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Addiction and the brain

BrigidBrigid Veteran
edited February 2007 in Arts & Writings
Here's an article from the New York Times yesterday that has me very excited and grateful to be living in this day and age:
The New York Times

Scientists Tie Part of Brain to Urge to Smoke

Published: January 25, 2007

Scientists studying stroke patients are reporting that an injury to a specific part of the brain, near the ear, can instantly and permanently break a smoking habit, effectively erasing the most stubborn of addictions. People with the injury who stopped smoking found that their bodies, as one man put it, “forgot the urge to smoke.”

The new finding, which is to appear in the journal Science on Friday, is likely to alter the course of addiction research, pointing researchers toward new ideas for treatment, experts say. While no one is suggesting brain injury as a solution for addiction, the findings suggest that therapies might focus on the insula, a prune-sized region under the frontal lobes that is thought to register gut feelings and is apparently a critical part of the network that sustains addictive behavior.

Previous research on addicts focused on regions of the cortex involved in thinking and decision-making. But while those regions are involved in maintaining habits, the new study suggests that they are not as central.

The study did not examine dependence on alcohol, cocaine or other substances. Yet smoking is as at least as hard to quit as any habit, and it probably involves the same brain circuits, experts said. Most smokers who manage to quit do so only after repeated attempts, and the craving for cigarettes usually lasts for years, if not a lifetime.

“This is the first time we’ve shown anything like this, that damage to a specific brain area could remove the problem of addiction entirely,” said Dr. Nora Volkow, director of the National Institute on Drug Abuse, which financed the study, along with the National Institute of Neurological Disorders and Stroke. “It’s absolutely mind-boggling.”

Others cautioned that the study was small, and that scientists still knew little about the widely distributed neural networks involved in sustaining habits.

“One has to be careful not to extrapolate too much based on brain injuries to what’s going on in all addictive behavior, in healthy brains,” said Dr. Martin Paulus, a psychiatric researcher at the University of California in San Diego, and the San Diego VA Medical Center. Still, he added, the study “opens up a whole new way to think about addiction.”

The researchers, from the University of Iowa and the University of Southern California, examined 32 former smokers, all of whom had suffered a brain injury. The men and women were lucid enough to answer a battery of questions about their habits, and to rate how hard it was to quit and the strength of their subsequent urges to smoke. They all had smoked at least five cigarettes a day for two years or more, and 16 of them said they quit with ease, losing their cravings entirely.

The researchers performed M.R.I. scans on all of the patients’ brains to specify the location and extent of each injury. They found that these 16 were far more likely to have an injury to their insula than to any other area. The researchers found no association between a diminished urge to smoke and injuries to other regions of the brain, including tissue surrounding the insula.

“There’s a whole neural circuit critical to maintaining addiction, but if you knock out this one area, it appears to wipe out the behavior,” said Dr. Antoine Bechara, a senior author of the new paper, who is a neuroscientist at U.S.C.’s Brain and Creativity Institute. His co-authors were Dr. Hanna Damasio, also of U.S.C., and Nasir Naqvi and David Rudrauf of the University of Iowa.

The patients’ desire to eat, by contrast, was intact. This suggests, the authors wrote, that the insula is critical for behaviors whose bodily effects become pleasurable because they are learned, like cigarette smoking.

The insula, for years a wallflower of brain anatomy, has emerged as region of interest based in part on recent work by Dr. Antonio Damasio, a neurologist and director of the Brain and Creativity Institute. The insula has widely distributed connections, both in the thinking cortex above, and down below in subcortical areas, like the brain stem, that maintain heart rate, blood pressure and body temperature, the body’s primal survival systems.

Based on his studies and others’, Dr. Damasio argues that the insula, in effect, maps these signals from the body’s physical plant, and integrates them so the conscious brain can interpret them as a coherent emotion.

The system works from the bottom up. First, the body senses cues in the outside world and responds. The heart rate might elevate at the sight of a stranger’s angry face, for example; other muscles might relax in response to a pleasant whiff of smoke.

All of this happens instantaneously and unconsciously, Dr. Damasio said — until the insula integrates the information and makes it readable to the conscious regions of the brain.

“In a sense it’s not surprising that the insula is an important part of this circuit maintaining addiction because we realized some years ago that it was going to be a critical platform for emotions,” Dr. Damasio said in a telephone interview. “It is on this platform that we first anticipate pain and pleasure, not just smoking but eating chocolate, drinking a glass of wine, all of it.”

