How Science Has Revolutionized the Understanding of Drug Addiction
Throughout much of the last century, scientists studying drug abuse labored in the shadows of powerful myths and misconceptions about the nature of addiction. When science began to study addictive behavior in the 1930s, people addicted to drugs were thought to be morally flawed and lacking in willpower. Those views shaped society's responses to drug abuse, treating it as a moral failing rather than a health problem, which led to an emphasis on punitive rather than preventative and therapeutic actions. Today, thanks to science, our views and our responses to drug abuse have changed dramatically. Groundbreaking discoveries about the brain have revolutionized our understanding of drug addiction, enabling us to respond effectively to the problem.
As a result of scientific research, we know that addiction is a disease that affects both brain and behavior. We have identified many of the biological and environmental factors and are beginning to search for the genetic variations that contribute to the development and progression of the disease. Scientists use this knowledge to develop effective prevention and treatment approaches that reduce the toll drug abuse takes on individuals, families, and communities.
Despite these advances, many people today do not understand why individuals become addicted to drugs or how drugs change the brain to foster compulsive drug abuse. This booklet aims to fill that knowledge gap by providing scientific information about the disease of drug addiction, including the many harmful consequences of drug abuse and the basic approaches that have been developed to prevent and treat the disease. At the National Institute on Drug Abuse (NIDA), we believe that increased understanding of the basics of addiction will empower people to make informed choices in their own lives, adopt science-based policies and programs that reduce drug abuse and addiction in their communities, and support scientific research that improves the Nation's well-being.
Nora D. Volkow, M.D.
National Institute on Drug Abuse
DRUGS & THE BRAIN
Introducing the Human Brain
The human brain is the most complex organ in the body. This three-pound mass of gray and white matter sits at the center of all human activity - you need it to drive a car, to enjoy a meal, to breathe, to create an artistic masterpiece, and to enjoy everyday activities. In brief, the brain regulates your basic body functions; enables you to interpret and respond to everything you experience; and shapes your thoughts, emotions, and behavior.
The brain is made up of many parts that all work together as a team. Different parts of the brain are responsible for coordinating and performing specific functions. Drugs can alter important brain areas that are necessary for life-sustaining functions and can drive the compulsive drug abuse that marks addiction. Brain areas affected by drug abuse - Brain diagram
- The brain stem controls basic functions critical to life, such as heart rate, breathing, and sleeping.
- The limbic system contains the brain's reward circuit - it links together a number of brain structures that control and regulate our ability to feel pleasure. Feeling pleasure motivates us to repeat behaviors such as eating - actions that are critical to our existence. The limbic system is activated when we perform these activities - and also by drugs of abuse. In addition, the limbic system is responsible for our perception of other emotions, both positive and negative, which explains the mood-altering properties of many drugs.
- The cerebral cortex is divided into areas that control specific functions. Different areas process information from our senses, enabling us to see, feel, hear, and taste. The front part of the cortex, the frontal cortex or forebrain, is the thinking center of the brain; it powers our ability to think, plan, solve problems, and make decisions.
How Does the Brain Communicate?
The brain is a communications center consisting of billions of neurons, or nerve cells. Networks of neurons pass messages back and forth to different structures within the brain, the spinal column, and the peripheral nervous system. These nerve networks coordinate and regulate everything we feel, think, and do.
Neuron to Neuron
Each nerve cell in the brain sends and receives messages in the form of electrical impulses. Once a cell receives and processes a message, it sends it on to other neurons.
Neurotransmitters: The Brain's Chemical Messengers
The messages are carried between neurons by chemicals called neurotransmitters. (They transmit messages between neurons.)
Receptors: The Brain's Chemical Receivers
The neurotransmitter attaches to a specialized site on the receiving cell called a receptor. A neurotransmitter and its receptor operate like a "key and lock," an exquisitely specific mechanism that ensures that each receptor will forward the appropriate message only after interacting with the right kind of neurotransmitter.
Transporters: The Brain's Chemical Recyclers
Located on the cell that releases the neurotransmitter, transporters recycle these neurotransmitters (i.e., bringing them back into the cell that released them), thereby shutting off the signal between neurons.
How the Brain Communicates: To send a message a brain cell releases a chemical (neurotransmitter) into the space separating two cells called the synapse. The neurotransmitter crosses the synapse and attaches to proteins (receptors) on the receiving brain cell. This causes changes in the receiving brain cell and the message is delivered.
All drugs of abuse target the brain's reward system by flooding the circuit with dopamine.
How do drugs work in the brain?
