What role does the brain play in addiction?
Is addiction a matter of willpower and choice or is it about biology?
Addiction is a hard thing for many people to talk about. Either their own addiction or their loved one’s addiction. This is because addiction is destructive and it leaves people wondering “why” a person does this to themselves. In this episode we talk about what is happening in the brain when someone is using substances and address the question of how addiction happens.
In this Podcast
- Brain research has been done and outcomes show that the brain is physically changed by addiction in ways that make addiction thrive
- The basal ganglia has two subparts (nucleus accumbens and dorsal striatum) that are integral in the binge/intoxication stage
- The extended amygdala is involved with the withdrawal/negative effect stage
- The frontal cortex is involved with the preoccupation/anticipation stage
- Addiction creates powerful changes in need for pleasure, dopamine release, habit forming, increased sensitivity to stress and reduced ability to manage stress.
- The changes in the brain happen without a dramatic shift at one time so people don’t notice they are in over their heads until its too late and addiction has set in.
A Description of Addiction https://www.asam.org/Quality-Science/resource-links/a-description-of-addiction
What Is Addiction? https://www.psychiatry.org/patients-families/addiction/what-is-addiction
Chapter 2 The Neurobiology of Substance Use, Misuse, and Addiction, The Surgeon General’s Report on Alcohol, Drugs, and Health – chapter-2-neurobiology.pdf
Drug addiction (substance use disorder) – Symptoms and causes – Mayo Clinic https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112
Disease Stages https://www.asam.org/docs/default-document-library/nccbh-infographic.pdf?sfvrsn=dfe787ab_0
Free Treatment Planning Tool www.betsybyler.com/treatmenttool
You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler, and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and confidence needed to add substance use to their scope of practice.
I take topics that are typically aimed at substance abuse counselors and share them with mental health therapists in a way that is relevant and tailored to meet our needs. By adding substance abuse to your scope, you can expand your ability to treat the whole person and better meet your client’s needs.Bringing more hope, healing and freedom to the people you serve.
Doing therapy is hard work. Made harder when addiction is thrown into the mix. Many of us didn’t get the training we needed to deal with substance use and finding the knowledge that you need to fill that gap can be difficult. Each episode, I’ll bring you information on substance abuse, topics that impact our work, helping you gain knowledge and confidence. In a relatable and practical way. So join me each week as we talk about All Things Substance.
Welcome back. Last week, we talked about addiction and a basic overview. We talked about the five main components of addiction, which are the inability to consistently abstain, impairment in behavioral control, cravings, diminished recognition of problems and dysfunctional emotional response.
And all of that was setting up the concept that addiction isn’t a choice. It’s a complex chronic medical illness that causes changes in the brain. It can be treated and people do recover.
This week, we’re going to talk about the brain science of addiction. There’s been a ton of research done. And the conclusion that has come out is that it’s a complex chronic medical illness, where the brain has changes that happened during addiction that caused the person to continue the cycle.
The caveat here is that this is way more complex than I’m able to cover in a podcast. There are interactions between certain parts of the brain, a number of different brain functions, a number of different types of neurotransmitters and neuroadaptation that would require way more than we have for a podcast. I’m going to be telling you the parts that I think are most relevant for us as therapists,
I didn’t arrange the podcast to leave out parts that would cast doubt on it being a chronic medical illness and not a choice. They’re just more in depth than what we really need. And I’m including the parts that are most relevant for us.
So most of us are not science majors and maybe didn’t do as well in science. Possibly we did better in science than many of us did in math, but science wasn’t necessarily our gig. It’s not that we can’t understand it. And it’s not that research wasn’t important because it absolutely is important, but it’s just that we didn’t really study it. Sometimes that can mean that people will start to glaze over when they see science things talking about different parts of the brain, so know that I’m in a similar camp,
I found places where I feel like it explains it in a way that’s accessible for average non-science people. So this explanation is meant to be somewhat brief, accurate, and useful. As always, if you want to read up on some of the things that I use to write the podcast, you can go to the show notes at betsybyler.com/podcast. I’m going to go through the different sections and then I’ll pull it together in a case example, to help illustrate it when talking about a real person.
