Addiction science has come a long way, but old ideas are still hanging around. Regrettably, one-third of Americans still regard addiction as a moral failing or a lack of willpower rather than a treatable disease. People still want to see addicts punished rather than rehabilitated, and addiction remains more stigmatized than depression, schizophrenia and other mental health conditions.
Widespread misunderstanding about addiction exists even in the treatment field. Despite all of our sophisticated brain imaging techniques, our knowledge about genetic predispositions to addiction, emerging theories about how drugs work and the hundreds of compounds being tested that promise to “cure” addiction, we still don’t have a single treatment that works more often than not.
Here are three common misconceptions that are preventing people from getting the help they need:
Scientific research has established that the dopamine system in the brain is the reason people experience pleasure when they take a drug. Based on the assumption that people will no longer use drugs if the rewarding effects are reduced or eliminated, scientists have sought to develop treatments that block dopamine receptors in the brain, mimic the effects of dopamine in the brain and stimulate the production of dopamine.
If the dopamine hypothesis is correct, we would expect treatments that restore dopamine levels to stop drug cravings or decrease the risk of addiction. But this hypothesis falls short. In studies of people who were dependent on cocaine, receiving treatment that restored dopamine to normal levels did not consistently keep addicts in treatment, did not improve abstinence and did not increase the number of clean urine tests. In short, medical treatments based on dopamine have been a spectacular failure.
Thus, dopamine is only part of the story. It helps explain why people start using drugs, but it doesn’t explain why people continue using drugs even after the pleasure is gone. It helps us understand why people get addicted but does little to guide our efforts in figuring out how they recover.
Other areas of the brain affected by drugs, such as those that govern learning and memory, are not directly regulated by dopamine, yet they play a significant role in relapse. We have to consider that the way into addiction – manipulating dopamine – is not necessarily the way out of addiction.
Even though science has characterized addiction as a chronic, progressive disease, modern treatment methods are more akin to emergency room medicine than chronic disease management. In fact, many addicts enter rehab expecting to be “cured” of addiction in 30 days or less.
Given its similarities to other chronic disorders, we can improve our approach to addiction by embracing the principles of treatment for diabetes, heart disease and other conditions. This approach is characterized by comprehensive, individualized and holistic care that combines medications, behavioral therapies, skills training and other interventions, ongoing monitoring and an immediate return to treatment in the event of relapse.
Science has made significant strides in establishing that addiction is a brain disease with a strong biological component. But like other chronic diseases, addiction also has a strong behavioral component. Just as heart disease is associated with poor diet, smoking and lack of exercise, there is a whole range of complex behavioral disturbances that puts someone at risk of developing addiction.
There are also behavioral changes that occur as a result of abusing drugs, such as acute changes in mood, memory, perception and emotions, which are part of the reason that people continue to use. Thus, treatments that focus solely on the biology of the brain are, at best, only a partial answer.
Instead, let’s look at what does seem to work. Twelve-Step recovery has been one of the most effective, time-tested approaches to addiction, yet science has spent little time studying how and why it works. Participants may not only stop abusing drugs but they have meaningful improvements in their interpersonal relationships, their moral character and their ability to help others.
These effects are not random, but rather the result of a complex neurophysiological process that reshapes the brain, remedying deficits caused by drugs.
People share their stories in 12-Step meetings, not just because it makes them feel less alone but because sharing addresses specific learning problems that occur in people who abuse alcohol and drugs. Twelve-Step recovery also seeks to restore empathy using a model that reinforces the process of caring and the importance of participation in altruistic activities.
Understanding more about recovery’s powerful effect on learning, memory, empathy and altruism could lead the way to new and better biological targets for treatment.
To date, addiction treatment has been an either/or proposition: use science and medicine to treat the biological side of the disease or 12-Step recovery to address the behavioral side. But to be truly effective, these two constituencies need to come together to create a new science of addiction – one that focuses not only on the biology of reward but also the range of complex psychological and physical changes that occur with chronic drug use.
David Sack, M.D., is board certified in addiction psychiatry and addiction medicine. Dr. Sack served as a senior clinical scientist at the National Institute of Mental Health (NIMH) where his research interests included affective disorders, seasonal and circadian rhythms, and neuroendocrinology. He currently serves as CEO of Elements Behavioral Health, a network of treatment centers that includes Promises, The Recovery Place, The Sexual Recovery Institute, and The Ranch.
Neurons image available from Shutterstock
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Last reviewed: 23 Jul 2012