Addiction is the last topic I’ll be talking about in this Mental Health Month series, but since it’s such an important issue and big one, I’m going to divide it up into three parts:
How Do We Become Addicted?
In a previous series, A “Whole Brain” Theory of Human Motivation, I discussed the natural and healthy relationship between our shared universal needs and how we are motivated. In brief, whereas needs are the basis of human motivation, its our feelings that provide the means. When our needs are met, we feel pleasant emotions such as happiness, peace, love, and comfort. These “good” feelings reinforce the positives in our lives and we are internally motivated to integrate them as consistent experiences in our living. When our needs are unmet, unpleasant emotions arise creating a pattern of energy and motivation to course correct our behavior back towards healthy. In this unpleasant state, we feel levels of discomfort, but in useful ways this discomfort can contribute to our self-awareness and drive us to make changes towards what we need. All the above describe the normal, optimal, and healthy way in which our minds and bodies are coordinated to influence our thoughts and behaviors.
One way to think of addiction is that for whatever reason, something that is unhealthy, unnatural, or damaging has hijacked this motivational system. This can be drugs, food, gambling, sex, or even your Facebook feed. Looking closely, we can see the parallels in mindset and behavior between the natural state of being deprived of something we need versus the behavior of someone who is addicted to a drug like heroin. Let’s use the normal situation of thirst. Thirst is the feeling we get when certain sensors in our body tell us that we’ve become dehydrated. The level of thirst we feel is proportional to the significance of our need. Very dehydrated equals very thirsty. Appropriately, if this is the case, our minds create a sense of urgency to get something to drink now, taking priority over whatever else we may have otherwise been doing at the moment. Next, our behavior becomes motivated to find water, and if water is not available then a close and safe substitute, like a sports drink or iced tea. If a comparable substitute is not available, we then become willing to make compromises to quench our thirst, even if we know that what we’ve chosen isn’t the best option for other reasons, like a couple of beers or a late night coffee. And until our thirst is quenched, it’s likely that we would stay preoccupied to find something to drink, regardless of what other important issues need to be addressed in the moment, because our minds have convinced us that for this moment, this is more important than that.
This example of the natural drive to meet a need is the same mechanism seen in addictive behaviors. However, with addiction the difference is that there is at least one of two conditions, but usually both:
1) an unhealthy strategy to meet a legitimate or valid need, or
2) the need that drives the addiction is artificial or inauthentic
Let’s look at a few examples. A person could have a need for comfort, for space, or for peace. This is relatable right? It’s a pretty common situation that we all inevitably come across, where a strategy that makes us feel relaxed would likely meet these needs. The specifics of how we can achieve this should be healthy and sustainable, such as with exercise, meditation, or spending time with a loved one. Or we could seek some form of engaging entertainment, like watching our favorite TV show. Or we could have a glass of wine. Or we could do something mindless like surf the web. Or we could watch some porn. Or we could have some more wine. Or we could smoke a bowl. Some of these strategies are better than others, and we can measure their usefulness by how effective they are at meeting our needs, which justifies almost any of the above. However, when we think about others measures beyond effectiveness, such as value or cost, sustainability, safety versus harm – then we can start to understand why certain strategies are healthy and should be repeated, and why others are unhealthy and should be avoided. In many cases of how addictions start, it’s the justification of effectiveness alone that allows us to continue certain behaviors.
Without scrutinizing the other costs of these strategies, we passively allow ourselves to repeat behaviors that are hurtful in the long run. What do these costs look like? Because these addictive states are inconsistent with our optimal human experience, the outcomes inevitably lead to unhealthiness and sometimes true states of dysfunction and disability. The consequences of these problematic states are the typical patterns of behavior we see in addiction. Escalating use despite obvious self-harm. Physical and mental deterioration. Strong drives to seek after more of the damaging substance at the expense of other basic needs. Pain, both emotional and physical, when deprived of the substance.
