The Biology of Addiction Part 1
Posted on January 30, 2015
The power of our biology to control our lives is no better demonstrated than with the impact of addiction. I’ve worked with many people struggling with addiction throughout my career and I was always struck by how a behavior or chemical could dominate and often destroy a person’s life. Recovery, and the hope that is necessary to recovery, seemed elusive, as the addiction had total control over the client.
Any discussion of addiction needs to go back to the Triad of Unconscious Motivation. You can find an in-depth discussion on the Triad in four posts, starting here. To summarize, our biological systems and brain are designed around three key motivators: Energy Efficiency, Seeking Pleasure, and Avoiding Pain. Putting the three together, we naturally attempt to minimize pain and maximize pleasure, and we do this by expanding as little energy and effort as we can. We have these unconscious motivators to thank for many of our habits and addictions.
Let’s start our exploration of addiction with convergence the motivations towards pleasure and away from pain. Let’s first acknowledge that using substances to kill pain and experience pleasure is a universal trait of humans throughout history (from shamans to today’s big pharmaceutical companies) and is reinforced by popular media. Take a second to watch this commercial (http://www.adforum.com/creative-work/ad/player/34483715). It is a great example of how having a drink in the sanctuary of a bar helps leave the pressures of the day behind.
Many people can hear these messages and use chemicals without a great deal of negative consequences. The same substances that can destroy lives can also enhance the lives of those who don’t experience their negative consequences. What differentiates those who can get the positive experiences from chemicals versus those that go down the road of addiction?
One answer to this question is unresolved trauma. Whether we have studied the research or not, most of us see this connection in our work with clients. We work with people whose traumatic pasts, combined with an addiction, leads them to a life on the streets, imprisonment, and other negative consequences. We know that the traumatized individual is five times more likely to experience addiction. On one level this is a simple equation:
Trauma = Emotional Pain = Drugs (which replace the pain and suffering with pleasure)
But without the science, it is hard to see why a client continues to use substances, when the addiction itself becomes a source of pain through destruction of relationships, loss of home and employment, physical deterioration, and social isolation. Shouldn’t the pain of the addiction and the loss of pleasure (due to increased tolerance) activate the Triad of Motivation, in order to move the client away from the pain and consequences of the addiction?
Let’s start with a simple model and build our conceptualization through science. One way to look at addiction is to start with a baseline of life satisfaction. Let’s say a 10 is someone who is extremely satisfied with their life and a 1 is someone clinically and severely depressed and unsatisfied with life. If Bill experiences life at an 8 and then uses cocaine, the chemical might boost the 8 up to a 9 or 10 during the high. This is a nice experience for Bill and might add a little fun to a social experience or party. However, the return to 8 isn’t a far fall from the high. Being an 8, Bill has many other things in his life that bring pleasure. So while he might use again, the pull back to the drug is not necessarily that great.
Now let’s consider Robert, who lives life at a 2. Robert’s satisfaction with life is low due to past unresolved trauma, stresses of poverty, and unhealthy relationships. He then uses cocaine at the same party as Bill, and cocaine brings Robert’s experience of life from a 2 to a 7. This might be the first time in his life that Robert has experienced anything greater than a 5. The emotional pain of his past and present disappear from a brief time while high, and the party becomes the greatest moment of his life. For Bill, the experience just triggered the Seek Pleasure motivator, but for Robert it both killed the pain and brought pleasure to his life. His pull back towards the drug is much greater, as he naturally seeks to get back to the 7.
According to Gabor Mate, addiction requires three things: a susceptible organism (Robert), a drug or behavior with addictive potential (killing pain/providing pleasure), and stress. STRESS!!! I started my career working in a center that labeled addicted clients sick, as if something was wrong with them – and we also told them that they would ALWAYS be sick, even if they achieved years of sobriety. I would never call a traumatized person “sick,” I would never call someone struggling with the stress and trauma of homelessness, poverty, domestic violence, war, or social stigma “sick.” If Mate is right, which I think he absolutely is, and addiction is partly a result of stress, it takes the demon out of the individual. The question then becomes, “What has happened to you?” instead of “What is wrong with you?” (This was put forth by Sandra Bloom as a critical shift from traditional service models to the trauma informed paradigm).
Let’s review what we’ve established so far. Those with low life satisfaction (often resulting from stress and past trauma) experience a greater pleasure and relief from pain than those with high life satisfaction. Stress and unresolved trauma, not personal shortcomings, are requirements for use to become addiction.
To demonstrate the power of stress, we can look at a critical study coming from Vietnam Vets returning to the States. Let’s set the stage. I think we can agree that war is traumatizing for many of the soldiers we send to fight. Vietnam was not a proud moment in our country’s history. For the first time, we lost a war, and instead of parades, many of our soldiers took the brunt of the country’s frustration when they reentered their communities. My point is that war is traumatic, but these soldiers were not received as heroes, and often their reintegration into their communities was very stressful. In addition, many veterans come home with not just physical scars, but also the emotional scars of war in the form of post-traumatic stress disorder.
Coming home from Vietnam, 1 in 5 soldiers met the criteria for addiction, mainly to heroin. For many, drugs allowed the soldier to escape the horrors of Vietnam, even for just a brief time. In other words, the traumatic stress of war, a person impacted by this stress, and easy access to drugs all came together in a very predictable way. Here again, I think it is important that we say these soldiers were not chronically sick or weak. They found a way to survive a hell most were forced to take part in.
What happened next reinforces this point. Tens of thousands of veterans were coming home addicted to hard drugs, adding to the already-existing fear of an exploding drug culture in the States and people worried about losing the whole Baby Boom generation in a haze of pot smoke and heroin needles. As far as the military and public health infrastructure were concerned, this spelled a public health disaster.
However, something very different happened. Once the stress of war was taken away, 95% of the soldiers meeting the criteria for addiction stopped using and never used heroin again. This 95% remission rate is something that has been rarely matched in modern day substance abuse programs. I’ve heard some argue that many soldiers lost access to heroin and that is why they stopped. I think that argument has some validity, but not much as the fact that most soldiers came back to a robust drug culture. If heroin wasn’t available the vets could have easily continue their addiction through alcohol, pot, LSD, and other highs were not very hard to find; this simply didn’t happen with 95% of those returning home.
Regardless of which explanation you subscribe to, the solution lies in a change of environment. Remove the trauma of being in the middle of a war and you remove (for all but 5% of the soldiers) the need to self-medicate away the pain. This is one reason we are seeing great success in the Housing First Program (which rapidly getting people experiencing homelessness into housing), where providers get people out of the trauma of homelessness and into permanent housing. For many, eliminating the stress of living on the streets opens up a wide range of possibilities for treatment, recovery, and growth.
Those experiencing homelessness, struggling with the public stigma of HIV or their sexual orientation, living in extreme poverty, facing the emotional wounds of multiple deployments in the Middle East, growing up in the foster care system, trying to survive a prison environment…the people turn to chemicals, not out of a personal defect, but as a quick and efficient way to eliminate pain and experience some joy in their existence.
Next week, we’ll take this a step further and examine addiction from the perspective of the brain. For this week, my question is whether you can identify other stressors facing your client population that might increase the likelihood of addiction? Please feel free to put your insights in the comment section.