There are three stages to the cycle and addiction. And each one corresponds with a part of the brain. The first stage is binge intoxication. This is the pleasure or reward that they’re seeking. The second, withdrawal or negative effect where the person experiences negative emotional effects from the absence of the substance. So this could be an affect and effect here. We could be talking about their negative emotions or the negative effects from the withdrawal of the substance. The third stage preoccupation and anticipation where the person seeks the substance after a period of abstinence. People can go through this cycle in hours, days, weeks, or months. It all depends on the person and how far into the progression of use they are
Next we’re going to be talking about three main parts of the brain. One of those parts has two subparts so technically it’s five parts. So there are more things involved, but these are the ones we’re going to be concerned with. There are also a number of different chemicals involved as well. And the one we’re mainly concerned with is dopamine.
The first part of the brain, we’re going to talk about this called the basal ganglia and it’s involved with keeping body movements smooth and coordinated. The two sub parts of it are involved with motivation and the experience of reward, that’s the nucleus accumbens. And with forming habits and other routine behaviors, the dorsal striatum.
The basal ganglia is involved with the first stage of the cycle, the binge intoxication stage. During this stage, the nucleus accumbens drives a desire for reward and pleasure, and the dorsal striatum works on forming habits around that substance and pleasure reward. The nucleus accumbens pushes the person to get the good feeling again. The urges to use are rewarded with positive reinforcement. The positive reinforcement here is the high that the person gets or the intoxicated feeling that they get from using it.
The second part of this brain function, the dorsal striatum, is where we need to talk about conditioning. And there are two main types of conditioning and both are involved in addiction, but for today’s discussion, we’re going to leave classical conditioning in the background and instead talk about operant conditioning.
Operant conditioning is where a voluntary behavior is paired with a pre planned event or consequence. So I’m going to use a bunny to talk about this type of conditioning. Researchers use rats and mice quite a bit and I have a strong aversion to rodents, no offense to the rodent lovers, but I’m going to use a bunny for the example.
So let’s say we have Mr. Bunny and we want him to push a button in order to get a treat. The voluntary behavior here is pushing the button.The result or the consequence of that action is getting the treat. The bunny would get the treat every time he pushed the button. The treat would come out every time he pushed the button rather than on a different kind of schedule. So if it only came out every third time or a random number of times, it would take longer for him to learn that, but since it’s one action, one reward, he’s going to learn that pretty quickly.
In the same way a human would have the same response. Every time they smoke weed, they get high. That’s something that the brain is going to learn really quickly. Now, of course, the person logically knows this because that’s typically why they’re going to use the substance. Remember, we’re talking about brain function in the background. Therefore we’re concerned mainly with how the brain is learning this behavior.
With substance use, the nucleus accumbens provides the reward and the dorsal striatum reinforces the habit. While the person knows that they can use a substance and get the feeling the brain is learning on its own. And it’s starting to act on its own. It wants the reward and so it’s pushing that person to do it. This is where dopamine comes in.
Dopamine is our “feel good” chemical. It’s what gets released when we eat something amazing, have sex or in this case, use a mood altering substance. Humans want to feel good. It’s in our biology to seek things out that are good. The whole job of the reward system in the brain is to push humans to fulfill the prime directive of creating more humans. And in order to do that, we need to make sure we eat and we need to make sure we’re having sex. So the body is set up to do just that. With substance use though, addiction hijacks that circuitry and the drive becomes about getting the feeling from using.
So let’s talk about dopamine. So our dopamine levels sit at baseline. And so if we’re at a hundred percent of baseline, Good food brings it up to about 150, having sex up to 200, cocaine about 350, alcohol it’s about 200, meth goes up to1000. So when we’re talking about dopamine, it’s important that we know that it’s rising and falling. And different drugs and different experiences last a certain amount of time.
For instance, the dopamine level for nicotine rises and then falls about 45 minutes later. This is the reason why people who smoke consistently want another cigarette about every hour. It’s because the dopamine level goes back down. And so they’re seeking that other increase, not to mention withdrawal of facts that get into play.
So when we’re talking about dopamine, we’re talking about the brain learning that it’s found something that will make it feel good. And in most cases it’s higher, if not significantly higher, than anything we could do that doesn’t involve a mood altering substance. And the brain wants to feel as good as possible. And so while the nucleus accumbens is learning that this thing makes them feel extra good, the dorsal striatum comes along and is now forming habits around that reward. This would work if it wasn’t for something called tolerance.
