Neuroscience of Addiction
Sometimes when we can't stop scrolling, we will joke that it's like we are addicted to our phones. Are we?
Addiction is so prevalent both in numbers and in casual conversation, to the point where 'Wine Mom' and 'Beer Dad' are big box store t-shirts.
But what is addiction?
Is it a feeling that we crave, or is it more of an escape from something else? What keeps someone addicted, and why are addictions so hard to break?
In this month's deep-dive episode, Laine walks us through some of the science behind the most prevalent and most impactful diagnosis we have had yet. Using findings from scientists Uhl, Koob, Cable, Volkow and Boyle, we discuss things like:
what parts of the brain are involved in pleasure and reward
how addiction can and will rewire your brain
why its so hard for someone to stop
a major take away to not only long term recovery possible but to help prevent addiction from occuring
For more resources on addiction, head to the episode on our website www.brainblownpodcast.com. If you have any topics you'd be interested in learning more about, please feel free to send us an email at info@brainblownpodcast.com!
We'd love to hear from you.
REFERENCES
Donald L. Hilton, Jr, and Clark Watts -- Pornography addiction: A neuroscience perspective
George F. Koob, Pietro Paolo Sanna and Floyd E. Bloom -- Neuroscience of Addiction
Nora D. Volkow, M.D., Maureen Boyle, Ph.D. -- Neuroscience of Addiction: Relevance to Prevention and Treatment
George R. Ulh, George F. Koob, and Jennifer Cable -- The Neurobiology of Addiction
General Outline of Episode
Chemical Dependency
A word that’s been thrown out of proportion, but what does it really mean to be addicted? Is it a feeling that we crave, or is it more of an escape from something else? What keeps someone addicted, and why are addictions so hard to break?
This is the neuroscience of Addiction.
LAINE
Prevalence - difficult to define - easy to get numbers of usage - but we want to focus on here is not just using it but being addicted to it.
National Center for Drug Abuse states 28.320 million or 20.4% of Americans 12 and older have an alcohol use disorder.
37.309 million were current illegal drug users (used within the last 30 days) as of 2020 and 25.4% of illegal drug users have a drug disorder.
Over 70,000 drug overdose deaths occur in the US annually.
The number of overdose deaths increases at an annual rate of 4.0%.
The average life expectancy in the United States actually declined between 2015 and 2017 because of overdose and it hasn’t gotten much better since than
Addiction center states Almost 21 million Americans have at least 1 addiction, yet only 10% of them receive treatment.
Drug overdose deaths have more than tripled since 1990.
Alcohol and drug addiction cost the US economy over $600 billion every year.
About 20% of Americans who have depression or an anxiety disorder also have a substance use disorder.
addiction(colloquially)
We have a lot on this colloquially - as this can be everything to a drunk, to your friend who just seems to never be sober, to what we see on street corners. This can feel very close to home and very distant at the same time, but addiction has become almost casual due to likely the commonality of it.
addiction(clinically) - Clinically when it comes to addiction is looking at “Substance-related and addictive disorders”. DSM5 breaks down substances into 10 different classes (inhalants, opioids, sedatives, hypnotics, anxiolytics i.e. tranquilizers, stimulates, tobacco, and other) but state all drugs taken in excess can “intense activation of the reward system that normal activities may be neglected” The DSM also has a diagnosis for gambling disorders becuase it states there is “reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse and product some behavioral symptoms that appear comparable to those produced by substance use disorders”, internet gaming, and behavioral accretion that includes sex addiction is not currently listed. Not because they may not be additive, and not because they may not be activating the same area of the brain but more because we don’t have enough longitudinal data yet to know.
A simplified way I have heard and used in conversations with clinicians is addiction is present if it's in the driver's seat. That isn’t always easy to suss out - but trying to differentiate between doing an activity and being addicted to an activity is not easy
The DSM does this through each category by looking at the disorder (specifically is this causing clinically significant symptoms), a look at intoxication a look at withdrawal - generally, these read very similarly, with gambling only looking at the disorder (ie clinically significant distress)
There is also a look at what we call comorbidity - a diagnosis that presents at the same time
What is starting to be looked at, though not historically looked at, is what is causing the addiction instead of just trying to treat the addiction alone
PART 1: Terms & Background Info (5-10 minutes)
Difficult to say because we know that usage of mild-altering substances goes back a very long time, but addiction is trickier to show.
