26 literature for an example. It’s right there.

Additionally an entire body of literature exists that shows differential activation, as well as structural differences, between addicts and non-addicts in regions as varied as the OFC, PFC, Insula, and more. This is not to mention a slew of evidence that shows different behavioral test performance on risk-taking, impulsivity, and delay-discounting, all personality variables highly associated with addiction. If one simply ignore all of this evidence, it may be easy to believe that there is no biological explanation for these phenomena, but that’s just wrong.

To say that mesolimbic activation (what the good doctor called “pleasure centers”) is the only evidence for physiological factors in addiction is dismissive at best.

Drug addiction develops in only some drug users

The notion that not everyone who takes drugs becomes addicted is nothing close to evidence against a brain explanation for addiction. Everyone’s motor–cortex, striatum, and substantia nigra (the areas of the brain responsible for movement) activate in the same way during movement, but only a small group ends up suffering from Parkinson’s or Huntington’s disorders. One fact does not preclude the other but instead may specifically point to the fact the group which develops the disorder has somewhat different neurological functioning. Researchers aren’t concerned with explaining why all individuals can become addicted to drugs, but rather why that small subgroup develops compulsive behavior. A short reading of the literature makes that fact pretty clear. Additionally, while Dr. Dodes’ claims otherwise, imaging technology HAS produced evidence explaining this “mystery”, including differences in the ways addicted smokers respond to smoking-related triggers, and an increased dopamine response in cocaine addicts to cues, and well as to cocaine.

As mentioned in the motor disorder section above, ingestion of chemicals is not at all necessary for brain disorders to occur or indeed develop later in life. Dr. Dodes example of shifting addiction could be used as evidence for an underlying neurological difference just as well as it would serve to make his point… Or even better. If there’s a faulty basic mechanism attached to rewarding behaviors, it doesn’t really matter what the behavior is, does it? Sex addiction, gambling, and more can all be explained using a similar mechanism, though drugs of abuse may just have a more direct impact. I know, I’ve written about them all.

The Vietnam vet heroin story used by Dr. Dodes as evidence that emotional, rather than physiological, factors are responsible for addiction actually fits right in line with the notion of predisposition and underlying differences, and I’m surprised to hear a physician point to group differences as an indicator of no neurobiological basis. Indeed, when it comes to the emotional reactivity associated with drug associated cues, normal learning literature, as well as drug-specific learning research, has revealed over and over that drug-related stimuli activate brain regions associated with drug reward in the same way that natural-reward predictors do for things like food and sex. Once again, these facts are part of the basic understanding of the neuroscience of learning, with or without drug abuse involvement.

My own dissertation work shows that it is very likely that only a subsection of those exposed to nicotine will develop abnormal learning patterns associated with that drug. However, among those, learning about drug-related stimuli (as in “triggers”) continues in an exaggerated manner long after the other “normal” animals have stopped learning. That sort of difference can lead to a seriously problematic behavioral-selection problem whereby drug-related stimuli are attended to, and pursued, more so than other,  non-drug-related ones. If that sounds familiar, it should, since drug users continuously pursue drug-associated activities and exposures in a way that seems irrational to the rest of the world. It just might be due to such a mechanism and others like it.

Some important points about science in Dr. Dodes’ article

One very true fact about mental health pointed out by Dr. Dodes is that diseases like schizophrenia, which used to be explained simply as demon possession and evidence of witchcraft can now be, to a large extent, explained by the study of behavioral neuroscience and cognition. The same is true for bipolar disorder, depression, ADHD, and a host of other such conditions. In fact, the study of psychology has only been able to rely on technological advances that allow us to “see” brain function for a few short decades, leading to incredible advances in the field that I think will continue. The thinking that no such advances have, or will continue to be, made in the study of addiction is, in my opinion short sighted.

As I mentioned above, I don’t for a second think that the entire explanation for drug abuse and addiction will come from neurophysiological evidence. The doctor points out that “If we could take a more accurate image of addiction in the brain, it would encompass much of the history and many of the events that make us who we are.” I agree that we need to advance our technology as well as expand our understanding, but I think that to discount neuroscientific explanations completely is a big mistake.

About Addiction: Drug use, Addiction Recovery, and smoking

We’re back with our weekly post about addiction news and research. We’ve got harm reduction in Australia, heroin ads that don’t work, the impact of drug abuse on children, and more. Get your 30 seconds of education for the day.

Using Drugs – Heroin, HIV, the law, and recovery

The Australian– There is a state approved heroin injecting room in Australia. The center opened to create a safer place for drug users to shoot heroin. 3500 individuals have overdosed on the premises without a single fatality, making for a very interesting way of combating drug addiction that would definitely fall under that harm-reduction model American hate so much!

