This book looks at the disease of addiction from a Christian physician's perspective.
There are very few books written about addiction from a Christian perspective.
Chapter 7 "Addiction"
Addiction has become a prevalent topic. Our media reports daily the tragic stories of the opioid epidemic or the accidental overdose death of a celebrity.
Addiction is enslaving and killing our young people, devastating families, overstressing first responders and emergency room staff, and financially draining limited healthcare dollars.
Addiction is a monster that needs to be understood and contained.
The purpose of this chapter is to take a look into the eyes of this monster.
Why does it have so much power? Why is it so hard to overcome?
The AMERICAN SOCIETY OF ADDICTION MEDICINE’S short definition of addition states:
“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and relief by substance use and other behaviors.
Addiction is characterized by an inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
What does this mean? What is the DISEASE of addiction?
Addiction was first classified as a disease in 1987. At that time, “addiction” described a specific group of individuals that were seeking help, and the medical community had some things of value to offer. This disease classification also provided a diagnostic code number to the disease for billing.
The disease part of this condition was not well understood, and often, what we do not understand we demonize. The stigma and prejudice around addiction are still present today.
If you were to take a survey today – what do you expect would be the answer to the question – What is the cause of addiction?
Some would say that addiction is a lack of moral character. The addict is somehow an inferior human being and does not have the strength of character to say no to alcohol or drugs. If we were honest, this would be a common belief. This prejudice is seen in the treatment of an addict when they present for a primary care office visit, a trip to the Urgent Care or the Emergency Department, or talked about by misinformed family members.
On the other hand, an addict will often present as someone who lacks moral character. This behavior is a demonstration of the brain areas affected by addiction. The disease of addiction is not a lack of moral character.
Perhaps it is a lack of will power. It takes a lot of will power to overcome an addiction – so maybe it is just a lack of willpower that allows addiction to continue.
Recent studies of how the brain works using functional MRIs and PET scans show that this disease is a lot more than just a lack of will power. These studies show permanent areas of functional and structural brain changes.
Maybe it is a sign of acting out, open rebellion, or defiance. Even if the addiction started as a form of rebellion, is that the cause of the current ongoing struggle?
Is addiction a form of mental illness. Addiction is associated with a lot of irrational thinking – is that mental illness? Is it a chemical imbalance or the result of an inherited mental illness?
There is a lot of confusion surrounding the disease of addiction, a difficulty that needs dispelling if we are to know what to do for our suffering child, parent, patient, or friend.
A “disease” is an abnormal condition that negatively affects the structure or function of part or all of an organism. A disease is a dysfunction of the body’s homeostatic processes. The body needs to be in balance to function correctly.
The organ of disease in addiction is the brain, particularly the part of the brain called the reward pathway.
Your brain is fantastic; it consumes 20% of your body’s daily calorie requirements, yet only weighs a little more than 2 pounds. Your brain is made up of more than 86 billion neurons. The brain does what it does through the movement and activity of chemical messengers called neurotransmitters. These chemicals are tiny molecular keys that lock or unlock cell receptors that then cause a reaction in the neuron. These neurons, in turn, attach in a specific pattern to other neurons through their dendritic spines to form a network. The particular activation of this system will result in a thought, an emotion, or an action.
Classifying addiction as a disease could be used as an excuse to justify ongoing self-destructive behavior and attitudes or a way of avoiding personal responsibility. To use the disease diagnosis, this way, could be fatal.
We must understand what we are dealing with if we have any hope of effectively treating the disease of addiction.
The problem with addiction is that it is locked up in the brain – how do we understand what we cannot see?
What we see are the annoying symptoms of the disease, a presentation that often limits our ability to be aware of the disease.
Medical science has taught us a lot about addiction in recent years – with functional MRIs, tagged neurotransmitters, and PET scans. We now have a much better understanding of the brain pathology in addiction.
We need to understand this disease in terms we can all understand. How is this possible? The answer is the development of memory. If we can understand the formation of a memory, we will have a better understanding of how addiction develops.
Addiction is a strong memory in the reward pathway of the brain.
To understand memory, we need to understand epigenetics. Genetics is the DNA that we inherit, accounting for our hair color, eye color, etc. Epigenetics is how individual segments of DNA get expressed in a cell.