We have proof of a frozen body found with mild altering substances in a pouch that was being carried. That body dates back to about 3300 BC
But that can be very different from addiction as substances have been used for religious purposes, medical purposes (we used to use cocaine in medicine), and recreational purposes but without addiction
Aristotle did document the effects of alcohol withdrawal, and Celceus stated that dependence on alcohol was a disease
That being said the American Medical Association did not classify this same thing as a disease until 1956 and did not recognize addiction until 1987. Additionally, it has historically been seen as a choice or a behavioral problem up until 2011!
PART 2: What About Neuroscience (5 minutes)
Why are we looking at THIS TOPIC through this lens?
What unique perspective will Neuroscience show us in regard to this topic?
To quote Uhl, Koob, and Cable “Substance and alcohol use disorders impose large health and economic burdens on individuals, families, communities, and society. Neither prevention nor treatment efforts are effective in all individuals. Results are often modest. Advances in neuroscience and addiction research have helped to describe the neurobiological changes that occur when a person transitions from recreational substance use to a substance use disorder or addiction. Understanding both the drivers and consequences of substance use in vulnerable populations, including those whose brains are still maturing, has revealed behavioral and biological characteristics that can increase risks of addiction.”
Volkow and Boyle state both the excess we see - death, overdose, accidents, health consequences, and cost and state “while research has identified many evidence-based prevention and treatment strategies that could help reduce alcohol use and drug use and their consequences, these interventions are highly underutilized and not effective for everyone. Our deepening understanding of the neurobiological, genetic, epigenetic, and environmental mechanisms underlying addiction is helping researchers identify new targets for prevention and treatment interventions.”
Neuroscience is uniquely suited to being able to address something so complex and so impactful. We have been seeing the result of addiction for a long time, even if it's not talked about. Generally most chronic homeless individuals are suffering from a combination of mental illness and chemical dependency - and treatment, therapy, and everything we’ve used so far often struggles with lasting results. We just agreed 10 years ago that this might be more than someone's ‘bad choices’, in fact, it's likely a brain reaction. Why neuroscience - because once we could admit that this was the brain instead of the mind - it was the most sensible place to go.
**BREAK**
PART 3: The Science (30-35 minutes)
Mesolimbic Reward Centers
Dr. Eric Nester - we have pleasure/reward pathways - your mesolimbic system - domaine neurons of the ventral tegmental area (hand model of the brain - the most outside part of your thumb that is touching your palm - this is focused on a reward!) to the striatum(located deep in your brain, center of your palm in the basal ganglia - focus can be summed up by the Reel 2 Real Song made popular by the movie Madagascar called ‘I like to move it, move it’ - reward when you move), prefrontal cortex (we discussed that a lot) and your limbic system (amygdala, hippocampus, thalamus, hypothalamus, basal ganglia, and cingulate gyrus). Nestler stated that these areas and their normal process are kidnapped/stolen/hijacked. He states we have growing evidence that things (drugs, food, sex, gambling, etc) can take over our natural pathways and hyperfocus them on this one thing.
Natural addiction may specifically focus on nucleus accumbens in overconsumption of what they call natural rewards, and state that the results of recent studies could show that this activation “may mediate not only key aspects of drug addiction, but also aspects of so-called natural addictions involving compulsive consumption of natural rewards” More is coming out about this to include the head of the National Institute of Drub abuse sating “NIDA Director Nora Volkow also felt that her institute’s name should encompass addictions such as pornography, gambling, and food”
Koob, Sanna and Bloom also argue this stating that “specific parts of the nucleus accumbens and amygdala, may underlie drug reward and the motivational effects associated with dependence” and also state that the mesolimbic system is impacted by this.
