Addiction: The Disease Joseph A. Troncale, MD FASAM
So What is the Problem Here? The medical system does a relatively poor job to treat both alcohol and drug abuse and addiction. Since addiction has a social and a behavioral component, it is not a clean problem. People who are drunk or under the influence or who are addicted are not pleasant or rewarding to deal with. The morbidity, morbidity and costs associated with substance use and addiction is astounding. Addicted persons have twice the likelihood of being hospitalized and at least four times the likelihood of being incarcerated.
Just Think About This Please Why do addicts get incarcerated when they are intoxicated and diabetics who don t take their insulin get hospitalized? Why do we hospitalize people with their fourth heart attack, but the system does not hospitalize people with addiction who have relapsed four times?
What is Addic;on? Addiction is a chronic illness of the limbic system of the brain causing chronic and relapsing behaviors of afflicted individuals. The problems of addiction can manifest itself as alcoholism, drug addiction, eating addiction, gambling addiction, sex addiction and other compulsive behavioral disorders. We are going to concentrate on substance addiction today, but the principles are the same for all addictive behavior.
Prevalence About 8 per cent of the population gets addicted. This number remains constant through much of the population of the world, but there are genetic factors that we will discuss. People become addicts and generally addiction sneaks up on people and so denial is a big part of the disease. We will discuss more about the timing of addiction.
Who Gets Addicted? We know that if you have 2 parents who are addicts, you have a 50% chance of being an addict/alcoholic. If you have one parent who is an addict, then you have a 30-35% chance of being an addict/alcoholic. So we see there is a definite genetic component. Obviously, if you never drink or drug, you will not become an alcoholic or drug addict.
What Are the Most Addic;ve Substances? If you do use substances and open the door to addiction, then this is how the statistics work: If you use the following substances, your chances for becoming addicted are: Tobacco 40% Heroin 20% Cocaine 20% Alcohol 12% Cannabis 10%
Are Substances Dangerous? 14,000 opiate addicts die in the US every year If you are a heroin addict your morbidity and mortality is 64 times greater than the general population 443,000 tobacco- related deaths annually in US (CDC data) 80% of incarcerated individuals have substance abuse issues. (CDC data) Marijuana users have a 7 times greater suicide rate than non- users.
The Key Issue What I think makes abuse and addiction so problematic for the medical provider is that medical people do not and generally do not care about the difference between substance addiction and abuse. Why is this important? Because we treat people with disdain who choose to make bad choices. Because we are not generally astute enough or aware enough to make the distinction between someone who has made a bad choice and someone who is out of control because of compulsive use.
The Limbic System What is the limbic system? Why is it so powerful? Why do I call it the lizard brain?
The Limbic System Described in 1952, the limbic system was found to be a series of nuclei in the brain that determines the emotional regulatory systems dealing with the 4 F s Fight Flight Feeding Reproduction
The Power of the Limbic System When you get angry or emotional, what happens? Basically, the limbic system determines the survival mechanisms and takes over from the logical mechanisms when stress or mood altering substances are introduced.
This is the Major Problem in Behavioral Medicine The limbic system and its regulation makes ALL the difference in people s lives. Whether one is a normal person, an anxious person, a schizophrenic person, an addicted person, a jerk person, a (fill in the blank) person, it is ALL determined by limbic system activity and how well a person is able to deal with their limbic activity. Limbic activity is totally unconscious and is only regulated by how well you are able to deal with your environment. Once the limbic system dysregulates, as it does in addiction and mental illness and bad behavior, the person is in trouble as are people who are interacting with that person.
Why the Lizard Brain? Anyone ever had a lizard for a pet? What did you get out of the relationship? The answer is NOTHING! So when people are in their limbic system, they are ONLY interested in the 4 F s. They are out of control and capable of any sort of behavior depending on how they have been programmed either environmentally or genetically. This is regulated by neurotransmitters.
So How Does This Have Anything to do with Addic;on? The answer is EVERYTHING If you don t get anything else out of this presentation, it is important that you understand that addiction and mental health issues are all manifestations of limbic system dysfunction. Addiction is a particular type as are every other type of mental illness. I could talk about other mental health issues, but this presentation is about addiction.
So What is Addic;on vis- à- vis the Limbic System? There is a specific lesion in the limbic system in addiction. We are going to go through the anatomy of the limbic system, and I plan to show you specifically why addiction is a disease just like diabetes or heart attacks are diseases.
