More than three decades of research supported by the National Institute on Drug Abuse (NIDA) has proven that addiction is a complex brain disease characterized by compulsive, at times uncontrollable, drug craving, seeking, and use that persist despite potentially devastating consequences. Addiction is also a developmental disease; that is, it usually starts in adolescence or even childhood and can last a lifetime if untreated. Disagreements about the nature of addiction remain: namely, whether it reflects voluntary or involuntary behavior and whether it should be punished or treated as a health issue. Even though the first time a person takes a drug, it is often by choice—to achieve a pleasurable sensation or desired emotional state—we now know from a large body of research that this ability to choose can be affected by drugs. And when addiction takes hold in the brain, it disrupts a person’s ability to exert control over behavior— reflecting the compulsive nature of this disease.
The human brain is an extraordinarily complex and fine-tuned communications network made up of billions of cells that govern our thoughts, emotions, perceptions, and drives. Our brains reward certain behaviors such as eating or procreating—registering these as pleasurable activities that we want to repeat. Drug addiction taps into these vital mechanisms geared for our survival. And although not a life necessity, to an addicted person, drugs become life itself, driving the compulsive use of drugs—even in the face of dire life consequences—that is the essence of addiction.
How Does Addiction Take Hold in the Brain?
The rewarding effects of drugs of abuse come from large and rapid upsurges in dopamine, a neurochemical critical to stimulating feelings of pleasure and to motivating behavior. The rapid dopamine “rush” from drugs of abuse mimics but greatly exceeds in intensity and duration the feelings that occur in response to such pleasurable stimuli as the sight or smell of food, for example. Repeated exposure to large, drug-induced dopamine surges has the insidious consequence of ultimately blunting the response of the dopamine system to everyday stimuli. Thus the drug disturbs a person’s normal hierarchy of needs and desires and substitutes new priorities concerned with procuring and using the drug.
Drug abuse also disrupts the brain circuits involved in memory and control over behavior. Memories of the drug experience can trigger craving as can exposure to people, places, or things associated with former drug use. Stress is also a powerful trigger for craving. Control over behavior is compromised because the affected frontal brain regions are what a person needs to exert inhibitory control over desires and emotions.
That is why addiction is a brain disease. As a person’s reward circuitry becomes increasingly dulled and desensitized by drugs, nothing else can compete with them—food, family, and friends lose their relative value, while the ability to curb the need to seek and use drugs evaporates. Ironically and cruelly, eventually even the drug loses its ability to reward, but the compromised brain leads addicted people to pursue it, anyway; the memory of the drug has become more powerful than the drug itself.
When does drug abuse become drug addiction? It rarely happens with the first use of a drug. Drug abuse and drug addiction can be thought of as points along a continuum. Any use of a mind-altering drug or the inappropriate use of medication (either prescription or over-the-counter drugs) is drug abuse, but the point when drug abuse becomes drug addiction is less clear. Different people may reach the point of addiction at different stages. Scientists continue to investigate the factors that contribute to the transition to drug addiction.
Drug addiction is defined as the continued compulsive use of drugs despite adverse health or social consequences. Drug-addicted people have lost control of their drug use. Individuals who are addicted to drugs often become isolated from family or friends, have difficulty at work or school, may commit crimes, and become involved with the criminal justice system. For a person addicted to drugs, continuing to take them becomes the primary focus in life.