Fowler et all states “Studies of addicts show reduced cellular activity in the orbitofrontal cortex, a brain area…[relied upon]…to make strategic, rather than impulsive, decisions. Patients with traumatic injuries to this area of the brain display problems–aggressiveness, poor judgment of future consequences, inability to inhibit inappropriate responses that are similar to those observed in substance abusers.”
So at the moment - you consume something super positive - it stimulates your dopamine that’s hanging out in the mesolimbic system - your dopamine starts sending you DMs about how good this feels and how amazing this is and why don’t we always feel this good, why don’t we consume more to feel even better!) Your nucleus accumbens and dorsal striatum get these DMs and they are like ‘Hey - you’re pretty awesome friend - we should hang out a lot more! And you know what - I’ve got access to the boss’s calendar - I can totally make this happen”.
So you hang out again - but dopamine isn’t as friendly and it takes a lot more focused attention to get those DMs to come in again, to feel that good again. That substance’s Gram is still pretty sexy though - so you want more -in fact you get some DM slides by just being on their page - making you want more. Every time you do it you both create that pathway in your brain (you are walking on that snowy field over and over again) but you are also eroding away the dirt and soil when you do it - so the field itself is changing. It changes so much that your natural reactions are starting to also erode.
Hilton and Watts state “All addictions create, in addition to chemical changes in the brain, anatomical and pathological changes which result in various manifestations of cerebral dysfunction collectively labeled hypofrontal syndromes. In these syndromes, the underlying defect, reduced to its simplest description, is damage to the “braking system” of the brain.”
Volkow and Boyle state “In a brain not affected by addiction, the circuits controlling desire for a drug are held in check by prefrontal cortical regions that underlie executive functions, which support making rational, healthy decisions, and that regulate emotions. Thus, the awareness that a drug will provide an immediate reward is balanced by consideration of long-term goals, and the individual is able to make a reasonable choice and carry it through. However, when the prefrontal cortical circuits underlying executive functions are hypofunctional—as a result of repeated drug exposure or from an underlying vulnerability—and the limbic circuits underlying conditioned responses and stress reactivity are hyperactive—as a result of drug withdrawal and long-term neuroadaptations that downregulate sensitivity to nondrug rewards—the addicted individual is at a tremendous disadvantage in opposing the strong motivation to take the drug.”
This is why it's so hard to stop, your brain has been rewired and it has a very new job - and now it's harder to change it back.
And honestly - it isn’t just an addictive substance that can do this.
Addiction to food: Hilton and Watts state “In 2006, a VBM study was published looking specifically at obesity, and the results were very similar to the cocaine and methamphetamine studies.[20] The obesity study demonstrated multiple areas of volume loss, particularly in the frontal lobes, areas associated with judgment and control.”
Hilton and Watts also looked at addictive sexuality and a 2007 study that saw “ almost identical findings to the cocaine, methamphetamine, and obesity studies.[25] It concludes for the first time that a sexual compulsion can cause physical, anatomic changes in the brain, the hallmark of brain addiction. A preliminary study showed frontal dysfunction specifically in patients unable to control their sexual behavior.[16] This study used diffusion MRI to evaluate the function of nerve transmission through white matter. It demonstrated abnormality in the superior frontal region, an area associated with compulsivity.”
Instead of the body and behavior - we want to look at why this happens. It is looked at as complex interactions between biological factors - genetics, epigenetics, development attitudes, neurocircuitry, and environmental factors. Specifically to quote Volkow and Boyle “Research has started to uncover how psychological traits, emotions, and behaviors are encoded in the brain; how environmental factors influence brain circuits and subsequent behavior; and how genetic and epigenetic factors influence the development and functioning of the brain, all of which are of relevance to addiction risk and resilience.” It's never nurture or nature - it is always both!
