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A multilevel exploration is necessary because it’s impossible to understand addiction fully from any one perspective, no matter how accurate. Addiction is a complex condition, a complex interaction between human beings and their environment. We need to view it simultaneously from many different angles—or, at least, while examining it from one angle, we need to keep the others in mind. Addiction has biological, chemical, neurological, psychological, medical, emotional, social, political, economic, and spiritual underpinnings—and
As defined in medical terms, physical dependence is manifested when a person stops taking a substance and, due to changes in the brain and body, she experiences withdrawal symptoms. Those temporary, drug-induced changes form the basis of physical dependence. Although a feature of drug addiction, a person’s physical dependence on a substance does not necessarily imply that he is addicted to it.
Withdrawal does not mean you were addicted; for addiction, there also needs to be craving and relapse.
The addict comes to depend on the substance or behavior in order to make himself feel momentarily calmer or more excited or less dissatisfied with his life.
Clearly, if drugs by themselves could cause addiction, we would not be safe offering narcotics to anyone. Medical evidence has repeatedly shown that opioids prescribed for cancer pain, even for long periods of time, do not lead to addiction except in a minority of susceptible people.
“Addiction is a human problem that resides in people, not in the drug or in the drug’s capacity to produce physical effects,”
It is true that some people will become hooked on substances after only a few times of using, with potentially tragic consequences, but to understand why, we have to know what about those individuals makes them vulnerable to addiction. Mere exposure to a stimulant or narcotic or to any other mood-altering chemical does not make a person susceptible. If she becomes an addict, it’s because she’s already at risk.
According to a U.S. national survey, the highest rate of dependence after any use is for tobacco: 32 percent of people who used nicotine even once went on to long-term habitual use. For alcohol, marijuana, and cocaine the rate is about 15 percent, and for heroin the rate is 23 percent.6 Taken together, American and Canadian population surveys indicate that merely having used cocaine a number of times is associated with an addiction risk of less than 10 percent.7 This doesn’t prove, of course, that nicotine is “more” addictive than, say, cocaine. We cannot know, since tobacco—unlike cocaine—is
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emotional isolation, powerlessness, and stress are exactly the conditions that promote the neurobiology of addiction in human beings
under certain conditions of stress many people can be made susceptible to addiction, but if circumstances change for the better, the addictive drive will abate.
About half of all the American soldiers in Vietnam who began to use heroin developed addiction to the drug. Once the stress of military service in a brutal and dangerous war ended, so, in the vast majority of cases, did the addiction. The ones who persisted in heroin addiction back home were, for the most part, those with histories of unstable childhoods and previous drug use problems.14
In earlier military conflicts relatively few U.S. military personnel succumbed to addiction. What distinguished the Vietnam experience from these wars? The ready availability of pure heroin and of other drugs is only part of the answer. This war, unlike previous ones, quickly lost meaning for those ordered to fight and die in the faraway jungles and fields of Southeast Asia. There was too wide a gap between what they’d been told and the reality they witnessed and experienced. Lack of mea...
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Thus, we might say that three factors need to coincide for substance addiction to occur: a susceptible organism; a drug with addictive potential; and stress.
As we age, we develop more active connections and therefore more white matter. In the brains of cocaine addicts the age-related expansion of white matter is absent.3 Functionally, this means a loss of learning capacity—a diminished ability to make new choices, acquire new information, and adapt to new circumstances.
Other studies have shown that gray matter density, too, is reduced in the cerebral cortex of cocaine addicts—that is, they have smaller or fewer nerve cells than is normal. A diminished volume of gray matter has also been shown in heroin addicts and alcoholics, and this reduction in brain size is correlated with the years of use: the longer the person has been addicted, the greater the loss of volume.4 In the part of the cerebral cortex responsible for regulating emotional impulses and for making rational decisions, addicted brains have reduced activity.
the user has to inject, ingest, or inhale higher and higher doses of a substance to get the same effect as before. If deprived of the drug, the user goes into withdrawal partly because the diminished number of receptors can no longer generate the required normal dopamine activity: hence the irritability, depressed mood, alienation, and extreme fatigue of the stimulant addict without his drug: this is the physical dependence
food seeking can increase brain dopamine levels in some key brain centers by 50 percent. Sexual arousal will do so by a factor of 100 percent, as will nicotine and alcohol. But none of these can compete with cocaine, which more than triples dopamine levels. Yet cocaine is a miser compared with crystal meth, or “speed,” whose dopamine-enhancing effect is an astounding 1,200 percent.