This explains why cravings are so physical and so hard to shake, he said: they have taken hold in the visceral reaches of the body well before they are even conscious.

And at least one previous study suggests that people can reduce the sensation of pain by learning to modulate the activity in an area of their brain linked to pain — suggesting another possible therapy.

“The question is, Can you learn to deactivate the insula?” said Dr. Volkow said. “Now, everybody’s going to be looking at the insula.”


  • BrigidBrigid Veteran
    edited January 2007
    The reason why I posted this article is because I think it's important to understand that addiction is not caused by weakness, lack of self control or some personality flaw. It has nothing whatsoever to do with a persons ability to control themselves and everything to do with brain function. This is scientific proof that addicts should never, ever, be treated with disdain, disgust or disregard. Faith, love, compassion, empathy and understanding have been guiding and encouraging us never to negatively judge addicts and now science has caught up.

    My doctor and I talk a lot about my attempts to quit smoking and he once said something that stuck in my head. He said "Brigid, it's not you that's smoking. It's your brain."

    I consider myself (or my brain, I should say) to be a heavily addicted smoker and I have beaten myself up about it ever since my teens. I've always considered it my greatest regret, weakness and failure and have extremely deep shame about it. I always support and applaud efforts by governments around the world to help stop the spread of the habit by enacting anti-smoking legislation because of how much shame and guilt I feel about it and because anything that makes it easier to protect workers and harder for people to start the habit is a good thing in my book. (Not at the expense of civil rights though, obviously.)

    My mother smoked heavily when she was pregnant with me and from the day I was born until I smoked my first cigarette at the age of 12 I was always in the presence of cigarette smoke except when I was in school or at a friends house. Everyone in my family smoked. My mother and my four older siblings all smoked cigarettes and my father smoked a pipe and cigars. Even in the car when I was a baby. I was born and raised in the late 1960s and early 1970s in a fairly constant cloud of cigarette smoke. So the chances are very good that I was already addicted to nicotine before I ever smoked my first cigarette.

    I tell you this for two reasons: It helps to assuage my guilt and shame by shifting the blame from myself, and also because it's true. I know, addicts always want to blame someone or something else for their addiction. We're always making lame excuses, lying to ourselves and to others. But I'm struggling to find the middle ground in all of this. I need to get rid of some of the horrible guilt and shame I feel because it's not helpful in the least. In fact, it does more harm than good. But I still need to retain some regret and responsibility for my smoking in order to remain in reality, which is the only place I'm going to be able to quit once and for all.

    I've tried SO hard to quit and you wouldn't believe the abuse I've heaped upon myself for my failure to do so, which makes it all the worse. So if science can teach me that I'm not some kind of pathetic, weak willed, pleasure and comfort seeking person, that there are other reasons why I may find it so hard to quit smoking, I may actually succeed after all. In fact, if the brain sciences continue to advance at this amazing rate someday, maybe soon, there will be more understanding, empathy and compassion for those of us who are addicts as more proof surfaces that we are not as in control of our addictions as some might think. Which is, of course, a double edged sword. But if this new information brings about new ways to treat addiction we could be on the verge of something very good and hopeful. Taking the hard road with some addicts may work. Tough love and so on. But I think a scientific understanding of the nature of addiction will help more.
  • edited January 2007

    I read this article this morning. Very interesting to say the least. And like you said, for us smokers that have been trying to quit for what seems like aeons, there may finally be some hope to being able to quit. I have tried the patch, the pill, the gum, cold turkey, weening myself off of them, etc... There were a couple month spurts here and there when I quit but the urge was so strong I always went back to it. Maybe some day...
  • NirvanaNirvana aka BUBBA   `     `   South Carolina, USA Veteran
    edited January 2007

    Does that mean I have to have compassion even for Rush Limbaugh, addicted as he was to the pain medicine OxyContin? Gee, you'd think that would really be a diificult "comfort" to shed. (I mean the drug, not the compassion.)

    If it turns out that there is a God,
    I don't think that he's evil.
    But the worst that you can say
    about him is that basically
    he's an underachiever.
    —Woody Allen
  • buddhafootbuddhafoot Veteran
    edited January 2007
    I smoked twice in my life.

    Yes... twice - and both of these instances lasted for years.

