Is Addiction Really a Disease?

A review of the film, “Pleasure Unwoven”

Kevin McCauley, M.D. (2009) was a recovering addict himself, when he first heard from his counselors that addiction is a disease. Yet, at that time, no one could explain to him how or why. Thus began his journey into neuroscience, to find answers within the brain of the addict. Over a decade of neuroscientific research by many top professionals in the field has brought astounding new information about how addiction works upon the brain and seems to have answered, at last, the question, “Is addiction really a disease?”

Dr. McCauly begins the film by stating that all drugs, from alcohol to heroin, originate from plants. Even methamphetamines can be traced back to the ephedra plant. As far back as recorded history can tell us, human beings have been seeking the “high” produced by the drugs they have extracted from plants. For many, the use of drugs leads to addiction. But how can addiction be a disease, when addiction is generally defined by a person’s behavior surrounding his or her use of a drug? Isn’t behavior a choice?

The Choice Argument

If drug taking is a behavior and behavior is a choice, then one could argue that addicts have a choice. The film uses the example that if you were to put a gun to the head of an alcoholic, offer him a drink, and then warn him that you will pull the trigger if he takes the drink, he most likely will choose not to drink. With a strong enough threat, you can get an addict to stop using, at least for the time being. The choice argument seems to be a strong argument against claiming addiction is a disease. The idea is that if an addict really wanted to, they could choose to stop using.

The Disease Argument

The problem with the choice argument is that it is based on outward behavior and fails to take into account the new research neuroscience has provided. This new science helps us understand some of what is actually going on inside the addict’s brain. While it is true that faced with an imminent threat, most addicts can temporarily stop using, it does not change the physiological processes affecting the addict from within.

Neuroscience teaches us that choice is a fragile process in the brain. But because it is choice and behavior we are dealing with, addiction comes with a great stigma. Ironically, so did cancer and many other illnesses before science was able to teach us the truth about these diseases. Just a few decades ago, people whispered about individuals diagnosed with cancer, hypothesizing about what they did wrong to “deserve” cancer. In the case of cancer, scientific advancements have dispelled such ideas in modern societies.

What defines disease then?

The disease model used by the doctors of today identifies a specific organ or part of the body, which has a specific defect, causing specific symptoms. In diabetes, for example, the affected organ is the pancreas. The defect is a loss of the ability of the pancreas to produce insulin. The symptoms of diabetes are many, but include vision problems, foot problems, and numbness.

If addiction can fit into this medical model of disease, would that have any eventual impact on the 2.3 million in prison today, most of whom are incarcerated for crimes connected to drug use? Sadly, the knowledge is now there, but how to make the change is a whole other question to explore. The fact is that neuroscientists now know the specific areas of the brain affected by addiction and, in large part, how these areas are affected.

Dr. McCauly continues his discussion of the brain as he describes what neuroscientists call “localization.” This refers to the fact that different areas of the brain serve different functions. The frontal cortex, for example, is what makes human beings stand apart from the animal kingdom. Located just behind the forehead, the frontal cortex is where our morality, wisdom, personality, spirituality, friendship, love, and such higher functions of the brain are processed. Considering addiction, it is important to note that the frontal cortex is also where we weigh options and make choices.

In the back of the head, at the base of the skull, resides the most primitive and animalistic part of the brain- the midbrain. Incapable of rational thought, its job is to keep us alive and help us protect ourselves from potential dangers such as starvation, thirst, or threat of physical harm. The fight or flight response originates from this part of the brain. The impulses to eat, defend, mate, and even breathe are driven by it. When we perform these survival behaviors, the reward center of the brain, incorporating the midbrain and part of the surrounding area, rewards us with a release of dopamine.

Dopamine is a neurotransmitter, or chemical messenger in the brain and nervous system, that makes us feel good. It is a pleasure chemical. It is why foods made with sugar and fat (high in calories, thus good for survival) taste so good. In fact, Dr. McCauly compares broccoli to chocolate cake, pointing out that this amazing process of our brain allows us to recognize, by taste and sensation, which could save us from starvation. (Ever wondered why there are so many overweight people in such advanced societies as ours?) Chocolate cake tastes delicious to us anytime, even though we are not under threat of starvation. The urges of the midbrain are powerful forces even for non-addicts.

If one can understand the difficulty of putting down the bag of chips, the cheeseburger, or the box of cookies, a non-addict can still not even fathom how much more powerful the urges of the midbrain are that drive the addict to the drug. The only possible comparison may be something like running out of air at the bottom of the swimming pool and feeling the burning and extreme urgency to breathe. Why would the addict crave the drug like someone who is desperate to breathe craves oxygen?

