Addiction, what’s it all about?

It is all about substance?

Reflecting on the start of the PhD, i was very much focused on what some may see as the medical model or a positivist stance. Terms like dual diagnosis and substance misuse/abuse were floating around my head constantly. I adopted the conventional way of looking at people with co-existing mental health and substance use difficulties, looking at it from a scientific perspective. Now I am certainly not saying this is the wrong way. However, we have adopted this approach since the 19th century, from the work of Philippe Pinel and Emil Kraepelin, and i think you will all agree that we are no further forward. If anything, it feels like we are moving backwards. I started to understand that my ontological and epistemological approaches to reality and knowledge were centred around constructivism and interpretivism. However, i chose to adopt a phenomenological approach, which is often seen as a standalone discipline because it is the study of experience. We all experience various types of experience, including perception, imagination, thought, emotion, desire, volition, and action. Thus, the domain of phenomenology is the range of experiences including these types (among others). Experience includes relatively passive experience in vision or hearing and active experience in walking, hammering a nail, or kicking a ball. For me, It was the experience of having co-existing mental health and substance use difficulties. Now, this is far more complicated than just the above and by no means do i feel that i fully understand the philosophical groundings for both, but this will be for another blog.

Although I was still enthralled by the science surrounding mental health and substance use, I had this ‘itch’ that i could not scratch, that something did not fit. I thought i understood the science, understood why we become anxious or depressed, so why can’t we prevent it? I will explore this later. But what bewildered me was addiction. Why do some people use specific substances, and why can’t they stop? But, more importantly, what is it? Where did it come from? Over the last three years, I have spent more time talking to people who have struggled with addiction than my own family (“I have got an amazing wife”). So here is what I have learnt from the people that know!

The Experience

It all starts with experience – what i mean by this is something that happens within the realms of us human beings. For instance, a relationship breakdown, stress at work, peer pressure, death of a close relative or a traumatic experience, etc. Ok, you may now argue that not all people who experience such things become addicted to a substance and of course, you are right. However, before i carry on, think about this:

 “On arriving home after a stressful day, have you ever reached for a beer or a glass of wine”? If you have, why?.

I started to research the concept of addiction, ‘google was my friend that day; how we described addiction was heartbreaking. For instance, an article by the National Institutes of Health • Department of Health and Human Services starts with, “People with addiction lose control over their actions. They crave and seek out drugs, alcohol, or other substances no matter what the cost— even at the risk of damaging friendships, hurting family, or losing jobs“. They conclude with “Addiction is a devastating disease, with a relatively high death rate and serious social consequences,” (National Institutes of Health 2015).

The Science of Addiction/Disease

The conclusion fascinated me – that addiction is a disease. I’d already started to read Alan Leshner’s paper “Addiction is a brain disease, and it matters” (Leshner, 1997). Leshner’s article, in essence, was in response to the negative stigma and discrimination that people with substance use difficulties were facing. In interpreting his writing, the disease model of addiction was an attempt to lessen this stigma and show that addiction was, in fact, a chronic relapsing illness characterised by compulsive drug seeking and use. Leshner then makes a critical point – he writes that “addiction is not just a brain disease’ (Leshner, 1997, p.46). He gives an example of war veterans returning from Vietnam who had become addicted to heroin. However, treatment for the addiction was successful upon returning home. The success of the treatment was attributed to the fact that they became addicted while in a setting almost totally different from the one to which they had returned.

Therefore, does it mean that it is not the substance (Heroin) but the environment or social circumstance that causes a person to act and behave the way addiction suggests? Neuroscientists have, however, identified areas of our brains, such as the mesolimbic dopamine systems, and argue that these areas play an important role in addiction. More specifically, Berridge (2017) proposes that after a long history of drug use, the person’s brain becomes sensitised to triggers and strong urges to retake drugs. What is interesting about Berridge’s proposal is that he argues that, unlike withdrawal, neural sensitisation does not go away following when the person stops using the substance. Does this theory fit Leshner’s (1997) notion that our circumstances and environment trigger and cause relapse? Lewis (2011, p.1) offers a unique perspective on addiction and neuroscience. In his own words, “I’m a drug addict turned neuroscientist”. However, Lewis does not dispel the arguments made by Berridge, nor does he disagree.

He argues that neuroscience is missing an essential part of the jig puzzle, actual experiences. Lewis’s book ‘Memoirs of an addicted brain’ is inspiring, captivating and enlightening. It is, however, his interpretation of his own experiences of addiction. Nonetheless, his description of his first experience of drinking alcohol is breathtaking, “The anxiety that would normally arise from his taunt melts as soon as it starts”, “Nothing feels threatening anymore”, and “I feel undeniably, unambiguously happy”. Lewis further remarks, “i have been deep in depression, the outcome of living in a circus of unkind acts. And suddenly I am completely free of it”.

I have heard similar, if not the same, from the people that i work with and have interviewed for my research. The power of alcohol is formidable to the person that requires a mood change in that it works quickly and changes your mood. “Did you answer the question i asked above?

“On arriving home after a stressful day, have you ever reached for a beer or a glass of wine”? If you have, why?. I am guessing for the same reason as above?