Star Advertiser– When it comes to scaring individuals into not using drugs, specifically heroin, fear appeals do not seem to work in preventing future drug users. Fear appeals ads show drug users as violent, and often have missing teeth or skin problems. Apparently, audiences are smart enough to see these as not really representative of heroin users in general and they’re not buying it, making the ads useless in combating drug addiction.

Global Development– Eastern Europe and Central Asia have the fastest growth rate of HIV infection in the world (Russia accounts for between 60% and 70% of the epidemic). This may be due to sharing dirty needles when using drugs and the biggest problem is likely lack of prevention efforts for high risk groups.

Guardian– A senior police officer from Britain thinks that individuals should not be criminally prosecuted for possessing marijuana. By focusing less on drugs found among youth the police can focus on things they see as more important like hard core criminals. I’m sure our legalization friends will love this, although again, this isn’t legalization but decriminalization and parents will hate it.

Addiction Inbox– Meditation and exercise play a role in drug addiction recovery. Both methods apparently help to eliminate the panic and anxiety that plays a role in detoxification. Although it may not be the most popular method of recovery, we at A3 have already written about this and think you should give it a try!

Breaking the cycles–  A program called Partnership for a Drug Free America has five new drug programs in order to eliminate drug use among teens. These programs educate teens as well as their parents with a variety to drug information.

Smoking, pregnancy, and attitude

Science Daily- Women who smoke during pregnancy can hinder their children’s coordination and physical control (likely affecting boys more). Smoking during pregnancy can damage development in the fetal stage, so if you are expecting try not to light up (as our other post on pregnancy and smoking recommends).

Decoder– You are in for a good read on the changing attitudes of smoking. This blog gives an inside perspective on smoking and how it has evolved from the time it was considered “cool”.

Addiction’s impact on others

Philly Daily News- Addiction impacts not only the drug addict but their children as well. 15% of all children live in a household with an alcoholic and one in four children is exposed to a family member’s alcohol abuse or dependence. These children are often neglected when their parents are under the influence and that neglect can lead to some pretty terrible outcomes for the children themselves down the line.

Addiction Recovery– This is an excellent read on the importance of patience when it comes to addiction recovery. Rome wasn’t built in a day and neither will a drug addict’s wonderful new life. Recovery takes time so take a deep  breath and enjoy!

Alcohol – Blackouts, Brownouts and how they affect your body

Do you remember what you did last night? Have you ever not remembered what you did after drinking? Drinking alcohol affects the brain and can cause lasting damage including, but not limited to, slips in memory. These memory slips can be due to lack of blood flow to brain areas that are important for memory consolidation and are commonly known as blackouts. Contrary to what popular belief, blackouts often occur in social drinkers and don’t seem to be related to age or level of alcohol dependence.

 

Blackouts and the Blood Alcohol Content (BAC) rate

Amnesia, or memory dysfunction, can begin to occur even with as few as one or two drinks containing alcohol. However, as the amount of alcohol intake increases so does the probability of memory impairment. Although heavy drinking alone will not always cause blackouts, heavy drinking of alcohol on an empty stomach or “chugging” alcoholic drinks often does cause blackouts.

The estimated BAC (blood alcohol content) range for blackouts begins at levels .14%- .20%. Individuals who reached high BAC levels slowly experienced far less common occurrences of blackouts. Additionally, while blackouts lead to forgetting entire events that happened while intoxicated, some individuals experience an inability to recall only parts of an event or episode (these are often called brownouts).

Blackouts can occur to anyone who drinks too much too fast. In a survey of college students, males and females experienced an equal number of blackouts, although men consumed a significantly more alcohol.

Although brain damage could potentially occur from heavy alcohol consumption, there is no evidence that blackouts are caused by brain damage per se. However, if brain damage is caused from excessive alcohol use, some studies show improvements in brain function with as little as a year of abstinence. Regardless of the possibility of reversing any effects, alcohol use causes damage in different areas of the body (including the liver), and those damages have been shown to occur more quickly among females.

Co-authored by Jamie Felzer

 

Citations:

1. White, Aaron M., Signer, Matthew L., Kraus, Courtney L. and Swartzwelder, H. Scott(2004). Experiential Aspects of Alcohol-Induced Blackouts Among College Students, The American Journal of Drug and Alcohol Abuse,30:1,205 — 224

2. Alcohol Alert (2004) . Alcoholic Brain Damage. Alcohol Research & Health, Vol. 27.

Two forms of alcoholism: One which warrants a chronic disease model, and college

I respect Stanton Peele, if for no other reason than simply because he is well informed and doesn’t mind telling us all about the way he sees things. However, even the mighty sometime misstep, and this article is about what I see as one of Dr. Peele’s errors.