All drugs, regardless of the type, release dopamine in the brain. That is why they are a drug. That is why they are “mind-altering.” They alter the chemical balance in the brain. Different drugs affect different neurochemicals as well, but they all affect dopamine. The massive releases of dopamine that drugs cause, however, are unnatural to the body and thus cause unnatural effects. In someone who has become an addict, the midbrain has become confused by the excessively large releases of dopamine caused by the drug.

With dopamine being released to reward survival behaviors, the midbrain, incapable of rational thought, eventually adapts to the effect. Water, food, sex, and other survival behaviors get bumped down the priority list with the drug now at the top. The person has become an addict. Now, when the addict becomes distressed or uncomfortable, the automatic response is for the midbrain to produce a craving for the drug.

This may seem bad enough, but such an major error in the lowest level of brain functioning causes additional errors to occur along each level of brain processing from the bottom to the top.

Neuroscience identifies five levels of processing involved in addiction:

1. Genes
2. Reward
3. Memory
4. Stress
5. Choice

Stepping back from the reward center to an even more foundational aspect of the brain is the genetics of the individual. Some people are more sensitive to the development of addiction than others, due to genetic predisposition. Others are more resilient and can have a drink from time to time without losing control.

The reward center, something already discussed, is not only a big part of the development of addiction, but can greatly hamper addiction recovery, because cross-dependencies are such a common cause for relapse. This can be with other mind-altering substances such as nicotine, caffeine, and alcohol or with behaviors such as shopping, gambling, or pornography.

The reward center is connected to the third level of processing, memory. But how does memory play a hand in addiction? When dopamine is released in connection to an event, it causes glutamate to be released from another level of the brain. Glutamate pulls together all the senses involved in making a memory such as sight, sound, and smell, creating one cohesive memory. Glutamate is released in correlation with the amount of dopamine released.

It follows that with drug use causing enormous releases of dopamine, the glutamate binds together an altogether more powerful memory than would otherwise happen. These drug memories can be triggered by a sight, sound, smell, etc. When addicts speak of triggers, this is what they are referring to, because these powerful drug memories also lead to powerful drug cravings. It could be that a person happens to walk into a place where a song is playing that the addict used to use listen to when he or she used drugs. The next thing the addict may know, relapse could occur, if the individual did not have sound recovery tools in place.

Stress is a fourth function of the brain that is drastically affected in addiction. Now that the brain knows that relief (in reality, a temporary sensation of relief) can be had in a moment, simply by using the drug, it is the first impulse of the addict to any situation of stress. Thus when the addict experiences the loss of a job, a conflict with a loved one, sickness, or any other stressor, the addict may turn to drugs for relief, even though the drug does nothing to resolve the stressor.

Finally, we come back to the discussion of choice, the final level of processing affected by addiction. Brain scans find abnormal activity in the frontal cortex of the addicts brain. This indicates that love, wisdom, values, and other factors behind our choices, are impaired. Literally, this means that the addict’s ability to choose has been impaired. The addict’s frontal cortex is impaired because of the defects in processing below.

Going back to the disease model of addiction, neuroscience has shown that the midbrain is the primary part of the brain affected. The defect is “stress-induced hedonic dysfunction” (or a brake in the reward system) produced by the addict’s midbrain. Symptoms include loss of control, craving, and use despite negative consequences.

Only the practice of true recovery over time can begin to heal this process in the brain, restoring someone to the person he or she was before, perhaps even better. But with this gift of recovery comes the realization that parts of the brain have been changed. Addiction is a chronic disease. To maintain recovery, one must stop the practice or use of anything that causes large surges of dopamine, the addict must learn to cope with drug cues (triggers) and cravings, and the addict must manage stress quickly and efficiently by using social and or spiritual means.

In this way, recovery is possible. But like a diabetic whose symptoms are under control, the addict must continue the healthy behaviors that keep the disease in check. Dr. McCauly reminds the viewer that while the current ‘solution’ for most of the negative behaviors of addiction is punishment or coercion, these things do not work. They are not the answer. The answer, Dr. McCauly proposes, is in treating the addict as a patient with a disease, not a “bad” person who needs to be punished.

Perhaps then society can reach out to more people struggling with this disease. If the addict becomes a patient, the stigma is put aside and society can put its energy into developing more effective help and support for addicts. The film ends with this challenge and message of hope.

Conclusion

In therapy, working with addicts and their families, this film has proved to be an eye-opening and helpful tool for both the addicts and their loved ones. For the addict, it helps remove some of the shame and guilt that is inherent to the disease of addiction, making sense of what they have felt and experienced. For the family members and friends, it takes away some of the hurt and confusion they have felt, after the way their loved ones had been acting prior to treatment. “Pleasure Unwoven” is a film that is highly recommended to any who hope to understand the nature of addiction and what is going on underneath the outward behavior and choices of the addict.

References

McCauly, K. (2009). Pleasure unwoven; A personal journey about addiction.

To get your own copy of this amazing DVD visit The Institute for Addiction Study.

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