Most people have heard the word tolerance when it comes to alcohol. Someone might get called a lightweight because they have a glass of wine and they’re already a little tipsy. Or if someone’s smoking weed, a couple hits and they’re already feeling high. Tolerance is something that we build over time. And so in the beginning, we don’t need very much of a substance in order to get the desired effect, whatever it is. Over time, though, we do need more.
The habit part makes it so we continually are doing more and so the tolerance is building in the background. This is the part that people don’t really think about. They know that they’re building tolerance and they know that eventually they’ll be able to drink or smoke more and they won’t get as high or as drunk. They can “handle their alcohol” or their weed or whatever.
The thing here is that tolerance doesn’t stop building, tolerance continues. And so the more you’re using, the more you’re going to build that tolerance up. So the impact of tolerance means that you aren’t getting the dopamine release that you were getting when you were using the previous amount.
So let’s say you go out to the bar and you have five drinks and five drinks would put you at happily buzzed. Well, the more that you’re drinking those five drinks, what happens with tolerance is that you’re getting less of the effect with the same amount. And so if you’re drinking five drinks, every time you go out and drink, and it’s fairly frequent saying more than just once every few months, you’re not going to be getting as buzzed as you were to begin with.
And so the level of buzz or intoxication that you’re getting decreases. And so that means that there’s less dopamine. And your brain, the nucleus accumbens, it doesn’t like that. And it’s going to push you to use more, to get to the level of dopamine release that you were experiencing. So you find, if you drink six drinks, that dopamine goes up again. And then tolerance kicks in and we go to seven and eight and so on.
All the while the dorsal striatum and was in the background, creating habit. Okay. Now our habits around six drinks now are habits formed around seven drinks. Now our habits formed around doing this numerous times a week. Maybe it was once a week. Now it’s three times a week. So as things progress, those two parts of the brain are adapting and pushing the use forward.
Here’s the kicker. When it comes to addiction, dopamine levels don’t go back to baseline. They go below baseline. And so there’s a certain point at which when somebody comes down from drinking or getting high, they’re no longer at baseline level. They’re dropping below. And so they feel worse than they did before they started drinking or using. That’s going to push the nucleus accumbens to ask for more. It’s called neurochemical rebound, where the reward function doesn’t simply revert to baseline, but drops below original levels.
Initially drinking smoking weed can be more impulsive and about wanting to feel good in the moment. But as this progresses, it becomes more compulsive because we’re seeking something on purpose to bring the dopamine levels back to where the brain likes them to be.
On to the second part of the brain, the extended amygdala. This is involved with the withdrawal or negative affect stage in the use cycle. And instead of positive reinforcement, this part involves negative reinforcement. Negative reinforcement is the removal of something negative. Not necessarily a negative consequence in a bad way, like having a hangover or getting sick, that kind of thing, but the removal of something negative. So for instance, let’s say you have a headache and you go to take Tylenol. That is negative reinforcement because it is removing the pain from the headache. Positive reinforcement adds something positive and negative reinforcement takes away something negative. Both are reinforcements, it’s just that they do different things.
Whereas the basal ganglia is involved with positive reinforcement, he extended amygdala is involved with negative reinforcement. In this stage, the withdrawal or negative affect stage, withdrawal is the first part we’ll talk about. Coming down from a substance is not fun. Each addictive substance has its own withdrawal and some withdrawal syndromes are worse than others. With marijuana, it could be irritability, headaches, sleep disturbance.
With meth, it’s far more intense and debilitating even though both marijuana withdrawal and meth withdrawal last about the same amount of time, which is around four days. Taking the drug again, we’ll remove the withdrawal symptoms. So it’s negatively reinforced.
Taking the drug again, will remove the withdrawal symptoms and give you a high. And so you get double the amount of reinforcement for doing the drug. So you get the high from taking it and it removes the negative effect of withdrawal. The extended him, the extended amygdala is also responsible for the stress response in our bodies. This is where fight flight or freeze gets triggered. Addiction heightens the activation of the brain system. Research shows that not only is this area of the brain activated, but that neuroadaptation causes an increased sensitivity to the stress reaction. The brain is literally changing, causing the person to be less able to tolerate distress.
So at the end of the second stage, the person has a decreased level of dopamine over time requiring more and more of the substance to be used. They have a habit formed around getting that particular dopamine release.They have increased activation of a stress response and decrease in the ability to tolerate that. So literally. It’s harder for them to cope with stress and they’re getting stressed more easily.