Why Stanton Peele thinks addiction isn’t a disease

In his recent post about why the disease concept of alcoholism, or addiction, is bull$&%# (his words), Dr. Peele decides to quote a piece from the NIAAA’s website that states that approximately 75% of people who’ve met the definition of alcohol dependence (read: alcoholism) in their lifetime quit by themselves without any outside intervention. That’s great, but what he forgot to also quote is another passage that states that while “70 percent of [alcoholics] have a single episode of less than 4 years, the remainder experience an average of five episodes. Thus, it appears that there are two forms of alcohol dependence: time-limited, and recurrent or chronic.”

Why Stanton Peele is a little right and a lot wrong

Maybe Stanton missed this sentence since it was a few lines above the one he was focusing on, but what it’s telling us is that the vast majority of people who meet alcohol dependence criteria do so for a very limited amount of time (seemingly their 4 years of college) while another 30% or so (or 25% according to the line Dr. Peele decided to use) have the chronic-relapsing version of alcoholism we’ve all come to know. I guess the question of what is substance abuse doesn’t have the simplest of answers.

So yes, most people quit without help, and as we’ve pointed out on this site before, most people who experiment with drugs never develop a problem with them. But the reality is that the remaining group has a hell of a time quitting and most of them need help and even then don’t necessarily respond to addiction treatment. I don’t know that this is very different from the percentage of people that eat too much and gain weight – some stop and return to a normal BMI, the rest become obese. The same story holds for the pre-diabetics who never quite cross that line but once they do, will need insulin and a strictly managed diet. In both cases I don’t think we need to discount the latter because the former exists.

I agree that this sort of nuanced observation is missing from the public discourse, and I think that it’s important to bring it in since it does something important – it lessens the stigma of alcoholism and addiction by showing us what is really happening without distortion. However, showing only the other side does little to improve the situation.

So in closing – most of those who meet the definition of alcohol-dependence should probably not be called alcoholics. Instead, they can be referred to a “Frat boys,” “Sorority girls,” or really “late teens to early adults.” However, there is a large enough group of people out there who really suffer with a condition that doesn’t go away when their first 4 year-long episode of hard alcohol use ends. They need addiction treatment and they’re the focus of most research on addiction and alcoholism, as they likely should be when it comes to treatment.  That other group, they just need to be careful not to get in a car accident or get pregnant too early.

That’s my take anyway.

 

 

p.s.

When people ask “what is substance abuse?”, they are probably referring to the former group most of the time, although based on our present definition, substance abuse per se is a diagnosis that is pretty easy to meet, which likely means both groups actually meet abuse criteria.

Is the drinking age getting lower and lower? Teenage alcoholism

How young do kids start drinking?We’ve already mentioned that kids tend to get in quite a bit of trouble during their teen years (see here). Well, adolescence is also a time when the brain is developing and therefore is at a high risk for damage, especially when alcohol abuse enters the picture.

Early use means more alcoholism later

While the risk taking can be playful and harmless, when it involves alcohol and drugs the consequences of use at an early age can be long-lasting. The earlier a person begins drinking the higher the reported rates of alcoholism later in life. During this time, when an adolescent’s brain is changing, they are less likely to be able to inhibit themselves, let alone anticipate the future. Those with hyperactive, disruptive, antisocial personalities are at the greatest risk for alcohol abuse at early ages, putting their already somewhat compromised brains at an even greater risk.

Teens, like adults, report feeling more at ease when under the effects of alcohol, which makes it easy to understand why they would want to continue. Less like (some) adults, teens rarely consider the negative consequences of their actions, a fact that has at least a little to do with their still developing brain structures. But there are consequences to alcohol abuse and they can be dire – over 5000 kids die each year as a result of underage drinking.

Young bodies and early alcohol damage

Before these young adults are truly mature, their intake of alcohol may not be properly resolved by their bodies because their regulatory systems are not fully developed and can be further taxed by the intake of alcohol. Alcohol abuse in a young age can have a lasting effect on brain development resulting in impairments for many years to follow. Reproductive organs and other important maturation factors may also be stunted due to a consumption of alcohol during a vital time (especially when binge drinking). As with most people who drink, regardless of the age, liver enzymes are elevated soon after the heavy drinking begins, meaning the body is less able to ward off other toxins.

Parents and alcoholism

Children of parents who drink more and view drinking with a laid back opinion are more likely to drink more as well. This may not be a problem as long as responsible consumption is discussed, but my guess is that it rarely is. Also, kids who have older friends are more likely to begin drinking at an earlier age. Teens that have become addicted to alcohol need help specifically tailored to their age group that does not remove them from their normal home and school setting. It’s been shown that isolating these kids, or specifically grouping them together, may do more harm than good.

Often, adolescents with alcohol abuse problems are also using other drugs, and they may be suffering from other psychological disorders. All of the issues need to be treated at the same time in order to effectively treat the entire person. No matter what the issue(s), the sooner they are dealt with the more effective the results.

