Author: John Carter
Addiction Relapse: The Risks, What It Means, and How to Avoid It
Contemporary neuroscience is illuminating how those factors penetrate the brain [77] and, in some cases, reveals pathways of resilience [78] and how evidence-based prevention can interrupt those adverse consequences [79, 80]. In other words, from our perspective, viewing addiction as a brain disease in no way negates the importance of social determinants of health or societal inequalities as critical influences. In fact, as shown by the studies correlating dopamine receptors with social experience, imaging is capable of capturing the impact of the social environment on brain function.
In the process of discussing these issues, we also address the common criticism that viewing addiction as a brain disease is a fully deterministic theory of addiction. For our argument, we use the term “addiction” as originally used by Leshner [1]; in Box 1, we map out and discuss how this construct may relate to the current diagnostic categories, such as Substance Use Disorder (SUD) and its different levels of severity (Fig. 1). The present paper is a response to the increasing number of criticisms of the view that addiction is a chronic relapsing brain disease. In many cases, we show that those criticisms target tenets that are neither needed nor held by a contemporary version of this view.
Critics question the existence of compulsivity in addiction altogether [5–7, 89], typically using a literal interpretation, i.e., that a person who uses alcohol or drugs simply can not do otherwise. Were that the intended meaning in theories of addiction—which it is not—it would clearly be invalidated by observations of preserved sensitivity of behavior to contingencies in addiction. Indeed, substance use is influenced both by the availability of alternative reinforcers, and the state of the organism. The roots of this insight date back to 1940, when Spragg found that chimpanzees would normally choose a banana over morphine.
Research shows that when treating addictions to opioids (prescription pain relievers or drugs like heroin or fentanyl), medication should be the first line of treatment, usually combined with some form of behavioral therapy or counseling. This explains why individuals who chronically abuse drugs or alcohol begin to appear lethargic, unmotivated and depressed, and report a lack of pleasure in things that were once pleasurable. To counter this, they increase their substance use in an attempt to feel the same pleasure they used to. This only exacerbates the problem, creating a vicious cycle of needing to take the drug in order to regain dopamine levels, then later needing to increase the dose, and so on, an effect known as tolerance. Research has identified a number of areas in the brain key to the development and persistence of addiction.
As we will show, stating that brain mechanisms are critical for understanding and treating addiction in no way negates the role of psychological, social and socioeconomic processes as both causes and consequences of substance use. To reflect this complex nature of addiction, we have assembled a team with expertise that spans from molecular neuroscience, through animal models of addiction, human brain imaging, clinical addiction medicine, to epidemiology. What brings us together is a passionate commitment to improving the lives of people with substance use problems through science and science-based treatments, with empirical evidence as the guiding principle. Close to a quarter of a century ago, then director of the US National Institute on Drug Abuse Alan Leshner famously asserted that “addiction is a brain disease”, articulated a set of implications of this position, and outlined an agenda for realizing its promise [1].
Explore a variety of healthcare news & stories by visiting the Health Lab home page for more articles. But if substance use continues, the brain produces less dopamine and/or reduces the number of brain structures that receive dopamine. Thus, dopamine’s impact on the reward network diminishes, along with the individual’s ability to experience pleasure. Even if you survive, an overdose can leave you and your family members with lots of feelings to sort through.
This may seem antithetical to a view of addiction as a distinct disease category, but the contradiction is only apparent, and one that has long been familiar to quantitative genetics. However, a heritability of addiction of ~50% indicates that DNA sequence variation accounts for 50% of the risk for this condition. Once whole genome sequencing is readily available, it is likely that it will be possible to identify most of that DNA variation. For clinical purposes, those polygenic scores will of course not replace an understanding of the intricate web of biological and social factors that promote or prevent expression of addiction in an individual case; rather, they will add to it [49]. Meanwhile, however, genome-wide association studies in addiction have already provided important information. For instance, they have established that the genetic underpinnings of alcohol addiction only partially overlap with those for alcohol consumption, underscoring the genetic distinction between pathological and nonpathological drinking behaviors [50].
A concentration on the chronic relapsing nature of alcohol dependence may lead to a preponderance of resources going towards those with severe dependence and other co-occurring health (including mental health) issues. The appropriate balance of resources requires an appreciation that dependence occurs on a continuum in which there are many more people with mild to moderate than severe behavioural dysfunction [38,44]. This continuum of severity does not in any way imply a necessary progression from early and mild to late and severe. A range of services of varying intensities is needed to address the continuum of severity of alcohol dependence [16,17]. Collectively, the data show that the course of SUD, as defined by current diagnostic criteria, is highly heterogeneous. Accordingly, we do not maintain that a chronic relapsing course is a defining feature of SUD.
