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How Addiction Happens: It's Not Just Poor Life Decisions

There's no known treatment that works for everyone

By National Institutes of Health

Addiction affects millions of Americans. It's not simply a failure of will or character; it is a disease of the brain. 

According to various estimates, about 3.6 million people in the United States are addicted to or dependent on a wide range of drugs. Many are addicted to more than one. In addition, there are about 18.7 million alcoholics. Millions more are functionally addicted to things we don't consider drugs, like tobacco, caffeine and food, as well as to such activities as gambling, shopping, sex and spending time on the Internet.

Of course, the term addiction can be used too loosely, so let's look at some definitions. Addiction is diagnosed by considering people's behavior. How much do they seem to need the substance (or addicting agent) to function? What are they willing to do to get it?  How reckless and risky do they act while feeling its effects? How much do they ignore other things in their lives as they pursue what they're addicted to?

The line between addiction and substance abuse can seem vague, but medical professionals have specific criteria to distinguish them. Substance abuse causes harm to the user; people are considered to be abusing a substance if, during a 12-month period, they do any one of the following:

  • Fail to meet responsibilities (educational, professional, or social) because of it.
  • Act in a reckless manner while under its influence.
  • Have legal problems because of it.
  • Continue to use it despite knowing the problems it causes.

Addiction is a more severe condition, and involves doing more than one behavior. The American Psychiatric Association lists a number of behaviors it considers symptomatic of addiction, and says a person must do three or more of them within a 12-month period to be considered "substance dependent." 

Among the symptoms are:

  • Developing a "tolerance" for the substance. Tolerance means needing increased amounts of it to feel its effects or feeling a decreased effect when using the same amount
  • Suffering withdrawal symptoms if one stops taking it or decreases the amount one takes. Withdrawal symptoms include an array of unpleasant effects, ranging from minor (such as sweating, anxiety) to the severe symptoms associated with withdrawal from narcotics (like pain, cramps, tremors and nausea).
  • Losing control, as shown by taking more of the substance than planned or trying but failing (several times) to stop using it.
  • Spending a lot of time trying to get it, use it or recover from its effects.
  • Ignoring other activities (educational, professional, social or personal) because of its effects.
  • Continuing to use it despite knowing the physical and/or psychological problems it creates.

In the past, this kind of behavior was seen as a moral weakness or spiritual failing. Today we know that addiction is a disease of the brain. What does this mean?

How Addiction Changes the Brain

In recent years, clinical research into addiction has been greatly aided by sophisticated imaging technologies that let us look at the brain and see how it changes because of addiction. It appears that addictive substances alter the nerve cells (neurons) in the brain, which affects how they transmit and receive information. Addictive substances, therefore, are things that can create these changes in the brain. Obviously, not all drugs have this effect; therefore, not all drugs are addictive.

Each substance can cause different changes, but in general they seem to affect the "reward circuits" or "pleasure pathways," the information pathways that tell the brain when something (a substance or an event) is pleasurable. The changes can make normal, pleasure-producing things seem less pleasurable, while reinforcing the need to use the addicting agent.

Other parts of the brain can also be affected, including those that control the memory-making process, decision-making skills, judgment, desires, emotional responses and motivation. The result of all these changes is that the brain is "rewired" so that it produces an all-consuming, uncontrollable craving for the addictive substance, a craving that overwhelms the addict's normal needs, desires and sense of values.

These changes in brain structure and function can last a long time, even after a person stops using the substance(s) that created them. But some changes may be reversible. That's why treating addiction is as important as treating any other disease. 

Some Get Hooked, Some Don't

Addiction is a serious problem, but let's be clear. Not everyone who takes drugs or drinks alcohol will become addicted. Not everyone with the addiction gene becomes an addict. Genetics and environment together play a role.

Why do some people become addicts and others don't?  The answers to this question are complex and not entirely understood.  We do know that being vulnerable to addiction seems to result from a combination of genetics and environment.  In other words, there are risk factors for addiction just as there are for other diseases and disorders. (Risk factors are things that increase your chance of developing a disease or condition, but they do not mean you definitely will get it.) 

The major risk factors appear to be:

  • Genetics: Most likely a number of genes are involved in making people more vulnerable to addiction. Studies of twins show that genetics explains perhaps 50 to 60 percent of the vulnerability. Children of alcoholics are four times more likely to develop alcoholism themselves than others and at least 60 percent of alcoholics have family histories of alcoholism.
  • Psychological problems: People with attention-deficit/hyperactivity disorder, post-traumatic stress disorder, anxiety, depression, mood disorders, feelings of loneliness and other psychological problems are at greater risk of developing addiction. Often drugs are used to cope with these problems, but then the drugs themselves become a greater problem.
  • Social environment: Peer pressure is a powerful influence in beginning drug use. People who live, go to school or work in an area where drug use, abuse and addiction are common are at greater risk of becoming drug users, abusers or addicts.
  • Type of drug: Addictive substances affect the brain and brain chemistry in different ways. Some can create the changes in the brain that cause addiction much faster than others.
  • Early drug use: Using addictive substances at an early age can put one at greater risk of developing addiction.
  • Early traumatic experiences: Children who have had a history of neglect, abuse (psychological, physical and/or sexual) and other traumatic experiences are at greater risk of developing addiction. These experiences can affect a person's brain chemistry in ways that make them more vulnerable to addiction.