    I even remember when I started up again. I thought I was in control. Hell!, I had quit before.

    I liked smoking. Still do. I love a good mild cigar. But, I know I can't do that.

    I know all the struggles you've gone through. I know how you've beaten yourself up. I know how you wish you could quit and can't. I know how you think, "What am I going to do when I quit? What will I enjoy? What will I do? What DID I do with my time before I smoked? I don't want to quit! I like smoking! I like relaxing with a smoke! Get off my BACK!"

    But, eventually, both of you will have to make the decision. You'll either make it on your own - or possibly at the end of a breather. Or when you have emphisema(I'm too lazy to check the spelling of that word), when you your life is cut short and you don't get to see your children or grandchildren get any older. Or maybe when you're stuck in the hospital watching your life and lungs rot away - coughing up shit all the time - never able to catch your breath - just sitting across the room from Death - waiting for your gab to gasp it's last breath... Then the time for a decision will come - whether YOU are actually making the decision (or your doctor is) or not. You won't be smoking in a hospital on an oxygen tank - and then you might even wonder if those little fuckers were worth all the pain, loss and suffering you'll be experiencing in that moment.

    You have to really want to. Not just "wish" that you didn't. I wished for years and years. Honestly! I hated it - but I liked it. I liked doing it - I hated the smell and the mess - but I sure did enjoy a smoke.

    Wishing won't do you jack shit. Failing? So you decide to quit and have to have one. Big deal! Your goal should still be to quit. It took you a long time to incorporate it into your system and psyche - it's going to take a long time to get rid of it. Both times I quit, I never said I was quitting. I just wasn't having a cigarette or a cigar. If I wanted to, I could with no sense of failing - but I just kept choosing NOT to at that moment. It was hard sometime. Actually, maybe what you should do is quit for two weeks - and the tell yourself you're going to smoke like 10 in a row and evaluate the situation. Then after you go through the sweats, nausea, illness - maybe you'll think, "Boy!, do I want to do THAT again!?!?!"

    I've heard many times that the physical addiction is gone in about a week. It's the oral fixation and the mental addiction that is so hard to get rid of.

    I wish I could have a stogey... right now, in fact. But... I'm glad that I don't smoke anymore. I wish you two the best with this. You will be in my thoughts.

  • BrigidBrigid Veteran
    edited January 2007

    As I said, the tough love approach like the one in your post may work for smokers who are in deep denial about their addiction but empathy and understanding through scientific knowledge will work better. Neither I nor LFA are in denial so your post is neither warranted nor helpful. It's just harsh. And you seem to have missed my point entirely which was that addicts deserve the same amount of compassion, empathy and understanding as anyone else who is battling a disease over which they have little control. Your post was unkind, unhelpful and unnecessary and illustrates the type of thinking that I hope this and future scientific discoveries will eventually dispel.
  • buddhafootbuddhafoot Veteran
    edited January 2007
    Boy... I don't know what to say.

  • BrigidBrigid Veteran
    edited January 2007
    I still love you, BF. Although I can't figure out why....
  • buddhafootbuddhafoot Veteran
    edited January 2007
    It's probably because you're a good person.

    You know, when I was writing that post... I wasn't assuming that I knew what you were thinking of or dealing with. It was mostly all the kinds of things that ran through my head as I tried to prepare myself for quitting.

    Did I want to end up on a respirator? Would it cause me to die early? Miss my son? Miss my grandchildren? What did my lungs look like? All the toxins I was sucking into my body.

    Those are things I thought of. They may never cross your mind.

    It wasn't really tough love as much as it was my experience. I mean, you really will have to make a decision someday - but that's totally up to you. I really wish you the best with your experience, Brigid. You know that.

  • buddhafootbuddhafoot Veteran
    edited January 2007
    I'll write more later about your other posts...

    Me and the boy are going boarding right now.

    Have a good day!

  • edited January 2007
    I too am a smoker and stopped smoking for 2 years. Gained 70lbs. during those 2 years. Just put food in place of the cigs. Started smoking again due to extreme stress.....lost the 70lbs and now am afraid I will do that again.

    I love to smoke........I know it is bad for me.......But my favorite time of day is in the morning when I sit down with a hot cup of tea and my smokes........I know's terrible. But it is the truth.................