Genetics can impact specifically how you metabolize something
Epigenetics can impact the focus of your neural pathways through generations - focusing on stress which rewires your brain
Neuroplasticity - neither good nor bad just is. What fires together wires together. The focus you give to something can and will rewire your brain. And this is why age matters
Volkow and Boyle remind us that the brain is actively developing till the mid-20s, and when the brain is developing it is MORE plastic (still has plasticity till death but is increased as you are growing) - specifically until the mid-20s the last thing that grows in impacts your rewards and motivation. They state “ As a result, during adolescence, the striatal reward/motivation and limbic-emotional circuits are hyperactive, leading to greater emotional reactivity and reward-seeking behaviors. Moreover, the prefrontal cortex cannot fully self-regulate, leading to more impulsivity and risk-taking (21). Early exposure to drugs of abuse may further impair the development of the prefrontal cortex, increasing the long-term risk for addiction”
And a big part of what we also need to look at is why a person started engaging with this in the first place - we have to look at the why! Volkow and Boyle state that we have to recognize that comorbidity - what is going on at the same time as addiction. “Many overlapping brain regions and circuits including those that mediate reward, executive function, and emotions—and neurotransmitter systems—including dopamine, serotonin, glutamate GABA and norepinephrine—have been implicated in substance use disorder and other mental illnesses.”:
Dr. Bruce Perry has also explored this in multiple books and talks - we covered some of them in empathy - understanding how stress can impact our DNA, and the DNA of our children so that it is harder to regulate - how parents treat their children will literally affect the DNA that gets transcribed and thus what happens in the babies brain/body - this is impacting not only that reward system but will also impact how we make sense of the world. Hence why children with high aces are more likely to take drugs and get addicted, more likely to use Ritalin, more likely to have high rates of teen pregnancy, and more likely to have high rates of obesity! How we feel about ourselves - he states a very high percentage of users are individuals who had developmental adversities - because addiction is a form of self-regulation - soothing that stress/response system and making us feel good. It helps us disassociate - so we need to figure out why we feel the need to disassociate in the first place! To quote what we stated in Season One Episodes 2 and 3 “Having four or more aces increases the odds of being a current smoker by 220%. It raises the odds of ever using illegal drugs by 470%. The chances of becoming an alcoholic go up by 740% in the chances of injecting drugs by a whopping 1030%. Perry “People at the CDC doing this work and they told me those numbers were numbers of the magnitude of which epidemiologists might see once in a career so that's plenty”.
We want to learn WHY we do what we do as humans, and we’ve looked to the brain for explanations…
**BREAK**
PART 4: TAKEAWAYS (10-15 minutes)
Very clear - I am in no way an expert in addiction at all. Simply sharing research here.
Really what we are talking about is a need to rewire the brain. We need that neuraplactisty. But that is not easy, and not quick.
How do we do that - most mental health professionals will focus on the need for the person to identify that there is a problem. Makes it a lot easier to rewire a brain if you know it needs rewiring. There needs to be a connection between x behavior causing y response that makes you feel good but also z's impact on life and the lives of others.
What else rewires the brain - mindfulness! But again this is where buy-in can be helpful.
Additional chemicals can also rewire the brain. I mean that’s what started this right? But we are looking at this the same way we look at things like Prozac when someone is anxious - sometimes we need to boost the brain till we can look at it another way.
Mental health is often a table - right - it has multiple legs, and the more you have the more stable the table. Therapy can be one of those legs, medication can be another, and so can the things you fill your life with to improve it (self-care, community care, mindfulness, giving back). But all of those are choices we make every single day, over and over again.
And that is one of the reasons why addiction is so complicated. A person is doing x thing. X thing feels great. Why would you want to change that? Why would you want to take away a thing that makes me feel good?
So we need to get to the heart of feeling good.
Dr. Bruce Perry will state there are so many ways to “activate the brain’s neural network of reward” that there are multiple routes to pleasure - multiple things that will activate the nucleus accumbens and the ventral tegmental area - specifically, he looks at alcohol, drugs of abuse as one of them, but as well as sex and sweet, salty fatty foods. He also includes cutting, picking, and pulling - self-harm. But additional routes are music and rhythmic sensory input (as we discussed in the neuroscience of music), behavior consistent with value or belief system, the sensation of pleasure and safety, the release of hormones and calmer regulation of stress response neural system, decreasing of physiological distress and positive human interaction.
He says this is key. He states that as humans we have something of a reward bucket - a biological need to feel rewarded and positive - (do the thing to get the thing, right), and “every single day, every single person has to fill up their reward bucket!” Think back to the neuroscience of music and neuroscience of empathy - when we engage in music and rhythmic sensory output (dancing) people’s chemical addiction decreased!