A brain disease? Then show me the brain lesion!
But with continued use, a person’s ability to exert self-control can become seriously impaired. Consider how a social drinker can become intoxicated, get behind the wheel of a car, and quickly turn a pleasurable activity into a tragedy that affects many lives. Occasional drug use, such as misusing an opioid to get high, can have similarly disastrous effects, including impaired driving and overdose. Many people who suffer from substance use disorders know they have a problem, and they want to stop, but they can’t, and as their use continues, it causes problems in every area of their life. Despite being aware of these harmful outcomes, many people who use drugs continue to take them, which is the nature of addiction.
Finally, we argue that progress would come from integration of these scientific perspectives and traditions. Wilson has argued more broadly for greater consilience [109], unity of knowledge, in science. A plurality of disciplines brings important and trenchant insights to bear on this condition; it is the exclusive remit of no single perspective or field. Moreover, those who suffer from addiction will benefit most from the application of the full armamentarium of scientific perspectives. Additionally, medications are used to help people detoxify from drugs, although detoxification is not the same as treatment and is not sufficient to help a person recover. Detoxification alone without subsequent treatment generally leads to resumption of drug use.
Drug Misuse and Addiction
As with other diseases and disorders, the likelihood of developing an addiction differs from person to person, and no single factor determines whether a person will become addicted to drugs. In general, the more risk factors a person has, the greater the chance that taking drugs will lead to drug use and addiction. Addiction has many characteristics in common with other chronic diseases, including the fact that some of the contributing factors are believed to run in families, and that environmental conditions can trigger the onset and determine the course of the disease. Also, as with other chronic diseases, treatments and management options are available, although there is no cure, and many of the treatments involve lifestyle changes.
- Why, then, do people continue to question if addiction is a disease, but not whether schizophrenia, major depressive disorder or post-traumatic stress disorder are diseases?
- Regarding alcohol dependence as a chronic relapsing disorder may be one of the contributing factors to the ongoing biomedicalization of alcohol problems.
- Type 2 diabetes arises from a combination of genetic and lifestyle factors, and there’s no cure necessarily, but there are medications and lifestyle changes that can be used in conjunction with one another to manage the symptoms and live a healthy, fulfilling life.
- As with most other chronic diseases, such as diabetes, asthma, or heart disease, treatment for drug addiction generally isn’t a cure.
- This continuum of severity does not in any way imply a necessary progression from early and mild to late and severe.
Our overarching concern is that questionable arguments against the notion of addiction as a brain disease may harm patients, by impeding access to care, and slowing development of novel treatments. The first is that any widely-used definition that spans the scientific, clinical, and lay literatures should encompass the reality that addiction is not only a chronic relapsing condition, but has considerable variability in its course and outcome. A working alternative definition could be that drug addiction is a condition characterized by clinically significant impairment or distress resulting from substance use, with substantial variability in course, ranging from full remission to a chronic relapsing profile. This definition situates the condition within the purview of medicine and identifies, but critically recognizes the variability in its course. It is by no means perfect, and the field would benefit from an expert consensus definition using a methodologically rigorous approach (e.g., Jorm, 2015). Nonetheless, it illustrates the point that a definition that recognizes the clinical variability of its course can be readily proffered.
Understanding Drug Use and Addiction DrugFacts
Viewed this way, addiction is a brain disease in which a person’s choice faculties become profoundly compromised. From a contemporary neuroscience perspective, pre-existing vulnerabilities and persistent drug use lead to a vicious circle of substantive disruptions in the brain that impair and undermine choice capacities for adaptive behavior, but do not annihilate them. Evidence of generally intact decision making does not fundamentally contradict addiction as a brain disease.
Addiction Science
There is, however, a growing disagreement with describing addiction as canonically being a chronic relapsing condition. These criticisms are on a number of grounds (Cunningham and McCambridge, 2012; Heyman, 2013; Levy, 2013; Peele, 2016), not the least of which is that the definition is incompatible with a growing number of empirical observations about addiction recovery. There is a clear need to understand more effectively the development of alcohol dependence over the life-course in people who do not seek treatment. This is particularly true as it may well be that dependence is just as modifiable, or indeed more so, among those who do not attend treatment services.
What it means instead is that you may need to seek professional help, and you will also likely need to adjust your treatment plan or make sure that you’re following it properly. In some cases, a relapse could mean that you need to seek out a different treatment approach, but as with other chronic diseases, you can get back on track following a relapse. The changes that happen in the brain of an addict aren’t the same as the intoxicating effects of the drug. For example, you can feel drunk from alcohol, but this doesn’t mean your brain wiring is changed and that you’re an addict.