    Boo, Don't be to hard on BF............A smokers most harsh critic is an X-smoker. They have gone thro it and did it.........So it is harder for them to understand why others can't.
  • NirvanaNirvana aka BUBBA   `     `   South Carolina, USA Veteran
    edited January 2007
    Wintertime is an easy time to quit. Something like ionization of the air or electricity: potential difference. I just went outside and sucked in the cool or cold air through pursed lips when I was quitting.

    I quit several times. Fun to quit and not too difficult. Hardest part is STAYING QUIT. That takes a lot of self-directed anti-smoke propaganda. (Have some compassion on your lungs! IT STINKS!! &C)

    I have had two or three smokes in the last nine years. Made me nauseous. I must be lucky, though, 'cuz I was really always allergic or something to the derned cigarettes. For years before I finally quit for the last time, when I didn't have to rush to get about the day's duties, I'd have my first cigarette kinda reluctantly, thinking, "well, eventually, I'm gonna need one." But in the background, I always realized that they made me feel so darned rotten and that if I really was sick, the tobacco usage would probably cover that fact up...

    Well, I think was Brigid has brought up here is a very important subject, and that WHATEVER anyone has to say, whether flippant, a bit ugly, constructive, or whatever; all can be appropriated towards some solution for somebody. I'm not sure I was ever so addicted, as I have had a brain injury, perhaps to that part of the brain.
  • buddhafootbuddhafoot Veteran
    edited January 2007
    First of all... I AM NOT BEING HARSH ON BRIGID. I'm not even being harsh on LFA. I have no problem with smokers! When smokers come to my house, I let them light up. I really don't have a problem with it. I believe it's a choice they've made and I could really care less. We're all adults and we all know what it does to us. My statements aren't going to shed any "NEW" light on anything. That isn't why I said them.

    I was merely relaying some of the thoughts I used to have when battling that monkey.

    I also have a hard time with "addiction is a disease". I think addiction is a choice. You're addicted because you made a choice to be addicted. I never said, "Becoming unaddicted is a cakewalk." Otherwise, what would be the big deal about an addiction?
    I can have compassion for people with addictions. Look at people in rehabs where they are physically kept from supporting their addiction. Some of them look incredibly sick and crazed. Who wouldn't feel compassion for the suffering of someone else.
    But, it's not like a person with Parkinsons can just go to a center where they lock you in a room and feed you really well for a month and then your disease is gone!

    I didn't mean to sound as if I didn't have any compassion for people that struggle with smoking or any other thing that brings us suffering.


  • buddhafootbuddhafoot Veteran
    edited January 2007
    I also ran across this - you know me... ever the Devil's Advocate :)
    Addiction Is a Choice

    by Jeffrey A. Schaler, Ph.D.

    October 2002, Vol. XIX, Issue 10

    (Please see Counterpoint article by by John H. Halpern, M.D.)

    Is addiction a disease, or is it a choice? To think clearly about this question, we need to make a sharp distinction between an activity and its results. Many activities that are not themselves diseases can cause diseases. And a foolish, self-destructive activity is not necessarily a disease.

    With those two vital points in mind, we observe a person ingesting some substance: alcohol, nicotine, cocaine or heroin. We have to decide, not whether this pattern of consumption causes disease nor whether it is foolish and self-destructive, but rather whether it is something altogether distinct and separate: Is this pattern of drug consumption itself a disease?

    Scientifically, the contention that addiction is a disease is empirically unsupported. Addiction is a behavior and thus clearly intended by the individual person. What is obvious to common sense has been corroborated by pertinent research for years (Table 1).

    The person we call an addict always monitors their rate of consumption in relation to relevant circumstances. For example, even in the most desperate, chronic cases, alcoholics never drink all the alcohol they can. They plan ahead, carefully nursing themselves back from the last drinking binge while deliberately preparing for the next one. This is not to say that their conduct is wise, simply that they are in control of what they are doing. Not only is there no evidence that they cannot moderate their drinking, there is clear evidence that they do so, rationally responding to incentives devised by hospital researchers. Again, the evidence supporting this assertion has been known in the scientific community for years (Table 2).

    My book Addiction Is a Choice was criticized in a recent review in a British scholarly journal of addiction studies because it states the obvious (Davidson, 2001). According to the reviewer, everyone in the addiction field now knows that addiction is a choice and not a disease, and I am, therefore, "violently pushing against a door which was opened decades ago." I'm delighted to hear that addiction specialists in Britain are so enlightened and that there is no need for me to argue my case over there.

