Seeking Common Ground in Our Understanding of Addiction

“Our agreement or disagreement is at times based on a misunderstanding.” – Mokokoma Mokhonoana

There are many current models conceptualizing substance misuse and addiction. Many generally agree on what happens in the brain yet offer various schools of thought to explain why it occurs. Despite a lot of common ground, the proponents of each school of thought tend to emphasis how they differ rather than how they are consistent. This makes differences appear greater than similarities. Add to this the dynamic of our field for having a proclivity to argue a lot, even over small and sometimes misunderstood points and it contibutes to our disjointed view of addiction and recovery.

First – the one that helped me. The hijacked brain school. To explain, in active addiction, I was unable to predict with any reliability what would occur when I used drugs, including alcohol. This is commonly known as loss of control. It was very frightening and it was getting worse. I was able to see in a moment of clarity that it would likely end in an early death preceded by a great deal of pain for me and those around me. I sought professional help and connected with recovery community mutual aid and started a new life. It was not easy, the very substances I had used had been the very refuge from the pain that their use had wrought in my life, the catch 22 of addiction. My experience here is not uncommon.

One of the things that helped me move forward was understanding more about addiction. Like risk factors including genetics, early life exposure and trauma. A lot of what I learned made sense to me. I gained insight into loss of control as a main feature of a severe substance use condition. As noted above, it was what I had experienced. Drug use was a very upsetting and dangerous thing for me and for people around me when I was using. Learning about loss of control was a huge factor in my recovery. It was empowering. It put me in the driver’s seat. By choosing not to reinitiate use, I had control over the direction of the rest of my life, something I lost at whatever point I had crossed the line into addiction.    

What I learned in those early years was consistent with what Dr Nora Volkow Director of NIDA talks about on Inside the Addicted Human Brain where she explains loss of control as a central feature of addiction. Loss of control does not mean that there is no sentient process governing behavior. My internal voice, that I understand now as coming from lower structures in the brain that deal with reward directed behavior to use were much louder than the myriad of rational thoughts on why not to use being generated in the areas that govern executive function. It said very loudly use more, now. My experience here is also not uncommon.

Additionally, the brain regions that deal with reward become less sensitive to everyday stimuli with repeated drug use. Users require more of whatever to produce a reward response. It gets more pronounced as addiction progresses. My really loud internal voice, some may characterize as a compulsion, led to me using more and more to get the response I needed with ever increasing consequences. Eventually I used just to feel normal, like little Kiwi in the NUGGETS video.

Drugs work, at least at first. As one neuroscientist once explained to me, the brain prefers opioids to broccoli. A whole lot more lights up in the reward pathways of our brain when we use an opioid or have a beer than when we eat our vegetables. Drugs make you feel good in ways that broccoli does not. But as noted above, tolerance invariably develops, so it takes more or more varied use of combinations of drugs with synergistic effects to get the same results over time. The negative consequences mount. This acts like the law of gravity. It is inviolable. Tolerance always occurs, although to a greater extent in some people. If you have a propensity for higher tolerance to drugs, it is also a risk factor.

There are other models that address substance misuse and addiction, most of them, upon examination explain some of the very same processes in the brain. One is the learning theory of addiction. It makes a lot of sense. Everything we experience after we are formed is in essence us learning from our environment. We learn from every single thing that we encounter. This can include experiences of trauma or social and economic factors, but also boredom, lack of purpose and challenge, things that are becoming increasingly common in our postindustrial world.    

Consider the well-known rat park video focuses on environmental factors on why people use drugs. The emphasis is on dynamics in our society that increase the likelihood that people will initiate drug use for relief. In digging through the literature, I have never seen the assertion that if we lived in a happy, connected society that addiction would be eliminated. Wealthy, well-adjusted, and bored people misuse drugs too. Instead, it helps us understand that things like social isolation, stress and lack of purpose tend to create situations in which people use substances for relief.