Every cell contains the same DNA. Through the mechanism of epigenetics, cells perform different functions meaning a muscle cell is different than a kidney cell. Epigenetics allows our nervous system to remain adaptable and learn new things. Memory is an epigenetic structural change in the DNA in the neurons in your brain.
Let’s take a look at how this works. Firstly, in the formation of memory and then in the development of an addiction. A stimulus causes a release of powerful neurotransmitters that directly impact the DNA in the neurons in various ways that will eventually result in the formation of a memory.
This process of change is called triggered neuroplasticity. Triggered neuroplasticity is the ability of the neurons to change or adjust because of a stimulus. Without neuroplasticity, we would not be able to learn or develop new memories or, as we shall see, develop an addiction.
The most common effect caused by the stimuli is called DNA methylation. DNA methylations lead to DNA exposure. This change in the DNA is similar to the impact a cancer-causing chemical has on a cell that results in it becoming cancer. DNA methylation prepares the cell to change its structure and function.
Also occurring is a process called posttranslational modifications of histones that allows the tightly coiled DNA to uncoil and expose areas of DNA that can then be modified. The DNA is now, no longer a tightly coiled bundle of DNA. The cell structure and function continue to change through modifications of noncoding RNAs that remodel chromatin and facilitate or suppress gene expression – the cell changes – protein manufacture can be turned on or turned off. The neuron has now changed both its structure and its function. Now you have a newly formed memory.
Let’s take a closer look at this process in the context of something we can all relate to – the development of different levels or types of memory.
Short term memory formation is the result of a minimal stimulus. This kind of memory extinguishes quickly.
For example, what do you remember about last Wednesday? It was not long ago. The chances are that unless it was somehow a particular day, you do not remember much. You might remember it if it was your birthday or anniversary, but otherwise, you have already forgotten much of what occurred just a short time ago.
If you increase the stimulus, the memory will last longer. This increased stimulus is the effect seen when cramming for exams, or with the memory of significant historical events –such as the assassination of President Kennedy or the first moon landing. How about September 11, 2001. What do you remember from that day? Do you remember what day of the week this was? Do you remember where you were? Do you remember what you did that morning or what you had for breakfast?
If you increase the stimulus, even more, the memory will also last longer, to the degree it may have a lasting, lifelong impression. The event changes you. You may even act differently or interpret the world differently because of this overwhelming stimulus caused memory. What do you remember about what happened in Boston on April 15, 2013? We most likely share very different memories of this day. On this cold, windy day on Boylston Street, my wife and I were standing across the street from the second bomb at the Boston Marathon. I can remember a lot about that day. I can easily relive that moment – from what I had for breakfast to the sensation of the hot cup of hot chocolate in my left hand as we experienced the explosion across the street. The overwhelming stimulus changed me.
This process of DNA unfolding and changing both its structure and function is how different degrees of memories are formed and stored.
Addiction develops similarly except the area of the brain being affected is the reward pathway of the limbic system, and the magnitude of the stimulus caused by drugs of addiction is more overwhelming than the stimuli that result in the formation of a memory. The structural and functional changes in the reward pathway of the brain have been confirmed with several medical studies. A study on the effects of cocaine on the brains of rats showed that there were 17 DNA changes in 6 brain areas. Another study was done on heroin addicts that had been in confirmed recovery for over nine years. This study showed ongoing significant functional MRI changes when they were exposed to auditory or visual drug stimuli. A study where subjects were given Morphine 50 mg daily for 30 days and then followed with monthly functional MRIs showed that the changes in brain function that occurred because of the morphine exposure did not improve six months after the completion of the study. Changes in these areas of the brain have a prolonged and dramatic effect. Some of these changes may be permanent.
Chemicals that can cause addiction can have their impact in several different ways. They can directly impact the neuron, or they can create a massive increase in the release of neurotransmitters and the reduction in the removal of these neurotransmitters. These actions result in an overwhelming stimulus to the neuron. This stimulus changes the DNA in the neuron. The stimuli cause a flood of dopamine from the nucleus accumbens that sends messages to parts of the brain, saying, “this is good and necessary.” The experience or feeling is something to be desired. You now have a powerful memory of desire and craving.
The impact of the stimulus in the hippocampus enhances the memory of the reward experience. It reinforces the memory that: “This is something I do not want to forget – I should remember as much about this reward as possible – where I got it, who I got it from, the people I used it with, the room I used it in – and on and on.”