Drugs are chemicals. They work in the brain by tapping into the brain's communication system and interfering with the way nerve cells normally send, receive, and process information. Some drugs, such as marijuana and heroin, can activate neurons because their chemical structure mimics that of a natural neurotransmitter. This similarity in structure "fools" receptors and allows the drugs to lock onto and activate the nerve cells. Although these drugs mimic brain chemicals, they don't activate nerve cells in the same way as a natural neurotransmitter, and they lead to abnormal messages being transmitted through the network.
Other drugs, such as amphetamine or cocaine, can cause the nerve cells to release abnormally large amounts of natural neurotransmitters or prevent the normal recycling of these brain chemicals. This disruption produces a greatly amplified message, ultimately disrupting communication channels. The difference in effect can be described as the difference between someone whispering into your ear and someone shouting into a microphone.
How do drugs work in the brain to produce pleasure?
All drugs of abuse directly or indirectly target the brain's reward system by flooding the circuit with dopamine. Dopamine is a neurotransmitter present in regions of the brain that regulate movement, emotion, cognition, motivation, and feelings of pleasure. The overstimulation of this system, which rewards our natural behaviors, produces the euphoric effects sought by people who abuse drugs and teaches them to repeat the behavior.
How does stimulation of the brain's pleasure circuit teach us to keep taking drugs?
Our brains are wired to ensure that we will repeat life-sustaining activities by associating those activities with pleasure or reward. Whenever this reward circuit is activated, the brain notes that something important is happening that needs to be remembered, and teaches us to do it again and again, without thinking about it. Because drugs of abuse stimulate the same circuit, we learn to abuse drugs in the same way.
Why are drugs more addictive than natural rewards?
When some drugs of abuse are taken, they can release 2 to 10 times the amount of dopamine that natural rewards do.In some cases, this occurs almost immediately (as when drugs are smoked or injected), and the effects can last much longer than those produced by natural rewards. The resulting effects on the brain's pleasure circuit dwarfs those produced by naturally rewarding behaviors such as eating and sex.The effect of such a powerful reward strongly motivates people to take drugs again and again. This is why scientists sometimes say that drug abuse is something we learn to do very, very well.
Long-term drug abuse impairs brain functioning.
What happens to your brain if you keep taking drugs?
Just as we turn down the volume on a radio that is too loud, the brain adjusts to the overwhelming surges in dopamine (and other neurotransmitters) by producing less dopamine or by reducing the number of receptors that can receive and transmit signals. As a result, dopamine's impact on the reward circuit of a drug abuser's brain can become abnormally low, and the ability to experience any pleasure is reduced. This is why the abuser eventually feels flat, lifeless, and depressed, and is unable to enjoy things that previously brought them pleasure. Now, they need to take drugs just to bring their dopamine function back up to normal. And, they must take larger amounts of the drug than they first did to create the dopamine high - an effect known as tolerance.
How does long-term drug taking affect brain circuits?
We know that the same sort of mechanisms involved in the development of tolerance can eventually lead to profound changes in neurons and brain circuits, with the potential to severely compromise the long-term health of the brain. For example, glutamate is another neurotransmitter that influences the reward circuit and the ability to learn. When the optimal concentration of glutamate is altered by drug abuse, the brain attempts to compensate for this change, which can cause impairment in cognitive function. Similarly, long-term drug abuse can trigger adaptations in habit or nonconscious memory systems. Conditioning is one example of this type of learning, whereby environmental cues become associated with the drug experience and can trigger uncontrollable cravings if the individual is later exposed to these cues, even without the drug itself being available. This learned "reflex" is extremely robust and can emerge even after many years of abstinence.
What other brain changes occur with abuse?
Chronic exposure to drugs of abuse disrupts the way critical brain structures interact to control behavior - behavior specifically related to drug abuse. Just as continued abuse may lead to tolerance or the need for higher drug dosages to produce an effecontrol and ability to make sound decisions, while sending intense impulses to take drugs.ct, it may also lead to addiction, which can drive an abuser to seek out and take drugs compulsively. Drug addiction erodes a person's self-worth
Addiction and Health
What are the medical consequences of drug addiction?
Individuals who suffer from addiction often have one or more accompanying medical issues, including lung and cardiovascular disease, stroke, cancer, and mental disorders. Imaging scans, chest X-rays, and blood tests show the damaging effects of drug abuse throughout the body. For example, tests show that tobacco smoke causes cancer of the mouth, throat, larynx, blood, lungs, stomach, pancreas, kidney, bladder, and cervix.19 In addition, some drugs of abuse, such as inhalants, are toxic to nerve cells and may damage or destroy them either in the brain or the peripheral nervous system.
Does drug abuse cause mental disorders, or vice versa?
Drug abuse and mental disorders often co-exist. In some cases, mental diseases may precede addiction; in other cases, drug abuse may trigger or exacerbate mental disorders, particularly in individuals with specific vulnerabilities.
How can addiction harm other people?