The second condition referenced above talks about the shift from legitimate universal needs initiating our behaviors, to the formation of artificial needs that are created only in the context of repetitive behaviors. There is a normal process within our brain’s reward circuit where activities that are enjoyable become less enjoyable over time when repeated. This is thought to occur because fewer and fewer “feel good” chemicals are released over time. This is called habituation. Think about the first time you went to your favorite restaurant and everything about that experience that made it memorable. Then think about your experiences going back. I bet that even though it’s still enjoyable to go there, it’s never been as enjoyable as the first time. In order for these types of “fun” experiences to continue to be maximally enjoyable, our brains need variety or greater intensity. For instance, if you enjoy snowboarding, but you were only able to go down the same slope over and over again, eventually you would grow bored. However, if you were able to try different challenging trails or go to a new ski resort, you would likely continue to enjoy yourself. Behavioral addictions, such as with gambling or sex, reinforce this pattern of thinking and behavior – seeking constant variety or escalating intensity.
With certain drugs there is also an additional biochemical process that further reinforces a need for escalating dosing. With most drugs of abuse, as higher and higher doses are used, the body and brain make accommodations to better “receive” the amount of drug that is being put into the body by increasing the number of available receptors. With many drugs of abuse, including certain prescription drugs that are misused, we can see this pattern of a gradual increase in a person’s “normal” dose. This is called tolerance. For many drugs, as this dose escalates, eventually our body systems become overwhelmed. Examples include liver toxicity in binge drinking or losing consciousness with high doses of opiates. The drive behind escalating use, despite these impending dangers, is motivated by wanting to replicate the early “good” feelings associated with the drug. However, because of habituation and tolerance, this can no longer be achieved at previous lower doses. Once that satisfying dose is achieved and reinforced, a positive feeling of relief is accompanied by the typical “high” of the drug, doubly reinforcing that taking this new higher dose is a “good” thing, even if in reality the escalated dose is dangerous.
Related to tolerance is the experience of withdrawal. So picture a popular local band on the rise with a loyal following, playing to packed clubs around town. As they start to get more exposure and gain more fans, they start playing in larger venues, eventually selling out arenas while touring the country. During the next album tour, the band decides that they’re going to do stadium shows, but they’ve overreached by overestimating their current popularity and appeal. Rather than packing a 20,000 person arena, they’ve got 60,000 fans but in a football stadium that can seat 85,000. Though there’s plenty of people there, the empty seats can’t help but be noticed, and there’s a let down because of the difference. So tolerance is like moving to larger venues with more seats to accommodate the growing fan base, whereas withdrawal is when there are now too many seats and not enough fans. More specifically, withdrawal is the experience of changes in the brain and body as a result of not having enough of a drug to fill empty receptors. These symptoms are more pronounced when the number of available receptors has multiplied because of the process of developing tolerance. With certain drugs that don’t stay in the body very long, a sudden experience of withdrawal is more likely, and often the more sudden the withdrawal, the more uncomfortable the symptoms are. As these experiences of withdrawal can be painful and occasionally dangerous, sometimes it’s in wanting to avoid a bad withdrawal experience that motivates a person to choose ongoing drug use. Also, if a person is already experiencing withdrawal symptoms but then takes an adequate amount of drug, the withdrawal symptoms are immediately relieved. Continuing with the above analogy, if on the next stop of the band’s tour the stadium is packed full of fans again, then everyone feels better. Maybe even better than they would otherwise, specifically because of the let down at the last stop. Since there’s both positive and negative reinforcement to resume drug use, the more primitive parts of the brain see this as a good decision, despite the smarter parts of the brain knowing better. This leads to the next important factor as to why addictions persist – impairments in judgment.
In Part 2, we’ll talk more specifically about how the different effects of the most common drugs of abuse lead to unique challenges in using our best judgment, and how partially met needs leads to ambivalence about quitting.