Successful Treatment for Addiction Doesn't Happen Overnight


While addiction is a disease of the brain, it can be successfully treated. Relapses are unfortunately sometimes part of the recovery process and the treatment does take time.

Perhaps the best way to understand why relapse is so common a problem among people with addiction is to think of addiction as a chronic disease. Chronic diseases are lifelong illnesses. They may never be cured, but they can be treated and managed so that their symptoms or negative effects are minimized. Sometimes the damage the disease has already caused makes the treatment difficult, and the patient may suffer relapses. And sometimes these relapses are caused, at least in part, by the person's behavior.

People with addiction have suffered changes in and damage to their brains that can linger for years. These long-lasting changes are what make addiction a chronic condition and people with it vulnerable to relapse.

Even after they have stopped using the addictive substance for a seemingly long time, the combination of external situations (like events that create stress or sadness, or the reverse, events that leave them excited or elated) and the damaged "wiring" in their brains can trigger cravings for it. Because their decision-making skills have been impaired, the cravings can overwhelm their better judgment. In other words, they give in to the craving even though they know it will harm them.

What is treatment for addiction? Because of the singularity of each human being, and because of the large variety of addictive substances, treatment must be tailored to the individual. But it usually does, and should, include both medications and psychological counseling.

The National Institute on Drug Abuse, one of the National Institutes of Health, discusses 13 principles of effective treatment for drug addiction.  They are:

  • No single treatment is appropriate for all individuals.
  • Treatment needs to be readily available.
  • Effective treatment attends to multiple needs of the individual, not just his or her drug use.
  • An individual's treatment plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs.
  • Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.
  • Treatment does not need to be voluntary to be effective.
  • Remaining in treatment for an adequate period of time is critical for treatment effectiveness.
  • Individual or group counseling and other behavioral therapies are critical components of effective treatment for addiction.
  • Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
  • Addicted or drug-abusing individuals with co-existing mental disorders should have both disorders treated in an integrated way.
  • Possible drug use during treatment must be monitored continuously.
  • Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection.
  • Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.

You can get detailed information about these principles, and about all other aspects of addiction, at the National Institute on Drug Abuse.

Many experts think of treatment for addiction as a three-stage process. The stages are:

  • Detoxification/stabilization (also known as withdrawal): The goal of this stage is to get the drugs or alcohol out of the patient's system and eliminate or minimize the physical and emotional symptoms they have produced. This can involve slowly reducing the dose of the drug to zero and/or substituting one with less severe effects. "Cold turkey" is a slang term that means drugs are suddenly and completely withdrawn. This process of total, rapid withdrawal can produce strongly unpleasant withdrawal symptoms.
  • Rehabilitation: This stage focuses on the patient's psychological and emotional problems, on helping the patient make the personal changes (in lifestyle, attitudes, etc.) they need to fight their vulnerability to relapse. This stage of treatment can (and usually should) involve both medications and various forms of psychotherapy, including:

    ◦    Individual talk therapy with a wide range of therapists, like psychologists and psychiatrists, clinical social workers and counselors, and clergy.
    ◦    Group therapy programs, including 12-step programs, like Alcoholics Anonymous. Group programs can be residential or outpatient. Currently, the "90-Day Rehab" model, which, as its name implies, tries to rehabilitate patients during an intense 90-day program, has been showing a lot of success.

  • Continuing care: because of their vulnerability to relapse, people recovering from addictions need services that monitor their progress, their physical, psychological, and emotional health, their attempts to change their attitudes and lifestyle, etc. Patients may need help with sucj issues as work or school, legal problems, and relationships with family and friends. The form of treatment in this stage is similar to that of the second stage, that is, various forms of individual and/or group psychotherapy; however, it is usually not as frequent or intense as during the second stage.

Finally, we need to remember that people don't become addicted to drugs or alcohol because they want to ruin their lives. They become addicted because at first using them makes them feel good. To be effective, a treatment program must accept and deal with this fact.

National Institutes of Health
By National Institutes of Health

The National Institutes of Health, a part of the U.S. Department of Health and Human Services, is the nation's medical research agency — making important discoveries that improve health and save lives. NIH is the largest single source of financing for medical research in the world, seeking new ways to cure disease, alleviate suffering and prevent illness. By providing the evidence base for health decisions by individuals and their clinicians, NIH is empowering Americans to embrace healthy living through informed decision-making. NIH is made up of 27 institutes and centers, each with a specific research agenda, focusing on stages of life, like aging or child health, or particular diseases or body systems.

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