    In the United States, we have not made so much progress. Why do some persist, in the face of all reason and all evidence, in pushing the disease model as the best explanation for addiction?

    I conjecture that the answer lies in a fashionable conception of the relation between mind and body. There are several competing philosophical theories about that relation. Let us accept, for the sake of argument, the most extreme "materialist" theory: the psychophysical identity theory. Accordingly, every mental event corresponds to a physical event, because it is a physical event. The relation between mind and the relevant parts of the body is, therefore, like the relation between heat and molecular motion: They are precisely the same thing, observed in two different ways. As it happens, I find this view of the relation between mind and body very congenial.

    However, I think it is often accompanied by a serious misunderstanding: the notion that when we find a parallel between physiological processes and mental or personality processes, the physiological process is what is really going on and the mental process is just a passive result of the physical process. What this overlooks is the reality of downward causation, the phenomenon in which an emergent property of a system can govern the position of elements within the system (Campbell, 1974; Sperry, 1969). Thus, the complex, symmetrical, six-pointed design of a snow crystal largely governs the position of each molecule of ice in that crystal.

    Hence, there is no theoretical obstacle to acknowledging the fact that thoughts, desires, values and other mental phenomena can dominate bodily functions. Suppose that a man's mother dies, and he undergoes the agonizing trauma we call unbearable grief. There is no doubt that if we examine this man's bodily processes we will find many physical changes, among them changes in his blood and stomach chemistry. It would be clearly wrong to say that these bodily changes cause him to be grief-stricken. It would be less misleading to say that his being grief-stricken causes the bodily changes, but this is also not entirely accurate. His knowledge of his mother's death (interacting with his prior beliefs and values) causes his grief, and his grief has blood-sugar and gastric concomitants, among many others.

    There is no dispute that various substances cause physiological changes in the bodies of people who ingest them. There is also no dispute, in principle, that these physiological changes may themselves change with repeated doses, nor that these changes may be correlated with subjective mental states like reward or enjoyment.

    I say "in principle" because I suspect that people sometimes tend to run away with these supposed correlations. For example, changes in dopamine levels have often been hypothesized as an integral part of the reward/reinforcement process. Yet research shows that dopamine in the nucleus accumbens does not mediate primary or unconditioned food reward in animals (Aberman and Salamone, 1999; Nowend et al., 2001; Salamone et al., 2001; Salamone et al., 1997). According to Salamone, the theory that drugs of abuse turn on a natural reward system is simplistic and inaccurate: "Dopamine in the nucleus accumbens plays a role in the self-administration of some drugs (i.e., stimulants), but certainly not all" (personal communication, Nov. 26, 2001).

    Garris et al. (1999) reached similar conclusions: "Dopamine may therefore be a neural substrate for novelty or reward expectation rather than reward itself." They concluded:

    [T]here is no correlation between continual bar pressing during [intracranial self-stimulation] and increased dopaminergic neurotransmission in the nucleus accumbensýour results are consistent with evidence that the dopaminergic component is not associated with the hedonistic or 'pleasure' aspects of rewardýLikewise, the rewarding effects of cocaine do not require dopamine; mice lacking the gene for the dopamine transporter, a major target of cocaine, will self-administer cocaine. However, increased dopamine neurotransmission in the nucleus accumbens shell is seen when rats are transiently exposed to a new environment. The increase in extracellular dopamine quickly returns to normal levels and remains there during continued exploration of the new environmentýdopamine release in the nucleus accumbens is related to novelty, predictability or some other aspects of the reward process, rather than to hedonism itself.

    Perhaps, then, some people have been too ready to jump to conclusions about specific mechanisms. Be that as it may, chemical rewards have no power to compel--although this notion of compulsion may be a cherished part of clinicians' folklore. I am rewarded every time I eat chocolate cake, but I often eschew this reward because I feel I ought to watch my weight.

    Experience with addiction treatment must surely make us even more dubious about the theory that addiction is a disease. The most popular way of helping people manage their addictive behavior is Alcoholics Anonymous (AA) and its various 12-step offshoots. Many observers have recognized the essentially religious nature of AA. The U.S. courts are increasingly regarding AA as a religious activity. In United States v Seeger (1965), the U.S. Supreme Court stated that the test to be applied as to whether a belief is religious is to enquire whether that belief "occupies a place in the life of its possessor parallel to that filled by the orthodox belief in God" in religions more widely accepted in the United States. This requirement is met by members of AA and other secular programs that help people with addictive behaviors and encourage their members to turn their will and lives over to the care of a supreme being. What kind of disease is this for which the best available treatment is religion (Antze, 1987)? Clinical applications are based on explanations for why the behavior occurs. An activity based on a religious belief masquerading as a clinical form of treatment tells us something about what the activity really is--an ethical, not medical, problem in living.