We all need to feel good. Until we address that need, we are not going to stop the pull that is happening. We have to be able to say ‘I hear you brain, you need a thing, how do we get this somewhere else”.
That’s why understanding that it's a brain thing and not a personal failing thing is so huge. And we struggle with that. Remember from the Neuroscience of Empathy, when Dr. Faletti presented his research on the fact that over 50% of obese individuals were sexually abused as children and instead of the excitement he was attacked and dismissed, and “One audience member even stood up and claimed that patients were merely making stories up to cover their further failed lives.”
Why neuroscience because it's so much easier to blame the person.
But Perry will argue it's about what happened to you and how that changes your brain. He states “People who have developmental trauma or adversity feel anxious all the time and it's such a common part of their life that they don’t even recognize that they are anxious…person may not identify that they are anxious at all”.... And then we age and someone introduces us to something like alcohol and we feel calm for maybe the first time.”
So take two people. Person A had loving engaged parents who were well-resourced (enough food, enough sleep, enough time) and had a huge friend group that was positive. They get positive human interaction ALL the time between friends and family. And they were shown positive human interaction so they are great at making more friends! They were encouraged to go out for the band, join sports or a dance team, so now as an adult, they still play music, they still dance, and maybe they have a rec league. They find things that have value to them like volunteering and giving back. They feel safe a lot of the time and they have stress because we all have stress, but it's stress that is good stress - it feels manageable and they tackle it knowing they have people behind them to support them.
Now take person B. Person B did not have resourced parents, their parents were stressed all the time and trying to make ends meet and cranky and not a regulatory partner. Making friends was hard because their base environment was so stressful that they were often not regulated and got anxious and angry very easily. They don’t have a lot of positive interactions with people. They might get yelled at a lot and told they are doing poorly. They didn’t have the resources to be able to pay for band or dance or sports, so they didn’t get to learn those things because that costs money and now they feel too old to learn. They haven’t been shown that people or things in life are positive, they feel everything is negative and terrible, so why would they volunteer or take care of others? Their stress feels unmanageable because their system isn’t helping them regulate it, they don’t have people to support it, and life has been chaotic. When life is uncontrollable and we just survive it somehow - that’s trauma. Even if it doesn’t look like an earthquake or being beaten or harmed. Trauma is a brain/body response that is about survival, and survival is about getting through it, being numb.
Both people have an evolutionary drive to feel good - our system will seek out pleasure. Both of them go to a party. What happens?
Think of us all during the pandemic. We were cut off from positive human interaction, volunteering was more difficult, finding a partner if you didn’t have one was harder and everything was changing and stressful. How many of us reached to foods, specifically sweet, salty, and fatty foods? How many of us increased how much we were drinking or started using other chemicals? How many of us disassociated through constant scrolling or playing hours and hours of video games?
So Perry will argue that for anything to be sustainable - we have to look to using those reward centers - that nucleus accumbens, that mesolimbic area - and we have to make sure that a person can activate them every day - that there has to be enough to fill a bucket or we will have an evolutionary need to fill it some other way.
Mostly we need to understand this more. This is your brain. Your brain wants something and it’s going to get it - that organ above all others! You will starve yourself if your brain wants something more. Trying to treat it like a chosen behavior isn’t getting us anywhere. You can be pissed off at diabetes all you want and it’s not going to help. And to be honest the behaviors of addicts are harmful. I won’t tell you to not take care of yourself - that doesn’t help anyone.
But we have to look at this from multiple areas:
Prevention matters! A lot! Stop the rewiring before it starts. But prevention isn’t just about ‘Hey kids, don’t do drugs’ we have to look at why it happens in the first place! We have to look at the need for human connection, for regulation, for care.
And if it happens - we need to look at WHY it happens. We have to address the underlying causes - loneliness, trauma, anxiety, and harm.
Understanding that each of us, every single human from birth to death is trying to get their needs met with whatever tools they have at their disposal. The needs are not going away. So let's change the tools.
