The complexity of this brain disease is not atypical, because virtually no brain diseases are simply biological in nature and expression. All, including stroke, Alzheimer's disease, schizophrenia, and clinical depression, include some behavioral and social aspects. What may make addiction seem unique among brain diseases, however, is that it does begin with a clearly voluntary behavior--the initial decision to use drugs. Moreover, not everyone who ever uses drugs goes on to become addicted. Individuals differ substantially in how easily and quickly they become addicted and in their preferences for particular substances. Consistent with the biobehavioral nature of addiction, these individual differences result from a combination of environmental and biological, particularly genetic, factors. In fact, estimates are that between 50 and 70 percent of the variability in susceptibility to becoming addicted can be accounted for by genetic factors.
Although genetic characteristics may predispose individuals to be more or less susceptible to becoming addicted, genes do not doom one to become an addict.
Over time the addict loses substantial control over his or her initially voluntary behavior, and it becomes compulsive. For many people these behaviors are truly uncontrollable, just like the behavioral expression of any other brain disease.
Schizophrenics cannot control their hallucinations and delusions. Parkinson's patients cannot control their trembling. Clinically depressed patients cannot voluntarily control their moods. Thus, once one is addicted, the characteristics of the illness--and the treatment approaches--are not that different from most other brain diseases. No matter how one develops an illness, once one has it, one is in the diseased state and needs treatment.
Moreover, voluntary behavior patterns are, of course, involved in the etiology and progression of many other illnesses, albeit not all brain diseases. Examples abound, including hypertension, arteriosclerosis and other cardiovascular diseases, diabetes, and forms of cancer in which the onset is heavily influenced by the individual's eating, exercise, smoking, and other behaviors.
Addictive behaviors do have special characteristics related to the social contexts in which they originate.
All of the environmental cues surrounding initial drug use and development of the addiction actually become "conditioned" to that drug use and are thus critical to the development and expression of addiction.
Environmental cues are paired in time with an individual's initial drug use experiences and, through classical conditioning, take on conditioned stimulus properties. When those cues are present at a later time, they elicit anticipation of a drug experience and thus generate tremendous drug craving. Cue-induced craving is one of the most frequent causes of drug use relapses, even after long periods of abstinence, independently of whether drugs are available.
The salience of environmental or contextual cues helps explain why reentry to one's community can be so difficult for addicts leaving the controlled environments of treatment or correctional settings and why aftercare is so essential to successful recovery. The person who became addicted in the home environment is constantly exposed to the cues conditioned to his or her initial drug use, such as the neighborhood where he or she hung out, drug-using buddies, or the lamppost where he or she bought drugs. Simple exposure to those cues automatically triggers craving and can lead rapidly to relapses. This is one reason why someone who apparently overcame drug cravings while in prison or residential treatment could quickly revert to drug use upon returning home.
In fact, one of the major goals of drug addiction treatment is to teach addicts how to deal with the cravings caused by inevitable exposure to these conditioned cues.
An excerpt from an article from the National Institute of Drug Addiction (NIDA)'s past president: Alan Leshner called "Addiction Is a Brain Disease." This is the prevailing thought among addiction scientists and addiction professionals.
The Essence of Addiction
~ Alan Leshner
The entire concept of addiction has suffered greatly from imprecision and misconception. In fact, if it were possible, it would be best to start all over with some new, more neutral term. The confusion comes about in part because of a now archaic distinction between whether specific drugs are "physically" or "psychologically" addicting. The distinction historically revolved around whether or not dramatic physical withdrawal symptoms occur when an individual stops taking a drug; what we in the field now call "physical dependence."
However, 20 years of scientific research has taught that focusing on this physical versus psychological distinction is off the mark and a distraction from the real issues. From both clinical and policy perspectives, it actually does not matter very much what physical withdrawal symptoms occur. Physical dependence is not that important, because even the dramatic withdrawal symptoms of heroin and alcohol addiction can now be easily managed with appropriate medications. Even more important, many of the most dangerous and addicting drugs, including methamphetamine and crack cocaine, do not produce very severe physical dependence symptoms upon withdrawal.