The last part of the brain, the prefrontal cortex is one we talk about a lot with adolescents and for sure that’s relevant here. We know that that part of the brain doesn’t stop developing until well into a person’s twenties. The majority of addicts and alcoholics start using in adolescents.
So impacting the prefrontal cortex at that stage of development has significant consequences. Some we understand and some we don’t fully understand. So keep that in mind, as we talk about the impact of addiction on this part of the brain.
The prefrontal cortex is involved with the preoccupation or anticipation stage. This is the substance seeking stage. An incredible amount of time and energy is spent thinking about when the person will be able to use again. We talked in the last episode about how a weekend drinker would days before be planning out their drinking. The further they are down the path of addiction, the more intense this preoccupation will be.
The main job of the prefrontal cortex is to control executive functions. Executive functions are the ability to organize thoughts, activities, prioritize tasks, manage time, make decisions, regulate one’s actions, emotions, and impulses. This is a big deal, even in adults with fully formed brains. Because executive function is essential for a person to make appropriate choices about whether or not to use a substance and to make choices about whether they’re going to override the strong urges to use. Especially when a person is experiencing multiple triggers or stressful experiences.
This region of the brain has a “go” function and a “stop” function. And the way the substance use impacts the brain is that the go function gets pushed far more often. Remember the nucleus accumbens is pushing on the go button and in doing so it releases another neurotransmitter, which is excitatory in nature.
The “go” system also activates the habit forming part of the brain. Well-traveled pathways are easy for the brain to find. And as would be expected, the “stop” system is under activated here, making it easier for the compromised brain to push the person to use again and ignore responsibilities and normative pro social behaviors.
Let’s do a case example,
A 19 year old male who is going out and partying on weekends with friends like a typical college student. When he was in high school, he drank every now and then and smoked pot every now and then. He largely stayed away from it because he knows his family has a lot of addiction in it. So he was being kind of careful, but going to college, he found that a lot of people were drinking and smoking weed and decided that he joined in a little more often.
By the end of his freshman year, he was drinking Thursday, Friday and Saturday night. In the beginning, it started out being just one night a weekend. Turning to two nights every weekend and then three nights every weekend, because he was able to do that and not have a lot of consequences because he didn’t have classes on Friday.
Now we have a habit; he’s drinking three nights a week and his tolerance has increased slowly over the semester. And so in order to get intoxicated, he has to drink eight to 10 beers. So each weekend he’s drinking close to 30 beers. The nucleus accumbens is used to getting that dopamine rush. And in order to get up to the level of 200%, which is where alcohol takes dopamine, he now has to drink eight to 10 beers in order to achieve that same effect.
Once or twice this year he’s woken up with a mean hangover and decided to drink “a little hair of the dog that bit him.” If you’re not familiar with that phrase, what it means is that in order to get rid of feeling terrible the next morning, you can drink a little bit of what you drank last night to try to take the edge away. And a lot of times it works and if it’s not beer, it could be a different type of alcohol.
So he’s done that a few times and found that it was effective. Now we have summer. And summer means no classes. And while he has a job, he’s able to party a few more nights a week. And so over the summer, it’s three, maybe four nights a week. And it’s not just all on the weekend. It’s starting to scatter throughout the week. He’s drinking a lot more than some of his friends who weren’t drinking as much. And so he started hanging around another group of people who was drinking quite often. And some of them every day. The trouble with this is that his drinking didn’t seem like a big deal anymore and so it wasn’t something to be concerned about. So three months of drinking like that, and now his tolerance has increased again.
We start fall semester and he’s continuing to drink. And it’s now always three nights a week, if not four and sometimes on a Monday night, because Monday night football. And so his tolerance has increased. He’s drinking probably 40 to 50 bears a week starting to manage hangovers by either drinking more or starting to smoke weed. Smoking weed wasn’t really something he was doing before, but found that it eased some of the hangover symptoms.
The start of the new semester means the start of a different schedule and having to change habits. And this was really hard because the dorsal striatum, in the basal ganglia, has a pattern now of getting drunk and having that intoxicated feeling multiple times a week. That makes it really hard to get up for an 8:00 AM, Friday class or even a 10:00 AM Friday class. And so he starts missing class because he’s not able to get up and doesn’t stop drinking the night before. . Remember that one of the hallmarks of prediction is not recognizing problems. And so his thing is the class is too early, not I’m drinking the night before, and maybe I should stop that. This kid was smart. It’s not like he didn’t have good cause and effect reasoning abilities. it is a function of addiction that he didn’t see the real problem for what it was. And instead decided that that class was just simply too early. And so why bother trying to get up.