    What passes as clinical treatment for addiction is psychotherapy, which essentially consists of various forms of conversation or rhetoric (Szasz, 1988). One person, the therapist, tries to influence another person, the patient, to change their values and behavior. While the conversation called therapy can be helpful, most of the conversation that occurs in therapy based on the disease model is potentially harmful. This is because the therapist misleads the patient into believing something that is simply untrue--that addiction is a disease, and, therefore, addicts cannot control their behavior. Preaching this falsehood to patients may encourage them to abandon any attempt to take responsibility for their actions.

    The treatment of drug effects, at the patient's request, is well within the domain of medicine, what passes as evidence for the theory that addiction is a disease is merely clinical folklore.

    Dr. Schaler teaches at American University's School of Public Affairs in Washington, D.C., and at Johns Hopkins University in Baltimore. Addiction is a Choice (Open Court Publishers, 2000) is among his published works on addiction.


    Aberman JE, Salamone JD (1999), Nucleus accumbens dopamine depletions make rats more sensitive to high ratio requirements but do not impair primary food reinforcement. Neuroscience 92(2):545-552.

    Antze P (1987), Symbolic action in Alcoholics Anonymous. In: Constructive Drinking: Perspectives on Drink From Anthropology, Douglas M, ed. New York: Cambridge University Press, pp149-181.

    Campbell DT (1974), 'Downward causation' in hierarchically organized biological systems. In: Studies in the Philosophy of Biology: Reduction and Related Problems, Ayala FJ, Dobzhansky T, eds. London: Macmillan.

    Davidson R (2001), Conspiracy, cults and choices. Addiction Research & Theory 9(1):92-92 [book review].

    Garris PA, Kilpatrick M, Bunin MA et al. (1999), Dissociation of dopamine release in the nucleus accumbens from intracranial self-stimulation. Nature 398(6722):67-69.

    Nowend KL, Arizzi M, Carlson BB, Salamone JD (2001), D1 or D2 antagonism in nucleus accumbens core or dorsomedial shell suppresses lever pressing for food but leads to compensatory increases in chow consumption. Pharmacol Biochem Behav 69(3-4):373-382.

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    Salamone JD, Wisniecki A, Carlson BB, Correa M (2001), Nucleus accumbens dopamine depletions make animals highly sensitive to high fixed ratio requirements but do not impair primary food reinforcement. Neuroscience 105(4):863-870.

    Sperry W (1969), A modified concept of consciousness. Psychol Rev 76(6):532-536.

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    United States v Seeger, 980 US 163 (1965).

  • buddhafootbuddhafoot Veteran
    edited January 2007
    And the counterpoint article...
    Addiction Is a Disease
    By John H. Halpern, M.D.
    Email this page to a friend
    Print this page

    Psychiatric Times October 2002 Vol. XIX Issue 10

    (Please see Point article by Jeffrey A. Schaler, Ph.D.)

    The practice of medicine obligates physicians to accept the responsibility of promoting the overall health of their patients. When dealing with patients who abuse substances, we can find direct and indirect adverse consequences from such use. Lung cancer, although rare in the general population, is linked to chronic tobacco smoking, for example. Cigarette smokers who begin this addiction in their teen years appear to have a higher incidence of adult depression (Goodman and Capitman, 2000); so, either early tobacco use is a marker for later mental illness or, more ominously, this legal drug of abuse may promote the development of mental illness. Multiple warning labels describing tobacco's toxicity and other risks to health have been printed for decades on each pack of cigarettes sold, yet more than 20% of Americans continue to "choose" to smoke (Centers for Disease Control and Prevention [CDC], 2001). Despite the hundreds of millions of dollars spent in anti-tobacco messages and education, the ever-increasing state and federal "sin" taxes collected on every pack of tobacco product sold, the harsh restrictions on tobacco advertisements by legislative mandate, and the high-profile lawsuits and settlements, the median prevalence figures of current tobacco use in the United States have held steady for the last five years.