What really matters most is whether or not a drug causes what we now know to be
...the essence of addiction: uncontrollable, compulsive drug craving, seeking, and use, even in the face of negative health and social consequences.
This is the crux of how the Institute of Medicine, the American Psychiatric Association, and the American Medical Association define addiction and how we all should use the term. It is really only this compulsive quality of addiction that matters in the long run to the addict and to his or her family and that should matter to society as a whole. Compulsive craving that overwhelms all other motivations is the root cause of the massive health and social problems associated with drug addiction. In updating our national discourse on drug abuse, we should keep in mind this simple definition: Addiction is a brain disease expressed in the form of compulsive behavior. Both developing and recovering from it depend on biology, behavior, and social context.
It is also important to correct the common misimpression that drug use, abuse, and addiction are points on a single continuum along which one slides back and forth over time, moving from user to addict, then back to occasional user, then back to addict.
Clinical observation and more formal research studies support the view that, once addicted, the individual has moved into a different state of being. It is as if a threshold has been crossed. Very few people appear able to successfully return to occasional use after having been truly addicted.
Unfortunately, we do not yet have a clear biological or behavioral marker of that transition from voluntary drug use to addiction. However, a body of scientific evidence is rapidly developing that points to an array of cellular and molecular changes in specific brain circuits. Moreover, many of these brain changes are common to all chemical addictions, and some also are typical of other compulsive behaviors such as pathological overeating.
Addiction should be understood as a chronic recurring illness. Although some addicts do gain full control over their drug use after a single treatment episode, many have relapses. Repeated treatments become necessary to increase the intervals between and diminish the intensity of relapses, until the individual achieves abstinence.
Relapse prevention therapy has become a general name for numerous different techniques for planning your sobriety and addressing what to do if you have a relapse into old addictive behavior patterns. Relapse prevention is an all encompassing term for numerous areas of focus during therapy.
Core issues: Were you attempting to self-medicate mood disorders or serious mental illness? Were you traumatized in your past and it had gone unrecognized? Core issues typically act as the unconscious driving forces underlying our self-sabotaging behavior. Sigmund Freud said that those who do not make conscious these things are doomed to repeat. In addiction that seems to be very true.
Conditioned cues: These are commonly called triggers. Has your brain learned to connect two things together that trigger you to desire your drug of choice? Just like Pavlov's dog you salivate when a bell rings when no one else seems to have this response. These can be effectively addressed in relapse prevention therapy.
Conditioned cues are seeing, feeling, remembering, or any kind of exposure to the persons, places or things that you associate in your mind with your substance use. In therapy we will work to unlink the conditioned cues so that the conditioning loses it's power and is replaced with healthier thinking.
Cognitive errors: The thinking you have used to support your drug use has kept you sick, elicited dangerous behavior, and created a lot of pain in your life. Not only is this supported your drug use but also effected your relationships.
Denial is often cited as the main cognitive error used by addicts, but there are more, such as justifying thinking, glamorizing your past use or lifestyle, belief that you can retain your drug using friends and maintain a sober lifestyle, disbelief that your recovery efforts will work, planning or fantasizing about using when you know others will not be around. There are many more thinking errors that get in your way to recovery. Feeling that others are pressuring you taking something away from you rather than you are taking control of your own life.
Emotional processing: This is an important healing element in your road to recovery, and if not addressed in therapy will undermine your recovery.
Coming out of the chaos of your addiction there is a lot of emotional damage to yourself and to others. There is a need to step back and look back at what has occurred--not an easy task as so often the substances have served to avoid this process altogether. If our emotional life goes unexamined we become stuck in the same patterns. And, our substances often became the means in which we numbed or distracted ourselves from painful feelings.
Consequential thinking: It is important to be able to analyze the good and bad consequences to each of our behaviors. In relapse prevention therapy the focus is on alcohol or drugs, but consequential thinking is very important in your goal development as well.