One of the questions most commonly asked by addicts and their families is: Why is it so darn hard to stay sober? To understand the answer to this question, it helps to have a basic understanding of how addiction rewires to the human brain. For simplicity’s sake I’ll use drug addiction as the basis of this discussion, but the same rewiring occurs with all forms of addiction, including behavioral addictions (sex addiction, compulsive gambling, food addiction, compulsive spending, etc.).
Essentially, in a normal, healthy brain the nucleus accumbens, also known as the “rewards center,” registers pleasurable feelings in response to naturally occurring, life-affirming stimuli (eating, sexual attraction, etc.) These activities are rewarded with feelings of enjoyment because they ensure survival of the individual and the species. This is intelligent design at its finest. These sensations of pleasure are caused primarily by the release of neurotransmitters (neurochemicals that carry messages in the brain) such as dopamine, serotonin, and oxytocin (mostly dopamine). The rewards center then communicates with other areas of the brain, including the centers involved in decision-making, memory, and mood, telling these areas how much it enjoyed eating, being sexual, etc. In this way human beings “learn” which things are pleasurable. We associate these activities with a sense of wellbeing, and we make future decisions based on this information.
Unfortunately, the rewards center can be manipulated. For instance, addictive drugs can artificially stimulate the system by flooding the brain with dopamine – anywhere from two to ten times the dopamine provided by natural stimuli (food, sex, etc.) That’s a pretty big blast of pleasure juice! And, as is the case with natural stimuli, this enjoyment-related information is transmitted to areas of the brain dealing with memory, mood, and decision-making. In this way we “learn” that taking drugs gives us a great big jolt of pleasure.
However, the brain is built to adapt to the input it receives. Over time, it adjusts to the excessive dopamine levels caused by continued drug use by producing less dopamine and/or eliminating dopamine receptors. Nevertheless, the brain remembers the pleasure it once got from drug use, and it continues to encourage use. So liking drugs turns into wanting drugs, and compulsion takes over. In other words, the brain hardwires itself for addiction. Drugs no longer provide the level of pleasure they once did, but the individual nevertheless feels compelled to continue using.
Triggers and Cravings and Relapse, Oh My!
After a brain is hardwired for addiction, “triggers” come into play. Triggers are the thoughts and feelings that induce drug cravings. If an addict can learn to identify triggers and stop them in their tracks – before they induce the phenomenon of craving – that person has a chance to stay sober, despite being triggered. It should be noted here that drug cravings are not the same as a non-addicted person craving a bag of potato chips or a scoop of ice-cream after a hard day at work. Drug cravings are more like the need for air after holding your breath for a minute or more. In other words, drug cravings, once they set in, are beyond conscious control. They escape reason and logic. They are so powerful that they simply overwhelm and take control of an individual’s thought process. When drug cravings set in, it is very, very difficult to stop the addictive cycle.
Unfortunately, anything that triggers the brain to remember the (long-lost) pleasure of using drugs is a potential precursor for cravings and relapse. This means that almost anything – items both internal and external – can be a trigger. Internal triggers typically involve uncomfortable emotions such as depression, anxiety, shame, anger, fear, guilt, remorse, etc. External triggers can be people, places, things, and events. For instance, seeing an old using buddy is almost certain to trigger a desire to pick up, as is driving past a dealer’s hangout. For some addicts, something as seemingly benign as a discarded soda can may be a trigger – reminding addicts that they used to modify old cans into pipes for smoking drugs. Fighting with one’s spouse or being reprimanded at work can also be a trigger. It is important to note that not all triggers are negative in nature. Sometimes material successes and positive emotions evoke the desire to party – i.e., the desire to use.