In short, drug use temporarily changes the brain’s internal environment: the “high” is produced by means of a rapid chemical shift. There are also long-term consequences: chronic drug use remodels the brain’s chemical structure, its anatomy, and its physiological functioning. It even alters the way the genes act in the nuclei of brain cells. “Among the most insidious consequences to drugs of abuse is the vulnerability to craving and relapse after many weeks or years of abstinence,” says a review of addiction neurobiology in a psychiatric journal. “The enduring nature of this behavioral
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In any disease, say smoking-induced lung or heart disease, organs and tissues are damaged and function in pathological ways. When the brain is diseased, the functions that become pathological are the person’s emotional life, thought processes, and behavior. And this creates addiction’s central dilemma: if recovery is to occur, the brain, the impaired organ of decision making, needs to initiate its own healing process. An altered and dysfunctional brain must decide that it wants to overcome its own dysfunction: to revert to normal—or, perhaps, become normal for the very first time. The worse
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Drugs influence and alter how we act and feel because they resemble the brain’s own natural chemicals.
Morphine and its opiate cousins fit into the brain’s endorphin receptors and thus, to quote a textbook on addiction research, the main endorphin receptor “represents the molecular gate for opioid addiction.”
endorphins do for us exactly what plant-derived opioids can do: they’re powerful soothers of pain, both physical and emotional. They grant, in the words of that opiate disciple Thomas De Quincey, “serenity, equipoise … the removal of any deep-seated irritation.” For the distracted and soul-suffering person, a hit of endorphins, just like an infusion of opium products, “composes what has been agitated, concentrates what has been distracted.”
oxytocin also interacts with opioids. It is not an endorphin, but it increases the sensitivity of the brain’s opioid systems to endorphins—Nature’s way of making sure that we don’t develop a tolerance to our own opiates. (Remember that tolerance is the process by which an addict no longer feels the benefit of previously enjoyable doses of a drug and has to seek more and more.) Why is it essential to prevent tolerance to our natural reward chemicals? Because opioids are necessary for parental love. The infant’s well-being would be jeopardized if the mother became insensitive to the effects of
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Opiates do not “take away” pain. Instead, they reduce our consciousness of it as an unpleasant stimulus. Pain begins as a physical phenomenon registered in the brain, but we may or may not consciously notice it at any given moment. What we call “being in pain” is our subjective experience of that stimulus (i.e., “Ouch, that hurts”) and our emotional reaction to the experience. Opiates help make some pain bearable.
opiates help us endure pain by reducing not its physical but its emotional impact.
we “feel” physical and emotional pain in the same part of the brain—and that, in turn, is crucial to our bonding with others who are important to us.
A child can also feel emotional distress when the parent is physically present but emotionally unavailable.
Children who have not received the attentive presence of the parent are, as we will see, at greater risk for seeking chemical satisfaction from external sources later in life.
In short, the life-foundational opioid love/pleasure/pain relief apparatus provides the entry point for narcotic substances into our brains. The less effective our own internal chemical happiness system is, the more driven we are to seek joy or relief through drug-taking or through other compulsions we perceive as rewarding.
Many addicts have told me that cocaine is a tougher taskmaster than heroin, harder to escape. Although it doesn’t cause physical withdrawal symptoms nearly as distressing, the psychological drive to use it seems more difficult to resist—even after it no longer gives much pleasure.
opioids help consummate our reward-seeking activities by giving us pleasure, dopamine initiates these activities in the first place. It also plays a major role in the learning of new behaviors and their incorporation into our lives.