    Perhaps, then, "choice" has little to do with the decision to continue tobacco use. Cigarette smokers are so concerned about their drug use that each year some 1 million of them attempt to quit; but, sadly, less than 15% succeed in abstinence for a full year (Rose, 1996). Despite understanding that risks outweigh perceived benefits, addicted individuals compulsively continue their drug use in a chronic, relapsing fashion. It is not that these individuals are devoid of any choice when engaging in behaviors that support and reinforce continued drug use; rather, we must accept that not all choices are equally easy to make, especially when there exists a host of genetic, environmental and non-environmental factors supporting continued drug use.

    Clinical research reveals that some individuals may be more vulnerable to drug dependence than others due to genetic and developmental risk factors. The best-validated risks are family history and male gender (Hyman, 2001). Studies of separated, adopted twins, for example, have found the risk for alcoholism and other addictive drugs is greater for those twins whose biological parents also had drug dependence, regardless of drug use status in the adoptive parents (Cadoret et al., 1995; Kendler et al., 2000; Tsuang et al., 1996). Drug craving and relapse are triggered by exposure to drug-related cues (e.g., photos of drugs and paraphernalia), as well as stress. Neuroimaging studies of former cocaine-dependent individuals have, for example, identified neural correlates of cue-induced craving for cocaine (Childress et al., 1999; Wexler et al., 2001).

    Preclinical studies also indicate that repeated exposure to highly addictive substances alters, perhaps permanently, a number of molecular and neurochemical indices, thereby changing physiologic homeostasis. In other words, even after detoxification, an individual may be sensitized to relapse because of changes in the brain from prior repeated use. We know the molecular targets in the central nervous system for most of the addictive drugs. As examples, opioids are agonists at µ opioid receptors; alcohol is an agonist at g-alphabutyric acid-A (GABA-A) receptors and an antagonist at -methyl-D-aspartate (NMDA) glutamate receptors; and tobacco's nicotine is an agonist at nicotinic acetylcholine receptors (Hyman, 2001). We also know that the principal CNS pathway for processing reward, punishment and reinforcement extends from the ventral tegmental area (VTA) to the nucleus accumbens (NAc), mediated, in particular, by the release of the neurotransmitter dopamine (Spanagel and Weiss, 1999). Preclinical evidence supports the "final common pathway" theory that addictive drugs, despite discordant molecular targets, all result in an increased release and dysregulation of synaptic dopamine in this region of the brain (Nestler, 2001). For example, the same dose of cocaine administered weekly to monkeys results in increased extracellular release of dopamine in the CNS, a phenomenon called neurochemical sensitization. When a second dose of cocaine is administered after the first dose is wearing off, a decreased release of extracellular dopamine is found in the CNS, a phenomenon called acute tolerance (Bradberry, 2000). As tolerance builds, increased amounts of the drug are ingested in an attempt to achieve the same rewards, which, in turn, will also further drive molecular changes in the brain. Drug dependence, then, is reinforced at the cellular level as the CNS adjusts to continued drug exposure. Such conditioning may be unmasked by abrupt cessation of drug use, resulting in a period of observable and reproducible symptoms of withdrawal.

    Chronic exposure to addictive substances also shifts signal transduction pathways within neurons, thereby altering gene expression (Matsumoto et al., 2001; Walton et al., 2001). New or different concentrations of regulatory proteins, in turn, are synthesized, directing neurons to form new synaptic branches and altered concentrations of cellular receptor density. Cocaine, for example, has been found to increase spine density and dendritic branching of neurons in the NAc and prefrontal cortex of rats (Robinson and Kolb, 1999). The remodeling of neurons involved with the maintenance of the brain's reward center also may continue long after drug use has ceased (Hyman and Malenka, 2001; Ungless et al., 2001). There are probably hundreds of transcription factors involved in gene regulation; already the cyclic-AMP response-element-binding protein (CREB) and FosB are implicated in addiction (Nestler, 2001). Interestingly, biochemically modified isoforms of FosB appear only slightly after acute drug exposure, but they accumulate over time with repeated drug administration. Other regulatory proteins of the Fos family rapidly break down after synthesis, but FosB is highly stable, persisting for months after drug withdrawal. Here, then, is one example of a molecular mechanism for drug-induced changes in gene expression persisting long after last use. Preclinical models reveal that chronic, but not acute, administration of cocaine, amphetamine, phencyclidine, alcohol, nicotine and opiates induces FosB release in the NAc and dorsal striatum (Kelz and Nestler, 2000).