These schools do not completely discount genetic factors that place people at greater risk for addiction, they simply emphasis other factors. They suggest that genetics are not the only factor or perhaps even the main event in who becomes addicted. They acknowledge that early use, while the brain is still forming in adolescence, is riskier. They highlight how people use to cope with profound emotional pain. From my perspective, these theories can be as beneficial in helping people find ways to heal from addiction as how learning about loss of control and the genetic risk factors felt empowering to me in early recovery.

The problem is that in our age, we prefer simple answers to complex problems. Take the model above that helped me understand what happened in my life. The hijacked brain school. It never asserts that people are zombies mindlessly using drugs. It does not assert that choice is fully removed, but rather that changes in the brain put the thumb upon the scale on reward responses in ways that can override reasoning processes. But people who do not like or fully understand the model argue against it by claiming it frames us all as mindless zombie drug users.  

Similarly, the leaning theory of addiction, at least from what I can see is consistent with the changes that Dr Volkow explains in the linked video above but rather emphasis how the brain is influenced by our experiences. It does not suggest that addiction can be unlearned, but rather that recovery involves learning new processes to overcome the changes in the brain and find new ways of doing things. It suggests learning strategies can be preventative of addiction or assist people in avoiding addiction in earlier stages of substance dependency. Things that certainly make sense to this clinician and as a person in recovery.

Framing new ways to conceptualize addiction helps sell books, book speaking engagements and get notoriety. Noting that most of these views have more consistencies than differences will not get one accolades from academia, fame or focus, even if it is true. But we tend to see things in an oversimplified manner as a result of the attention they get. We are not mindless drug consuming zombies. No, not all addiction is trauma related. Some people start using because they are bored or because substance use is common in their environments. Happy, socially connected rats (and people) can and do become addicted. Genetics are not fate. Genetics can increase the risks of becoming addicted, although genes are not the only factor. Once addicted, one cannot unlearn addiction and use in the way that people who never were addicted can use, although we certainly can learn new ways of living.

Things that I see there are consensus around in respect to the models of addiction:

• Addiction is complex with a myriad of causative factors, although each model tends to center on one as central.
• There are genetics and environmental risk factors, although each model tends to center on one facet as central.
• Addiction is not caused by a character defect or moral failing.
• Recovery is a probable outcome if people find support and pathways of healing.

One of the first things I learned when starting my journey from those who came before me was not to get so focused on the “why” I became addicted as to lose the focus on what I needed to do to heal. For me, it just so happened that learning the why helped reinforce for me why I needed to stay on the path to recovery. I have found this true for many of the people I have had the opportunity to help in their recovery journeys over the years. It is also true that different explanations resonate with people. Like recovery itself there is no one size fits all model.

Perhaps if we emphasized things in our models in commonality, we could develop a more cohesive message about substance misuse and addiction. I would suggest in parallel that the various schools of how drug use turns into addiction to start with the fact that there is broad agreement that drug use can change how some people function, that some people are at higher risk for addiction and that we do recover.

No matter what we do, that last point should consistently be repeated as much as possible. We do recover.

References

Filmbilder & Friends. (2014). Nuggets [YouTube Video]. In YouTube. https://www.youtube.com/watch?v=HUngLgGRJpo

FORA.tv. (2013). Dr. Nora Volkow: How Drug Addiction Hijacks the Brain. In YouTube. https://www.youtube.com/watch?v=cL97QKupu1g

How the flawed Rat Park experiment launched the drug war. (2018). Freethink. https://www.youtube.com/watch?v=d-0KfwFCMRM  

Inside the Addicted Human Brain by Dr. Nora Volkow. (2016). Www.youtube.com. https://www.youtube.com/watch?v=F-sfiQZqG24

Learning Theory of Addiction and Recovery Implications: (n.d.). Mentalhelp.net. https://www.mentalhelp.net/addiction/learning-theory/