Teenage alcoholism is a problem, and one that we shouldn’t be ignoring.

Co-authored by: Jamie Felzer

Citations:

“Adolescent Brain Development, Decision making, and Alcohol Abuse and Dependence” NIAAA Research. November 2007.

“Why do Adolescents drink, What are the Risks, and How can Underage Drinking be prevented?” Alcohol Alert. January 2006, 67

The alcoholism gene? That’s quite a long story!

If you were trying to find something to blame alcoholism on, genetics would be a good place to start: As much as 50-60% of the risk of becoming an alcoholic is determined by a person’s genes (1). We’ve discussed the genetics of addiction in general as they relate to other condition like ADHD, depression, and anxiety, but the risk that a person may become an alcoholic also depends on their sensitivity to alcohol’s effects, development of tolerance, susceptibility to withdrawal symptoms and alcohol-related organ damage, among others.

Alcohol related genes and alcoholism

The genetic causes of alcoholism are not always simple and straight-forward, especially because genes interact with one another (and the environment) in ways that can create unexpected results. However, some aspects of the genetics of alcoholism are clear, like the case of the genes that affect the speed with which liver enzymes will break down (metabolize) alcohol and its byproducts. Some people have a gene variation which produces liver enzymes that have trouble breaking down acetaldehyde (ALDH2-2, very common among Asians), a basic breakdown product of alcohol. As the levels of acetaldehyde increase, people experience flushing, nausea and rapid heartbeat which makes them less likely to consume alcohol and therefore less likely to become alcoholics. Not surprisingly, alcoholism rates have been historically low in Asian populations. However, recent increasing trends of alcoholism in Japan show that if you work at it hard enough, even a genetic predisposition that is supposed to protect you from alcoholism is no match for good old social pressures to drink.

Researchers have identified one neuropeptide (called NPY) that is located near known alcohol-related traits and indicates an alcohol preference in rats, consequently increasing response to alcohol (1). The effects of alcohol are increased with certain forms of NPY and  that gene has been linked to addiction-related, and anxiety, behaviors (2). It is also generally accepted that genes that affect the activity of serotonin and GABA (one of alcohol’s main targets in the brain and body) are likely to be involved in alcoholism risk.

It is important for everyone to remember that there is a predisposition to becoming an alcoholic and that alcoholism is a disease, not simply an outcome of poor behavior . There are ways to treat both the physical symptoms and the underlying addiction in alcoholics.

We’ve barely scraped the surface of the numerous influences on alcohol’s effects, and the predisposition to alcoholism, but hopefully this post leaves you with a slightly better appreciation of the complexity of the matter…

Co-authored by: Jamie Felzer

Citations:

1. Alcohol Alert-National Institute on Alcohol Abuse and Alcoholism. No.60. July 2003

2. Anxiety and alcohol abuse disorders: a common role for CREB and its target, the neuropeptide Y gene. Trends in Pharmacological Sciences, Volume 24, Issue 9, September 2003, Pages 456-460.

About Addiction: Kombucha, Alcoholism, Drug Crime, mental health, and the Law

These are the newest links about alcohol, drug crime and mental health. Let us know what you think and leave us your feedback!

Kombucha, Alcohol content, and teens

The New York Times: Some Kombucha drinks may have elevated alcohol content, with specific varieties reaching as high as 3% alcohol by volume, as high as some beers, and much higher than the legal limit on non-alcoholic drinks of 0.5%.

preventionworksct: Hospital emergency room visits linked to underage drinking almost double during the July 4 holiday weekend. Daily underage drinking-related visits are 87 percent higher during the July 4 holiday weekend than on an average day in July.

Caron: Good intentions of parents may unintentionally contribute to teenage alcohol abuse when mixed messages are presented. An expert suggests that substance abuse should be discussed before a kid reaches his or her teens.

Science Daily: Teens tend to increase their alcohol consumption in summer. Experts suggest parents monitor their children.

Drug Crime & Law

UPI: In Mexican drug smuggle, increasingly more teenagers are used to smuggle drugs across the U.S. border into Arizona. In 2009, 130 minors were arrested while allegedly trying to smuggle drugs across the border through entry ports from Sonora, Mexico, into Arizona.

Politica AP: Since the 2006 passage of an anti-methamphetamine law, the number of crystal meth lab cleanups nationwide has decrease. Investigators link the decline to the law that made it harder to buy chemicals used in this drug production.

About addiction and mental health

Reuters: There is an association between marijuana use and increased risks of depression and anxiety disorders. It is though unclear whether marijuana use itself, or some other factor, accounts for this connection.

Health Day: What works to treat adult addicts may not work for the younger population. According to experts, illnesses that start earlier in life are harder to treat than illnesses developed during adult life.