Dopamine activity also accounts for a curious fact reported by many drug addicts: that obtaining and preparing the substance gives them a rush, quite apart from the pharmaceutical effects that follow drug injection. “When I draw up the syringe, wrap the tie, and clean my arm, it’s like I’m already feeling a hit,” Celia, the pregnant woman described in Chapter Six, once told me. Many addicts confess that they’re as afraid of giving up the activities around drug use as they are of giving up the drugs themselves.
chronic cocaine use reduces the number of dopamine receptors and thereby keeps driving the addict to use the drug simply to make up for the loss of dopamine activity.
Dopamine receptor availability is also reduced in alcoholics, as well as in heroin and crystal meth addicts.
research now strongly suggests that the existence of relatively few dopamine receptors to begin with may be one of the biological bases of addictive behaviors.
Opioid circuits and dopamine pathways are important components of what has been called the limbic system, or the emotional brain. The circuits of the limbic system process emotions like love, joy, pleasure, pain, anger, and fear. For all their complexities, emotions exist for a very basic purpose: to initiate and maintain activities necessary for survival. In a nutshell, they modulate two drives that are absolutely essential to animal life, including human life: attachment and aversion. We always want to move toward something that is positive, inviting, and nurturing, and to repel or withdraw
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“Recent studies have shown that repeated drug use leads to long-lasting changes in the brain that undermine voluntary control,” says an article cowritten by Dr. Nora Volkow, director of the National Institute on Drug Abuse. “Although initial drug experimentation and recreational use may be volitional, once addiction develops this control is markedly disrupted.”1 In other words, drug addiction damages the parts of the brain responsible for decision making.
Many studies link addiction to the orbitofrontal cortex (OFC),
the OFC is the apex of the emotional brain and serves as its mission control room.
Through its access to memory traces, conscious and unconscious, the OFC “decides” the emotional value of stimuli—for example, are we intensely drawn to or repelled by a person or object or activity, or are we neutral? It is constantly surveying the emotional significance of situations, their personal meaning to the individual.
psychological testing shows drug addicts to be prone to “maladaptive decisions when faced with short-term versus long-term outcomes, especially under conditions that involve risk and uncertainty.”8 Due to their poorly regulated brain systems, including the OFC, they seem programmed to accept short-term gain—for example, the drug high—at the risk of long-term pain: disease, personal loss, legal troubles, and so on.
“these findings are reminiscent of the reports of drug addicts who claim that once they start taking a drug of abuse they cannot stop even when the drug is no longer pleasurable.”13
salience attribution: the assignment of great value to a false need and the depreciation of true ones. It occurs unconsciously and automatically.
Brain development in the uterus and during childhood is the single most important biological factor in determining whether or not a person will be predisposed to substance dependence and to addictive behaviors of any sort, whether drug-related or not.
Were we born with our brain development rigidly predetermined by heredity, the frontal lobes would be limited in their capacity to help us learn and adapt to the many different environments and social situations we humans now inhabit.
The three environmental conditions absolutely essential to optimal human brain development are nutrition, physical security, and consistent emotional nurturing.
Just as the visual circuits need light waves for their development, the emotional centers of the infant brain, in particular the all-important OFC, require healthy emotional input from the parenting adults.
the parent’s brain programs the infant’s, and this is why stressed parents will often rear children whose stress apparatus also runs in high gear, no matter how much they love their child and no matter that they strive to do their best.
“cells that fire together, wire together.” The infants of stressed or depressed parents are likely to encode negative emotional patterns in their brains.
Since the brain governs mood, emotional self-control, and social behavior, we can expect that the neurological consequences of adverse experiences will lead to deficits in the personal and social lives of people who suffer them in childhood, including, Dr. Joseph continues, “a reduced ability to anticipate consequences or to inhibit irrelevant or inappropriate, self-destructive behaviors.”
