Facing Addiction In America

The Report itself is impressive in both breadth and scope. It tackles many issues and perspectives, while providing a wealth of statistical information substantiating the need to take dramatic, immediate and urgent action to combat the acute public health crisis of addiction.

At times the task can seem overwhelming. However, the report does hold out a modicum of hope, noting that more than 25 million Americans have been successfully treated and remain sober. The report also sets forth a specific, unique and compelling paradigm for understanding addiction itself, which I feel deserves further explanation. You see, most of us think that we understand exactly what it means when we discuss ‘addiction’. However, this report provides such concise perspective that it will serve us well in providing better service and care for our patient addicts with improved insight on exactly what makes them tick.

Addiction As a Chronic Disease

The report begins by advancing a concept we are familiar with, the agenda of addiction as a chronic disease. The industry has already shifted convincingly in this direction, understanding addiction is akin to hypertension and diabetes: conditions requiring long-term, ongoing care. This point is underscored by greater availability of coverage from insurance companies. This is a very important social objective considering that every $1 invested in viable treatment options leads to savings of $4 in health care costs plus $7 in criminal justice costs. It will also place more demands on our industry in the coming years as compensation for patient care evolves to a “success based” model, starting with upcoming changes to Medicare and Medicaid reimbursement policies and procedures.

As with any chronic disease, it’s important to get a handle on why a disease presents itself to begin with. Not all people use substances, and even among those who do, not all are equally likely to become addicted. The onset of addiction is subject to the usual culprits of disease, including genetic, environmental, social and developmental factors, including trauma.

Genetic factors seems to be the most pressing, thought to account for 40-70 percent of the risk in becoming an addict. The second key indicator is the age of first use: the younger someone is when he or she tries drugs or alcohol for the first time, the more likely he or she is to succumb. That part of the equation has a lot to do with the fact that addiction stems from a brain disorder and that adolescent brains are still in the midst of forming. They are, therefore, more likely to have the actual drug or alcohol use cause direct damage to their brains, and that’s where we are going to turn next.

Use of Brain-Imaging Technologies In The Study of Addiction

Studies on addiction have benefited greatly from the use of brain-imaging technologies such as magnetic resonance imaging (MRI) and positron emission tomography (PET scans). They allow scientists to see the human brain in action, so they can investigate and characterize the structural changes in the brain from alcohol and drug use. The brain is made up of 86 billion neurons (nerve cells). The neurons communicate with each other through neurotransmitters (chemical messengers). Substance abuse affects the normal functioning of the brain in two very important ways. First, and as expected, the interior workings of the brain are altered during drug use, with specific effect depending on the drug itself. That’s what creates the “high” the user is looking for. For some people that’s where it ends. They have the ability to use alcohol or drugs recreationally, without becoming addicted. However, for many others, there is a secondary effect that is much more troubling. Continued abuse leads the brain to actually re-wire itself in a way that perpetuates the cycle of addiction.

The Addiction Cycle

Binging involves significant consumption of an intoxicating substance over a short period of time. During this time, the drug is acting on the neurons in the brain, typically increasing dopamine, serotonin and other brain chemicals, leading to the pleasurable affect. Withdrawal is when the “high” dissipates, simultaneously creating a deficit in the brain’s chemicals, leading to the opposite effect of the high. The “anticipation” stage is when one yearns for a drug in search of either another high or just to bring your body back into stasis, depending on just how drastic the situation of drug abuse is.

​Initial Use Of a Drug Typically Depends On Impulsivity

An adolescent usually doesn’t give much thought to consequences when offered that first pill, smoke or drink. In this instance social and environmental factors can lead to continued use, until the pleasure itself is the goal, leading to abuse and addiction. However, initial use can also arise from a desire to relieve negative feelings, like those of awkwardness in social settings, or the removal of pain, anxiety or depression. In those cases, it’s the relief that provides the desire to use again. Then, regardless of the motivation for the initial use, continued use leads to increased tolerance so that the user requires more of the drug of choice to achieve the desired effect. Meanwhile, the excessive drug abuse, while only taking the user to the same level of high, starts creating an ever more destructive cascade of withdrawal cycles and ever greater “anticipation”. In fact, it gets so bad that the person’s brain can no longer create normal on its own. The brain’s reward function is desensitized so dramatically that normally rewarding actions such as sex or a good meal, for example, are no longer of interest. The addicted person’s brain has been altered to the extent that he or she uses the substance just to relieve the symptoms of withdrawal. Eventually, impulsivity leads to compulsivity and the primary drivers of repeated substance use shift from seeking to get “high” to the mere elimination of the “low” of withdrawal. By way of example, former Major League Baseball star Doc Ellis famously threw a no-hitter while under the influence of an excessive amount of LSD. The LSD took him to normal and he performed at his athletic best.

The Report couldn’t have been released at a more critical and opportune time. It will play a vital role in educating our politicians and the population at large. Addicted Americans need to be treated with care and compassion, not like pariahs, tossed to the whimsy of the criminal justice system where they won’t get the treatment they so desperately need. Ideally, this is the first step, the shot across the bow, that helps our nation focus on the growing epidemic, to give it the attention and resources it demands to start changing the tide in resolving this perilous social health crisis.