Certain drugs, including opioids and alcohol, cause strong physical reactions in the body when drug use stops. When a person addicted to heroin stops taking heroin, he or she can experience a variety of symptoms ranging from watery eyes and a runny nose to irritability and loss of appetite and then diarrhea, shivering, sweating, abdominal cramps, increased sensitivity to pain, and sleep problems. In general, withdrawal from heroin makes people feel miserable. Withdrawal from alcohol can cause serious effects such as seizures and even death. Withdrawal from other drugs, such as cocaine and amphetamines, does not lead to strong physical reactions, but it may make the person feel depressed or lethargic. For most drugs, physical withdrawal symptoms can usually be controlled effectively with medications. Even though withdrawal from some drugs does not cause the person abusing them to have physical reactions, stopping drug use is difficult because of the changes the drugs have caused in the brain. Once the drugs stop, the person will have cravings, or intense desire for the drugs. Craving arises from the brain’s need to maintain a state of homeostasis that now relies on the presence of the drug. A person may experience cravings at any stage of drug abuse or addiction, even early in the experimentation phase of drug abuse. Cravings have a physical basis in the brain. Using PET imaging, scientists have shown that just seeing images of drug paraphernalia can stimulate the amygdala (part of the brain involved in emotional memory) in an addicted person.
Drugs of addiction do not merely cause short-term changes in an individual’s cognitive skill and behavior. A drug “high” lasts a short time, ranging from less than an hour to 12 hours, depending on the drug, dose, and route of administration. The changes in the brain that result from continued drug use, however, can last a long time. Scientists believe that some of these changes disappear when drug use stops; some disappear within a short time after drug use stops, and other changes are potentially permanent.
One of the first changes in the brain that may occur in response to repeated drug abuse is tolerance. Tolerance develops when a person needs increasing doses of a drug to achieve the same high or “rush” that previously resulted from a lower dose of the drug. Two primary mechanisms underlie the development of tolerance. First, the body may become more efficient at metabolizing the drug, thereby reducing the amount that enters the brain. Second, the cells of the body and brain may become more resistant to the effect of the drug. For example, after continued cocaine use, neurons decrease the number of dopamine receptors, which results in decreasing cocaine’s stimulatory effect. Opioids, on the other hand, do not cause a change in the number of receptors. Instead the opioid receptors become less efficient in activating associated cellular processes, thus reducing the effects of the opioids.
In addition to the functional and anatomical changes in the brain, drug abuse puts people at higher risk for other health problems. For example, inhalant abuse can lead to disruption of heart rhythms, and snorting cocaine can lead to ulcerations in the mucous membranes of the nose. In addition, injection drug users (IDUs) are at higher risk of contracting HIV through the sharing of potentially contaminated needles. Similarly, hepatitis B and hepatitis C are much more common among drug addicts than the general population. Tuberculosis is another concern. Drug abuse and addiction also are contributing factors in motor vehicle accidents.
Why Do Some People Become Addicted While Others Do Not?
No single factor can predict whether a person will become addicted to drugs. Risk for addiction is influenced by a combination of factors that include individual biology, social environment, and age or stage of development. The more risk factors an individual has, the greater the chance that taking drugs can lead to addiction.
Biology. The genes that people are born with––in combination with environmental influences––account for about half of their addiction vulnerability. Additionally, gender, ethnicity, and the presence of other mental disorders may influence risk for drug abuse and addiction.
Environment. A person’s environment includes many different influences, from family and friends to socioeconomic status and quality of life in general. Factors such as peer pressure, physical and sexual abuse, stress, and quality of parenting can greatly influence the occurrence of drug abuse and the escalation to addiction in a person’s life.
Development. Genetic and environmental factors interact with critical developmental stages in a person’s life to affect addiction vulnerability. Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it will progress to more serious abuse, which poses a special challenge to adolescents. Because their brains are still developing in the areas that govern decisionmaking, judgment, and self-control, adolescents may be especially prone to risk-taking behaviors, including trying drugs of abuse.
Prevention Is the Key
Drug addiction is a preventable disease. Results from NIDA-funded research have shown that prevention programs involving families, schools, communities, and the media are effective in reducing drug abuse. Although many events and cultural factors affect drug abuse trends, when youths perceive drug abuse as harmful, they reduce their drug taking. Thus, education and outreach are key in helping youth and the general public understand the risks of drug abuse. Teachers, parents, medical and public health professionals must keep sending the message that drug addiction can be prevented if one never abuses drugs.