Beyond the harmful consequences for the addicted individual, drug abuse can cause serious health problems for others. Three of the more devastating and troubling consequences of addiction are:
Negative effects of prenatal drug exposure on infants and children.
It is likely that some drug-exposed children will need educational support in the classroom to help them overcome what may be subtle deficits in developmental areas such as behavior, attention, and cognition. Ongoing work is investigating whether the effects of prenatal exposure on brain and behavior extend into adolescence to cause developmental problems during that time period.
Negative effects of second-hand smoke.
Second-hand tobacco smoke, also referred to as environmental tobacco smoke (ETS), is a significant source of exposure to a large number of substances known to be hazardous to human health, particularly to children. According to the Surgeon General's 2006 Report, The Health Consequences of Involuntary Exposure to Tobacco Smoke, involuntary smoking increases the risk of heart disease and lung cancer in never-smokers by 25-30 percent and 20-30 percent, respectively.
Increased spread of infectious diseases.
Injection of drugs such as heroin, cocaine, and methamphetamine accounts for more than a third of new AIDS cases.21 Injection drug use is also a major factor in the spread of hepatitis C, a serious, potentially fatal liver disease. Injection drug use is not the only way that drug abuse contributes to the spread of infectious diseases. All drugs of abuse cause some form of intoxication, which interferes with judgment and increases the likelihood of risky sexual behaviors. This, in turn, contributes to the spread of HIV/AIDS, hepatitis B and C, and other sexually transmitted diseases.
What are some effects of specific abused substances?
- Nicotine is an addictive stimulant found in cigarettes and other forms of tobacco. Tobacco smoke increases a user's risk of cancer, emphysema, bronchial disorders, and cardiovascular disease. The mortality rate associated with tobacco addiction is staggering. Tobacco use killed approximately 100 million people during the 20th century and, if current smoking trends continue, the cumulative death toll for this century has been projected to reach 1 billion.
- Alcohol consumption can damage the brain and most body organs. Areas of the brain that are especially vulnerable to alcohol-related damage are the cerebral cortex (largely responsible for our higher brain functions, including problem solving and decisionmaking), the hippocampus (important for memory and learning), and the cerebellum (important for movement coordination).
- Marijuana is the most commonly abused illicit substance. This drug impairs short-term memory and learning, the ability to focus attention, and coordination. It also increases heart rate, can harm the lungs, and can increase the risk of psychosis in those with an underlying vulnerability.
- Inhalants are volatile substances found in many household products, such as oven cleaners, gasoline, spray paints, and other aerosols, that induce mind-altering effects. Inhalants are extremely toxic and can damage the heart, kidneys, lungs, and brain. Even a healthy person can suffer heart failure and death within minutes of a single session of prolonged sniffing of an inhalant.
- Cocaine is a short-acting stimulant, which can lead abusers to "binge" (to take the drug many times in a single session). Cocaine abuse can lead to severe medical consequences related to the heart and the respiratory, nervous, and digestive systems.
- Amphetamines, including methamphetamine, are powerful stimulants that can produce feelings of euphoria and alertness. Methamphetamine's effects are particularly long lasting and harmful to the brain. Amphetamines can cause high body temperature and can lead to serious heart problems and seizures.
- Ecstasy (MDMA) produces both stimulant and mind-altering effects. It can increase body temperature, heart rate, blood pressure, and heart wall stress. Ecstasy may also be toxic to nerve cells.
- LSD is one of the most potent hallucinogenic, or perception-altering, drugs. Its effects are unpredictable, and abusers may see vivid colors and images, hear sounds, and feel sensations that seem real but do not exist. Abusers also may have traumatic experiences and emotions that can last for many hours. Some short-term effects can include increased body temperature, heart rate, and blood pressure; sweating; loss of appetite; sleeplessness; dry mouth; and tremors.
- Heroin is a powerful opiate drug that produces euphoria and feelings of relaxation. It slows respiration and its use is linked to an increased risk of serious infectious diseases, especially when taken intravenously. Other opioid drugs include morphine, OxyContin, Vicodin, and Percodan, which have legitimate medical uses; however, their nonmedical use or abuse can result in the same harmful consequences as abusing heroin.
- Prescription medications are increasingly being abused or used for nonmedical purposes. This practice cannot only be addictive, but in some cases also lethal. Commonly abused classes of prescription drugs include painkillers, sedatives, and stimulants. Among the most disturbing aspects of this emerging trend is its prevalence among teenagers and young adults, and the common misperception that because these medications are prescribed by physicians, they are safe even when used illicitly.
- Steroids, which can also be prescribed for certain medical conditions, are abused to increase muscle mass and to improve athletic performance or physical appearance. Serious consequences of abuse can include severe acne, heart disease, liver problems, stroke, infectious diseases, depression, and suicide.