I remember talking to an inspirational lady (I’ll call her Jane, not her real name). She recalled the first time she started to drink; her son was very unwell. She found dealing with the fact that he might die very hard. She wasn’t sleeping or eating. A friend told her to have a ‘stiff one, so she had a whiskey, which immediately made her feel better. This carried on for a few days. But then she didn’t drink again. However, when she experienced something else that made her feel bad, she recalled that whiskey made her feel better. This starting and stopping carried on for months. Until she was drinking every night, she remembers it was an insidious process that no one, including her, could see. It became the norm. What struck me about her story was not her path to becoming addicted to alcohol but how she struggled to get support when she asked. Again, she remembers being continually turned away from mental health services because she drank alcohol. She went through a detox and then had to wait months for any further support and, therefore, couldn’t cope and relapsed several times.

Ok, so let’s look back at the science in relation to the above example. Neurobiology tells us that once we drink alcohol, it enters our gastrointestinal tract to be absorbed into blood capillaries via the bloodstream. Once in the bloodstream, it runs around the heart, moves to the lungs and then back to the heart, which pumps it via the arterial system to all organs. However, it must enter the brain for the alcohol or ethanol to cause intoxication. However, it’s not that easy to access the brain due to the blood-brain barrier, which acts as a wall and protects us from substances that could harm us. Unfortunately, ethanol squeezes right through. Alcohol is now in the brain. It then activates the brain’s reward regions, increasing a dopamine neurotransmitter’s release. Activation of these areas of the brain results in feelings of euphoria and allows us to escape the feelings of dysphoria. What interested me next was that trigging of these brain areas was said to trigger associative learning or conditioning (Volkow et al., 2016). This makes sense when we review Pavlov’s theory of learning. Jane finds the anxiety and worries about her son hard to manage from a simplistic perspective. So, she drinks alcohol which then reduces the worry.

Her brain now associates alcohol as a coping mechanism that relives negative feelings. This is evident when Jane returns to alcohol when she has bad experiences. Neuroscience explains this process as repeated exposure to alcohol is said to stop the firing of dopamine to the reward itself, i.e. alcohol, and instead, dopamine is increased in an anticipatory response. Therefore, if Jane has had a bad day, she remembers alcohol helped take this feeling away. The thought of drinking alcohol increase dopamine and increase her motivation to access it. I’ve probably made that sound very simple, and neuroscientists will probably want to slap me, therefore, see Smith et al., (2011) and Volkow et al., (2016) for a much more in-depth explanation. What struck me during reading was that we talk about addiction being a phenomenon solely linked to substances. However, as Lewis (2017, p.12) boldly states, “if addiction is a disease, then so apparently is love”.

Following reading and writing the above, i was left more confused than when i started. We can hypothesise why someone may start using a substance. We can say how this substance may affect our brain and how it may cause addiction. I love science. It has an air of sophistication, complex brain images, and sensational ideas about neurotransmitters. It kind of makes sense – and certainly explains. But what if we have become blinded by science to the detriment of human-level explanations? Does our fascination with the brain stop us from focusing on the cause?

Interestingly we have already established that experience and environment are crucial. Therefore, are not these that we should focus on? What i now know is that the relationship between humans and psychoactive substances is complex. There have both positive and negative impacts. Prolonged use as a panacea for mental distress or social situations can have terrible negative consequences. Science goes some way to explain the reasoning and effect, but, as Lewis (2011) reminds us, it is the personal experiences that we must focus on. Therefore, should phenomenology be the approach we use going forward? Such an approach allows a perspective formed by interaction in the world. Listening to the person who is struggling, is it not them who are the experts? Does this negate the role of science? Of course not, but it allows us to listen to the person’s experiences. I don’t profess to have the answers, but could addiction be a word – its meaning open to interpretation. The danger of which has led us to where we are today. Debating the concept of addiction as a disease, arguing about what and how treatment should occur.

I will leave you this from a person with lived experience: 

“Addiction is something that crept up on me. It’s something that was my best friend and worst emery before i knew it took four years of my life. It changed me for years. Until i finally beat it. I now know that i was using heroin to cope with how i was feeling. If only i could have found an alternative, i wouldn’t have lost four years of my life. But I’ve never misused a drug. As they say. I’ve used them for a reason.

These are only my thoughts in the final years of my PhD. I say years – as it seems to be taking years. Maybe i should stop writing stuff like this and focus on PhD chapters. Lol! I now look forward to reading Evaluating the Brain Disease Model of Addiction (Heather et al., 2022) and attending ‘The Alcohol policy, treatment & research: New Directions for the post-Covid era conference.

References

Berridge, K. C. (2017). Is Addiction a Brain Disease? Neuroethics, 10(1), 29–33. https://doi.org/10.1007/s12152-016-9286-3

Leshner, A. I. (n.d.). Addiction Is a Brain Disease, and It Matters. www.sciencemag.org

Lewis, M.D. (2011). Memoirs of an addicted brain : a neuroscientist examines his former life on drugs /. Toronto: Doubleday Canada, C.

National Institutes of Health. (2015). Biology of Addiction | NIH News in Health. https://newsinhealth.nih.gov/2015/10/biology-addiction

NIDA. (2018). The Science of Drug Use and Addiction: The Basics | NIDA Archives. National Institute on Drug Abuse. https://archives.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basics

Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016). Neurobiologic Advances from the Brain Disease Model of Addiction. New England Journal of Medicine, 374(4), 363–371. https://doi.org/10.1056/nejmra1511480