Addiction: A Disease 

The narrative around the cause of addiction is that it's due to moral failure. In 1987 the American Medical Association (AMA) classified chemical abuse as a disease (1). In 2018 a survey composed of 1,337 people was conducted by the Associated Press - Center for Public Affairs Research (AP-NORC) to find out how many people viewed addiction as a disease. Results reported that 53% of the participants saw addiction as a disease. 44% of those surveyed regarded opioid addiction as a result of lacking discipline and willpower. 32% believed is was caused by bad parenting or a character defect. With that stated ⅔ believed that decision-makers should make treatment programs more accessible and affordable (2,7). Again the survey was conducted in 2018, in 2020 reported by the National Center for Drug Abuse Statistics (NCDAS) 25.4% of illegal drug users have a drug disorder (9). In 2021 more than 106,000 people in the U.S. died due to a drug overdose (8). It’s clear substance abuse is an issue. In order to move forward in constructing policy and medical infrastructure there needs to be an understanding that addiction is a disease.

There’s a misconception that classifying addiction as a disease it absolves responsibility from people with substance use disorders (SUD). When talking about addiction it should be viewed with a biopsychosociological approach. The biopsychosociological framework encompasses the complex intersection of biology, behavior, and environment when it comes to the development of addiction. In The New England Journal of Medicine, the article Neurobiologic Advances from the Brain Disease Model of Addiction by Nora D. Volkow et all, states some of the stages of addiction. For simplification purposes, it was divided into three categories: binge and intoxication, withdrawal and negative effects, and anticipation or craving.

Let's unravel the process by starting with binging and intoxication. What is happening when a person takes drugs? Essentially, the drug is stimulating the part of the brain that releases dopamine. Dopamine is a neurotransmitter that is in charge of experiencing pleasure, drive, and satisfaction (5). Activities like shopping, having sex, eating, etc all trigger a dopamine release. When someone takes an addictive substance it stimulates a reward signal in our receptors that commences associative conditioning. The associative conditioning sprouts the relationship associating the drug with pleasurable feelings. However, repeated exposure that garners the same reward causes dopamine cells to stop responding to the stimuli. Rather dopamine cells will release an anticipatory cue that expects the intake of the conditioned simulus[drug intake]. 

Since this process is ingrained in conditional learning, the greater the reward the greater effort the person is willing to exert. They are also more willing to endure negative consequences in order to obtain the reward, which in this case is the addictive substance. When finally receiving the reward, after repeated exposure, you were after (ex: eating) dopamine cells will stop firing. With drugs, dopamine levels continue to increase. 

  It’s important to understand that essential functions are trumped by the need to access the addictive substance in order to get that dopamine release. Previously, it was believed that drug users would become more sensitive to drug effects over time. However, when screening drug users versus non-drug users researchers noticed that a person with addiction had high levels of dopamine, so they theorized it was caused by increased sensitivity. However, what is actually occurring is that a person with a substance abuse disorder develops a tolerance to the drug effects (5). Over a period of exposure to the drug bodily enzymes become less reactive to the substance (6). So what does this mean? The person won’t experience the same type of euphoria they originally had when they first took the drug. Maybe you’ve heard the phrase chasing the high. Due to the built-up tolerance, people will seek higher doses in order to feel something. As a consequence, the person struggling with addiction won't react the same to everyday situations, which negatively impacts relationships, hobbies, career development, etc. Since the brain’s reward system has been reordered to prioritize drug intake it will be a gradual process until the person is able to respond to everyday stimulus as this did pre-drug addiction. 

Another change in the brain caused by drugs is observed in the extended amygdala located in the basal forebrain. The amygdala is responsible for the emotional evaluation of the stimuli. It’s due to the alterations in the amygdala that causes a person with a substance abuse disorder to have very strong positive or negative emotions (5). This altered system is then upheld by the neurotransmitters involved with stress response. The stress neurotransmitters become overly active, which leads to an increase in dysphoric emotions that are observed when the substance is withdrawn. This explains why people dealing with drug addiction experience an intense need to obtain the drug in order to get rid of the extreme pains caused by the absence of the drug.“In persons with addiction, the impaired signaling of dopamine and glutamate in the prefrontal regions of the brain weakens their ability to resist strong urges or to follow through on decisions to stop taking the drug. These effects explain why persons with addiction can be sincere in their desire and intention to stop using a drug and yet simultaneously impulsive and unable to follow through on their resolve.”

Extracted quote: “In a person with addiction, the reward and motivational systems become reoriented through conditioning to focus on the more potent release of dopamine produced by the drug and its cues. The landscape of the person with addiction becomes restricted to one of the cues and triggers for drug use. However, this is only one of the ways in which addiction changes motivation and behavior (5).” So, the changed prefrontal regulatory circuits system in conjunction with alternations in the reward and emotional response circuity stunts the development of controlling compulsive behavior and leads to the incapacity to voluntarily stop drug intake. 

We discussed a lot of the biological/genetic components that lead to addiction. That is not to say that substance abuse disorders aren’t influenced by other factors such as family history, environment, social factors, or development. The key component of a biopsychsociological view is to encompass the complexity of addiction both genetic and psychological. Understanding that addiction is a chronic disease, there needs to be medical infrastructure to be able to provide adequate long-term care for someone struggling with addiction. Although prevention programs are commonly in place there needs to be a system that concentrates on the development and access of treatment.

References

1. More Than Half of Americans View Addiction as Disease: Survey – Partnership News Service from the Partnership for Drug-Free Kids. (2018, April). Partnership to End Addiction. Retrieved May 9, 2023, from https://drugfree.org/drug-and-alcohol-news/half-americans-view-addiction-disease-survey/

2. More Than Half of Americans View Addiction as Disease: Survey – Partnership News Service from the Partnership for Drug-Free Kids. (2018, April). Partnership to End Addiction. Retrieved May 9, 2023, from https://drugfree.org/drug-and-alcohol-news/half-americans-view-addiction-disease-survey/

3. Volkow, N. D., Poznyak, V., Saxena, S., Gerra, G., & UNODC-WHO Informal International Scientific Network (2017). Drug use disorders: impact of a public health rather than a criminal justice approach. World psychiatry : official journal of the World Psychiatric Association (WPA), 16(2), 213–214. https://doi.org/10.1002/wps.20428

4. Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016, January 18). Neurobiologic Advances from the Brain Disease Model of Addiction (D. L. Longo, Ed.). The New England Journal of Medicine. 10.1056/NEJMra1511480

5. Dopamine | healthdirect. (n.d.). Healthdirect. Retrieved May 10, 2023, from https://www.healthdirect.gov.au/dopamine

6. Barnhart, R. (2022, March 28). Drug tolerance: What it is, how to deal with it, and more. Medical News Today. Retrieved June 18, 2023, from https://www.medicalnewstoday.com/articles/drug-tolerance#what-is-it

7. Americans Recognize the Growing Problem of Opioid Addiction. (n.d.). AP-NORC. https://apnorc.org/wp-content/uploads/2020/02/APNORC_Opioids_Report_2018.pdf

8. (n.d.). NIDA.NIH.GOV | National Institute on Drug Abuse (NIDA). Retrieved June 18, 2023, from https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates

9. (n.d.). NCDAS: Substance Abuse and Addiction Statistics [2023]. Retrieved June 18, 2023, from https://drugabusestatistics.org/