- Drug combinations. A particularly dangerous and not uncommon practice is the combining of two or more drugs. The practice ranges from the co-administration of legal drugs, like alcohol and nicotine, to the dangerous random mixing of prescription drugs, to the deadly combination of heroin or cocaine with fentanyl (an opioid pain medication). Whatever the context, it is critical to realize that because of drug-drug interactions, such practices often pose significantly higher risks than the already harmful individual drugs
Treatment and Recovery
Can Addiction be Treated Successfully?
Yes. Addiction is a treatable disease.
Discoveries in the science of addiction have led to advances in drug abuse treatment that help people stop abusing drugs and resume their productive lives.
Can Addiction Be Cured?
Addiction need not be a life sentence. Like other chronic diseases, addiction can be managed successfully. Treatment enables people to counteract addiction's powerful disruptive effects on brain and behavior and regain control of their lives.
These images of the dopamine transporter show the brain's remarkable potential to recover, at least partially, after a long abstinence from drugs - in this case, methamphetamine.
Source: The Journal of Neuroscience, 21(23):9414-9418. 200126
Does Relapse to Drug Abuse Mean Treatment Has Failed?
No. The chronic nature of the disease means that relapsing to drug abuse is not only possible, but likely, with relapse rates similar to those for other well-characterized chronic medical illnesses such as diabetes, hypertension, and asthma, which also have both physiological and behavioral components. Treatment of chronic diseases involves changing deeply imbedded behaviors, and relapse does not mean treatment failure. For the addicted patient, lapses back to drug abuse indicate that treatment needs to be reinstated or adjusted, or that alternate treatment is needed.
Relapse rates for drug-addicted patients are compared with those suffering from diabetes, hypertension, and asthma. Relapse is common and similar across these illnesses (as is adherence to medication). Thus, drug addiction should be treated like any other chronic illness, with relapse serving as a trigger for renewed intervention.
Source: McLellan et al., JAMA, 284:1689-1695, 200027.
What are the principles of effective addiction treatment?
Research shows that combining treatment medications, where available, with behavioral therapy is the best way to ensure success for most patients. Treatment approaches must be tailored to address each patient's drug abuse patterns and drug-related medical, psychiatric, and social problems.
How can medications help treat drug addiction?
Different types of medications may be useful at different stages of treatment to help a patient stop abusing drugs, stay in treatment, and avoid relapse.
When patients first stop abusing drugs, they can experience a variety of physical and emotional symptoms, including depression, anxiety, and other mood disorders; restlessness; and sleeplessness. Certain treatment medications are designed to reduce these symptoms, which makes it easier to stop the abuse.
Staying in Treatment.
Some treatment medications are used to help the brain adapt gradually to the absence of the abused drug. These medications act slowly to stave off drug cravings, and have a calming effect on body systems. They can help patients focus on counseling and other psychotherapies related to their drug treatment.
Science has taught us that stress, cues linked to the drug experience (e.g., people, places, things, moods), and exposure to drugs are the most common triggers for relapse. Medications are being developed to interfere with these triggers to help patients sustain recovery.
How do behavioral therapies treat drug addiction?
Behavioral treatments help engage people in drug abuse treatment, modifying their attitudes and behaviors related to drug abuse and increasing their life skills to handle stressful circumstances and environmental cues that may trigger intense craving for drugs and prompt another cycle of compulsive abuse. Moreover, behavioral therapies can enhance the effectiveness of medications and help people remain in treatment longer.
How do the best treatment programs help patients recover from the pervasive effects of addiction?
Getting an addicted person to stop abusing drugs is just one part of a long and complex recovery process. When people enter treatment, addiction has often taken over their lives. The compulsion to get drugs, take drugs, and experience the effects of drugs has dominated their every waking moment, and drug abuse has taken the place of all the things they used to enjoy doing. It has disrupted how they function in their family lives, at work, and in the community, and has made them more likely to suffer from other serious illnesses. Because addiction can affect so many aspects of a person's life, treatment must address the needs of the whole person to be successful. This is why the best programs incorporate a variety of rehabilitative services into their comprehensive treatment regimens. Treatment counselors select from a menu of services for meeting the individual medical, psychological, social, vocational, and legal needs of their patients to foster their recovery from addiction.
Cognitive Behavioral Therapy.
Seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs.
Uses positive reinforcement such as providing rewards or privileges for remaining drug free, for attending and participating in counseling sessions, or for taking treatment medications as prescribed.
Employs strategies to evoke rapid and internally motivated behavior change to stop drug use and facilitate treatment entry.
Helps patients face their drug abuse realistically, come to terms with its harmful consequences, and boost their motivation to stay drug free. Patients learn effective ways to solve their emotional and interpersonal problems without resorting to drugs.