Anatomy of the Limbic System
The Pleasure Center
What Happens in A Non- Addicted Person with Substance Use What makes an addict an addict and not a substance abuser? It has everything to do with the pleasure area we just discussed. Normally, if substances or certain types of stimulation are used by an individual, (use whatever mood altering substance you wish ), the ventral tegmental nucleus (VTN) sends out dopamine(da) to the nucleus accumbens (NA). When DA stimulates the NA, then intense pleasure is experienced.
What is the Difference Between an Addicted Person and a Non- Addicted Person? Practically everyone in life starts out non- addicted. The only exception to this may be individuals who are born to mothers of addicts who have been exposed to intense drug or alcohol use in gestation. For everyone else, we are born with the VTA- NA axis as regulated. So when mood- altering experiences or substances are introduced to non- addicts, what happens is that the dopamine levels in the axis are able to re- regulate once the mood- altering substance clears from the brain.
What is Addic;on? ADDICTION IS THE INABILITY OF THE DOPAMINE LEVELS IN THE NUCLEUS ACCUMBENS TO RE- REGULATE ONCE THE MOOD- ALTERING SUBSTANCE IS NO LONGER PRESENT. I would like to draw a diagram for you. What does this mean in practical terms?
What is Addic;on? Addiction, once it occurs, is a permanent change in brain function and anatomy. Addicts, once the VTN and NA regulatory mechanisms break, are then addicts for life. They can only manage their lives by REFRAINING FROM USE OF MOOD- ALTERING SUBSTANCES FOR THE REST OF THEIR LIVES. How difficult is this? If you are not an addict, you can only imagine
We Will Come Back to Treatment Later Anatomic Considera;ons Back to anatomy Let us look more carefully at the limbic system and its function The beginning of the limbic system is the prefrontal area The prefrontal area is responsible for olfaction, attention, and impulsivity. It is the area of the brain that we associate with ADD. It is the brakeman of the train. When the prefrontal area is not working properly, then the brakeman is asleep and the ability to pay attention goes badly. That is why stimulants are used to treat ADD to wake up the brakeman.
More Anatomy of the Limbic System The next stop in the limbic system is the Anterior Cyngulate Gyrus The Anterior Cyngulate Gyrus is associated with emotional regulation If you look at more recent literature on mental health issues and brain anatomy, the anterior cyngulate gyrus is associated with bipolar disorder and other affective disorders.
Anatomy (con;nued) The next stop is the ventral tegmental nucleus and the nucleus accumbens (The pleasure center) which we have already discussed as being the broken part of the limbic system for individuals with addiction.
Anatomy (con;nued) The next area is the hippocampus The hippocampus is the area of the limbic system associated with memory. This has important ramifications for people with addiction which we will discuss shortly.
Last Stop on the Limbic System The amygdala is the last part of the limbic system. The amygdala is the part of the brain that has to do with sexual behavior and rage. If one abuses an animal or a person and do a PET scan of the amygdala, one finds that the amygdala enlarges physically. If one removes certain parts of the amygdala, the subject becomes either hyper or hypo sexual or rageful or docile depending on what parts of the amygdala that are altered.
So How Does This All Fit Together? Here s what I need for you to understand today The limbic system is probably the most powerful system in the body from a behavioral standpoint. If you are an addict or alcoholic, the limbic system is dysregulated in the VTN and NA. But more importantly, it is important that you all understand that the VTN and NA are in the center of the limbic system and that all the other components of the limbic system are talking to each other, then you can see that the behavior and mental health of the individual is at high risk.
Some Examples If you have ADD or are bipolar or have been abused, your limbic system is always on edge. You are struggling to keep your emotions intact and unless you get expert help, you may find yourself trying to self- medicate with alcohol or drugs to stabilize your limbic system, but inadvertently set oneself up for getting into substance abuse or addiction.
The Twelve Steps of AA 1. We admitted we were powerless over alcohol that our lives had become unmanageable. 2. Came to believe a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
Twelve Steps (con t) 6.Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9.Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory and when we were wrong promptly admitted it.
Twelve Steps (con t) 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.
12 step recovery Alcoholics Anonymous is, in my opinion, a sort of a miraculous discovery understanding the limbic system in the 1930 s before the limbic system was discovered. It is important to understand that the 12 steps are all about behavior that is ANTI- LIMBIC. It is all about keeping the limbic system from becoming active.
To summarize Alcoholism/addiction is a chronic, relapsing disease of the limbic system. Once the limbic system breaks, it cannot be fixed. Just like in Type 1 diabetes, once it occurs, it has to be treated for life with sobriety and care of the limbic system. There are many paths to sobriety, but recovery is an ongoing lifestyle change and requires maintenance like any other disease process. Since there is such a strong behavioral component to addiction, it is imperative that health care providers be aware that addicts do not like to be sick any more than someone with any chronic illness.