Sadly, triggers are unavoidable. Think about alcoholics driving past billboard ads for beer, scotch, and vodka. Think about drug addicts watching television crime dramas where the “perps” are selling or using drugs. Think about any addict at all dealing with the rollercoaster of life and the emotions it induces. The worst part is that in the early stages of sobriety, when an addict is most vulnerable to relapse, the addict’s visceral response to the various emotional and textual cues that trigger cravings gets stronger rather than weaker, meaning that it’s actually harder to not pick up at thirty days than it is at three days. Compounding this is the fact that underlying (formerly self-medicated) psychological issues like anxiety and depression are likely to assert more and more as time away from drug use increases. In fact, studies show that triggers and underlying issues are at their peak when addicts are between thirty and ninety days clean. Happily, after ninety days the odds of long-term abstinence begin to increase, and after a year the odds of lasting sobriety are actually quite good. Thus, it is very important to teach recovering addicts, as quickly as possible, ways in which they can identify and counteract their triggers.
Changing It Up
The good news is that our neural systems are resilient and adaptable, and the overwhelming majority of addicts can expect their brain functioning to eventually improve to near-baseline, as long as they stay clean. The trick, then, is helping addicts to stay clean for the year to 18 months their brains need to normalize – which means breaking through denial, identifying triggers, and developing healthy coping mechanisms as quickly as possible. The most effective therapeutic modalities for these steps are Cognitive Behavioral Therapy (CBT), group therapy, and 12-step recovery meetings.
CBT differs significantly from traditional talk therapy (looking at how past trauma affects the present), taking instead a more directive, here-and-now approach. With CBT, therapists and addicts look at the people, places, and things that trigger and reinforce the cravings that drive addiction. Then they identify ways in which addicts can short-circuit the process. In other words, addicts are taught to recognize their triggers and to interrupt the addictive cycle early on by thinking about and/or doing something else. Instead of obsessing about when/where/how to score a fix, addicts learn to engage in other, healthier behaviors like going to a sobriety-focused support group, cleaning the house, reading a book, spending time with family, exercising, etc.
Group therapy is used to reinforce this process. In these therapist-facilitated settings addicts are able to see that their disease in not unique, that others have done the same things they’ve done, and that they’ve even used similar justifications. This alone helps to reduce the guilt and shame that both trigger and result from the addictive cycle. Furthermore, as addicts talk about their past drug use in group sessions a wide variety of triggers is illuminated. Addicts are then able to discuss, on a group level, how to effectively counteract those triggers. Over time they are able to share with each other, based on personal experience, which interventions work and which don’t.
A similar form of group learning occurs in 12-step meetings. Interestingly, AA and other 12-step programs learned how to counter addiction triggers long before the scientific and therapeutic communities figured it out. Basically, in 12-step meetings group members share their “experience, strength, and hope.” In so doing they create a perfect venue for combating both internal and external triggers. Essentially, as one member of the group shares, others vicariously experience the emotional or contextual triggers the speaker is talking about, and then they do not act on those triggers. As this repeatedly occurs, many triggers lose their power, making them much less likely to cause cravings and relapse.
That said, no addict ever has his or her problem licked. Addiction is a chronic, lifelong disease. Yes, the brain does normalize to a large extent over time, but addicts are forever vulnerable to relapse. As the power of some triggers abates, new ones arise to take their place. Thus, recovery is an ongoing process that can never be abandoned, just as recovery from other chronic problems like diabetes and heart disease can never safely be abandoned. As such, many recovering addicts, even those with long-term sobriety, require, in addition to regular attendance at 12-step meetings, some form “maintenance therapy” that keeps them on top of their disease in terms of recognizing and combating their triggers. Usually an addiction-focused weekly group is the most effective setting for this.
Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. A licensed UCLA MSW graduate and personal trainee of Dr. Patrick Carnes, he has developed clinical programs for The Ranch in Nunnelly, Tennessee, Promises Treatment Centers in Malibu, and The Sexual Recovery Institute in Los Angeles. Mr. Weiss has also provided clinical multi-addiction training and behavioral health program development for the US military and numerous other treatment centers throughout the United States, Europe, and Asia.