Something else started to happen that fall semester, he started having blackouts. Blackouts are not the same thing as passing out. Blackouts are when you’re walking, talking, moving, doing things and you literally can’t remember. So you’ll be talking to someone in a kitchen somewhere. And the next thing you know, you’re coming to, and you’re at home with no idea of how you got there. Car is in the driveway, but you don’t remember anything since the time you were standing in that kitchen. No matter how many hours that was. In crowds that drank quite a bit, blacking out seems like a normal thing. And it’s totally not a normal thing. Most people when they drink are not having blackouts. This has to do with the impairment in behavioral control which was one of those five things we talked about last episode.
Another thing he found is that if something got in the way of one of the nights he was supposed to be drinking with friends, he got really irritable. So he made it through fall semester, just barely.
And he’s drinking four nights a week one of those nights is getting in the way of the intramural basketball league. So gotta quit that. He likes basketball, really enjoys playing, but just isn’t as into it this year. Mid semester, one of his buddies turns 21 and that is where things went really down. Buddy had a house off campus and was 21. Alcohol was available all the time and so drinking increased again.
Every time he would stop drinking the dopamine level would go down below baseline and drinking would bring it up. But over time, 10, 12, 14 beers he was drinking at a shot, weren’t doing it. And he needed to start taking shots of hard liquor, along with beer in order to get the intoxicated level he needed. More blackouts, found out he really likes fighting when he’s drinking. And so we start getting some police involvement.
All three parts of the brain are active here and pushing him to drink and to drink more. Nucleus accumbens wants its reward. And if he’s not drinking enough to get that reward to the level that it’s used to, it’s going to push him to drink more. The dorsal striatum is creating habit around getting this reward the number of days a week that he’s doing it.
The extended amygdala is heightened to stress and not handling stress as well. And certainly having hangovers and coming down is not fun and it is stressful. And so he drinks again that goes away and he’s able to get the intoxicated feeling back. His prefrontal cortex is not fully developed and is also somewhat compromised now. He’s not recognizing problems. He’s having cravings to drink. His behavior is getting out of hand and he’s not able to really abstain from drinking for very long, at all. There’s no reason to try to curb your drinking if you’re going to flunk out of that semester and you know, you can’t pull it out, might as well keep drinking. That’s the dysfunctional response.
What happened here is that the person was no longer using to feel good, but to feel okay. To remove the negative feelings and physical consequences of withdrawal. To feel normal. And the person became more out of control. And it’s the brain’s basic survival instincts that are driving it. He was seeking pleasure, just like we all do and didn’t mean to get in over his head. He didn’t know that his brain was literally changing and pushing him in ways that he wasn’t able to tell were happening.
Addiction was not his choice. He was saying yes to feeling good. He was saying yes to experimenting with alcohol and drugs and hanging out with friends without parents around. That’s what he said yes to. He didn’t know where the line was, where things started to flip. But once that switch is flipped, he couldn’t go back. Just like every other addict and alcoholic.
I’m hopeful that this discussion about the brain science helped you see what’s at play when our clients are using. And why their reactions to things seem so off compared to what we think would be a normal or rational response. It can be frustrating to watch our clients do the same thing over and over. And remember the five parts. They can’t consistently abstain. They have a dysfunctional, emotional response to things. They have impaired behavioral control. They’re experiencing cravings. And they’re not able to see that their problems are caused by the substances they’re using.
We’ve got our work cut out for us. I absolutely believe that we can help them. I believe that as mental health therapists, we are uniquely gifted to help people face their substance use and support them while they work to get sober. And people do recover and live wonderful, healthy lives,
Let’s say that you buy what I’m selling; that addiction isn’t a choice. That it is a chronic medical illness caused by changes and neuro adaptations in the brain. Why then does one person become an addict or an alcoholic and another doesn’t.
Next podcast we’re going to talk about the risk factors for addiction, both genetic and environmental.
If you’re ready to take the next step in addressing your client’s substance use head on over to betsybyler.com/treatment tool. The treatment planning tool I created will help walk you through the process of evaluating your clients use and deciding how and when to intervene. The tool is completely free and will be delivered to your email so that you can use it right away.
Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist, friends, and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to email@example.com. I’ll see you on next week’s podcast and until then have a great week.
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