The impact on the amygdala is an emotional one. I now feel secure, confident, at peace – I have never felt this complete in the past.
The impact on the prefrontal cortex is to assign a high level of value to this experience. Nothing else compares to this experience – I am willing to pay whatever it may cost to maintain this feeling.
As previously described, different levels of stimulus cause different permanence of memory. Varying degrees of activation of the reward system results in different levels of formed desire.
If the reward stimulus is low-level, the result is a preference. I like puppies better than kittens is an example of preference, but I don’t want to pay for that puppy or pay to take care of it for the next 17 years. I experience a choice. Preferences can easily be changed, especially if you have an issue with your preference or a better preference presents itself. Wait till that puppy chews your favorite shoes.
Increase the stimulus in the reward pathway, and you get what we call a desire. A desire comes from a felt need for a sense of completeness. In other words, I will feel complete if I can get what I desire. This desire area is the zone of operation of the advertising industry. If I can link your desire with a product that I sell, then the sale is easy. If I can sell you the fantasy that an expensive exotic new car can give you a sense of contentment or acceptance, the vehicle is quickly sold.
Unfortunately, the fantasy quickly fades with the first scratch, the $1,000 oil change, the eventual awakening to the reality that the illusion did not bring the contentment or sense of wellbeing it promised. But we still keep searching.
If you increase the stimulus, even more, you have an overwhelming stimulus. This overwhelming stimulus requires significant brain changes to accommodate, and you end up with an addiction. You are now past mirror preference and desire, into the world of an intense craving. The chemical has effectively highjacked your neurons.
Your brain is telling you that you may die if you do not get the substance that produced the stimulus. Stimulus caused alteration in the function and structure of brain DNA is the disease of addiction.
So now we have a better understanding of the disease of addiction, but we still have a significant problem. The problem is with the presentation of the disease, the often obnoxious behaviors, and manipulations of the addict. In other words, our ability to see the pain in the disease is clouded by how it presents. The changes in the limbic system not only result in cravings but also causes characteristic, self-destructive behaviors.
One of the significant changes is a problem with abstaining. You may hear, “I want to quit but can’t.” There is a willingness to sacrifice family, friends, jobs, and finances to get more of the drug.
The brain changes also cause irrational thinking that presents in many ways. The thought and belief that the drug is not causing any harm. Or the idea that I can overcome this with ease. Another evidence of irrational thinking is the belief that the addiction is not affecting anyone else.
There is also fanciful beliefs or “magical answers” to life’s problems. This irrational thought shows itself as getting rich quick schemes and irrational beliefs about the future.
When the addiction takes hold, there is impairment in behavioral control, and the addict may do stupid or dangerous things to get the drug at high personal cost.
Another brain change is the painful cry of cravings. The pain is substantial, physically felt pain. It is often experienced as pain that is more significant than any previously experienced physical pain. The pain drives the suffering addict to seek and find more of the drug.
The changes in the limbic system also cause a diminished recognition of problems with behaviors and relationships with the eventual loss of supportive family and friends. The pursuit of the drug is now life’s only priority. Trust and family are lost.
These changes also cause a loss of standard reward capacity. Now there is only one reward. Reward from social interaction, creative activity, exercise, or good food is gone.
This complexity of symptoms is the major problem in dealing with addiction. The brain changes caused by the drug do not set the stage for a pleasant interaction or productive relationship. The addict has become his own worst enemy. The addict lives in this isolated world of increased physical pain from withdrawal, increased emotional pain from the loss of trust, guilt, and shame, and increased existential pain with complete loss of purpose and meaning.
The individual’s presentation blinds the eyes and minds of their family, friends, and health care providers to the underlying disease. There is a conflict between love and trust. The addict expects you to trust and respect them when they cannot trust or respect themselves. They are hostile to the necessary boundaries that must be put in place to save their life. At this point, they are often very resistant to change.
Picture a cute, quiet baby, sitting in a tub of bathwater. The image is a picture of the dueling realities of addiction. What you have is a precious, little life, like all of us, full of potential and promise. But if you move a little closer, you will find that there has been an accident and the water smells very bad.
One part you desires to nurture this little life, the other part will make you want to hold your nose and run away as fast as you can. Ponder the reality of this picture, and do not throw the baby out with the bathwater.
Engagement in a recovery program and living a life of recovery, with a lot of hard work, is highly successful.