Addiction in the Brain

So what is going on in our brain? The basic explanation is that there is a giant battle going on between two competing choice systems. One of them pertains to an area of the brain called the midbrain. This is an older, more primitive part of the brain. It is an automatic system that quickly sends signals through the brain up to the cortex that relay subconscious messages that affect our motivation – which is useful for survival. The other choice system is in the prefrontal cortex. This is the part of the brain that evolved most recently. Humans have a more advanced cortex that sets us apart from the rest of the animal kingdom. It’s a slower, more rational and deliberative system that sends signals back down to the midbrain. If the automatic system is about to make a bad decision, the cortex tries to veto it and stop us from doing something dangerous. Between the midbrain and the cortex is the amygdala. It adds an emotional spin to the information going up to the cortex and creates a conditioned response. In addiction, a flood of dopamine adds a barrage of emotional intensity to the automatic signals to the point where they can overpower the rational system.

Our reward system evolved for efficiency to further our survival. Though there are many brain chemicals involved in training our reward system, there is one chemical that is central to all drugs and addictive behaviors – dopamine. Dopamine is the chemical of reward and value. Anything that releases dopamine commands our attention, telling us it’s important and making us remember it. The process involved helps us identify and learn things that are good for survival. Our brains are designed to handle stable levels of dopamine that are released whenever we feel normal pleasure, whether it be from eating a piece of chocolate, embracing a loved one, or watching a good movie. Drugs and addictive behaviors, however, cause massive spikes in dopamine, which our brains weren’t meant to handle. With each spike, the drug’s pleasurable effects become reinforced until it’s the most important and desired thing. Any negative consequences have to be greater and greater to get us to stop, because our brains become more and more hard-wired to seek the reward at the expense of our health and well-being. This is why punishment usually fails. When craving kicks in, we will keep doing the drug even in the face of terrible consequences. Our use becomes impulsive and compulsive, and we cannot stop ourselves.

If we are exposed to any amount of the drug or anything that comes to be associated with it – people, places, or things – we are triggered into a pattern of thoughts that can trigger a relapse. So the first thing we have to do to avoid relapse is avoid anything that causes our dopamine to spike. Dopamine is the chemical associated with the automatic midbrain, while glutamate is the chemical involved in the inhibitory processes of the cortex. Spikes in dopamine cause severe damage to our glutamate system, which disrupts the control the cortex has over the midbrain. We lose our ability to inhibit our desire to do drugs – we simply can’t tell ourselves to stop!

This phenomenon can be observed directly whenever we make a sincere decision to get sober, but end up relapsing. If we want to stick with it, then we need to understand how our brain’s choice system overrides our intentions. What that means is that we have to come up with strategies to apply whenever the “let’s use drugs” part of our brain sneaks up and overpowers the “don’t use drugs” part. Ultimately, the reason we use drugs is because we like it, but there is a fault in the motivational system in our brain. This defect was built up over a long time and is very difficult to undo. Additionally, many of us suffered from physical or emotional pain from earlier in life that have caused us to feel inadequate or deficient as adults. Rather than learning how to cope with it in a healthy way, we turned to substances or unhealthy behaviors in order to numb it. This is why some people become addicts while others do not. These emotional wounds further complicate the recovery process and should be treated in addition to our addictive behavior.

So how can we make it stop?

As we discussed above, the first thing we have to do is avoid intoxication (dopamine spikes). But second and just as important, we have to avoid triggers. It takes a long time to repair the damage to our neural pathways. Even after we get sober, those learned pathways are still there, waiting for a trigger. So in addition to avoiding intoxication and dopamine spikes, we also have to avoid triggers – people, places, things – and learn how to cope with them. It takes time for the brain to heal from addiction - in some cases it can take years. But the good news is that it is possible with sustained abstinence.

The third thing we have to do is learn healthy ways to cope with stress. Stress is another trigger, one that’s almost impossible to avoid. Research shows that stress plays an important role in addiction, and in other mental health conditions. The reason it impacts us so greatly is because our brain produces stress chemicals to rebalance our system when it becomes flooded with dopamine. Repeated spikes in dopamine cause repeated stress responses, which eventually lead to one big continuous stress response. Then we need drugs just to push back against the constant stress and whenver we are feeling down. Stress is thus a big part of withdrawal. After initial withdrawal, long-term withdrawal continues to confront us with stress, and even normal stressors in our environment can trigger an exaggerated stress response. That’s why it’s important to learn very good stress management. The longer we expose ourselves to repeated patterns of intoxication and stress, the more we have our work cut out for us.

It is often said that the opposite of addiction is connection. That's why isolation is so dangerous for those of us in recovery. Simply put, we are social creatures. Everything we do requires social connectedness. It turns out that choice emerges from our sense of community. Three areas of the brain become impaired in addiction – the orbitofrontal cortex, the anterior cingular cortex, and the insular cortex. The orbitofrontal cortex gives value to things, to people, and to ideas. This area becomes impaired in that drugs override the things that we truly care about at our core, and we lose the ability to make decisions in accordance with our values. The anterior cingular cortex helps us pick up on social cues and guide our behavior accordingly. It is where we see ourselves in the eyes of others. When this area becomes impaired, we lose our ability to understand the opinions of other people. Our thinking becomes rigid, and we have difficulty seeing how our behavior harms the people around us. The insular cortex is important in self-awareness. When this part is impaired, we lose our ability to see that our thinking isn’t clear about our addiction, which leads to denial and rationalizing. Together, these areas allow us to make choices that reflect our values and help us to live socially. We lose insight when they are impaired – we fail to see our behavior is self-defeating, that it harms the people we care about, and that it violates our deepest values. So if we are going to have any chance at recovering successfully, we need social interaction. We need other people. We have to cease trying to control the problem on our own because our own decision-making is impaired – we have to get out of our own way – so that we can allow others to provide feedback on what we’re thinking and doing.

We often think of a relapse as a single event or mistake, but it is actually a series of mistakes that lead to a relapse. A successful relapse prevention plan identifies all potential risks and includes actions to address them. Each action on its own is insufficient to deal with risk because they can be circumvented. But together these actions create layers of safety so that if one fails, the others can provide additional support, which optimizes the chance of avoiding relapse. For more on how to set yourself up for success, see the articles on recovery basics and recovery management.