    In short, both human and preclinical data converge to suggest that addiction is associated with frank biological abnormalities that cannot be easily explained by a simple hypothesis of "choice." It is a strange set of societal circumstances that people may still consider the ingestion of some drugs as outside the purview of physicians, when clearly the practice of medicine deals with the impact of exogenous substances upon the human body and mind. Those individuals who abuse drugs do so absent the legal mechanisms for which society provides, i.e., a prescription or recommendation from a physician. Whether legal or not, all addictive substances should be carefully reviewed with our patients precisely because physicians must obtain all information that may assist in the diagnosis and treatment of disease and in the improved preventive health of patients.

    Drug dependence changes the lives of users and those around them. Tobacco, for example, is the single greatest cause of preventable death in the United States (CDC, 2001). Certainly, then, tobacco is a menace to public health and its continued popularity supports nicotine dependence as a chronic, relapsing disease in which volitional choice becomes but one negotiable variable in the struggle to achieve good health throughout the life cycle.

    Moral rejectionists mislabel drug dependence as a failure of volition only and, thereby, claim a right to assign judgment and blame. The absurdity of looking through such a narrow lens is that if addiction really were merely a choice, people would stop after experiencing more harm than perceived benefits!

    Accepting drug dependence as another mental illness does not typically abrogate responsibility for an addict's actions: Thousands each year are arrested, prosecuted and sentenced to serve jail time for simple drug possession, and, as for mental illness in general, consider that the two psychiatric inpatient facilities in the United States in which the largest numbers of patients reside are the Los Angeles County Jail and New York City Rikers Island Prison (Geller, 2000; Torrey, 1999; Watson et al., 2001). Obviously, such individuals' moment-to-moment decision-making can have long-term consequences that were never wished for or accurately anticipated.

    Not all choices can be equally entertained at every given moment either, and sometimes other options are not even known. For example, a young woman, supporting herself and her drug habit through prostitution, may not know of the different "ethical" choices available to her, especially when as a child she had been introduced to both drugs and her career by her mother's example. The reasons for experimenting with addictive drugs, then, may be quite different from the motivations fueling continued use. Relapse is not due to an absolute loss of volitional control but rather to loss of a perspective that cherishes good health and mental well-being above other, less healthy choices. In high-risk situations, this long-term desire for maintaining better health through abstinence is overwhelmed by the cued wish to re-experience a known, anticipated "high" available at that moment.

    Stigmatization of illness continues against many patients afflicted with brain pathology. Substance dependence is particularly stigmatized by those who wish to make this illness a debate over volition while denying the biological underpinnings of behavior. Moreover, demands for precise linguistic definitions of addiction and disease, as if they must forever be hermetically sealed within specific denotations of legalese and ethics, is of little value to physicians charged with the observation and treatment of pathology. History reveals many examples of debates over illness versus individual responsibility: Hansen's disease ("leprosy" from Mycobacterium leprae), seizure disorders ("epilepsy"), cancer and major depression are some examples of medical disorders now vindicated with the discovery of effective medications and procedures. Physicians, and psychiatrists in particular, are needed now more than ever to stand up and explain to the lay public how substance abuse and dependence can significantly alter brain function and physical health and that a variety of treatment modalities are available.

    Effective management of drug dependence requires a medical model so as to tailor therapy according to the condition of the individual. Faith-based support groups, Alcoholics Anonymous and its affiliates, and long-term residential programs have a long history of assisting people in achieving and maintaining abstinence via a combination of direct therapy, education, cognitive skill-building exercises, expanded non-drug social supports and providing a drug-free environment. Contingency management skills can be taught to provide individuals with extra time to anticipate the high-risk situations and emotions for relapse and then, hopefully, re-script behavior to minimize such exposures (Carroll et al., 2001). This helps individuals learn to avoid night clubs or other users because such settings and people may make the choice for continued abstinence appear less valuable than the immediate reward anticipated with use.

    Current pharmacotherapy for drug dependence includes screening for an underlying psychiatric condition after the patient has successfully completed detoxification. People may choose to self-medicate with an addictive drug, all the while unaware that they have a treatable psychiatric illness. For example, rates for alcoholism and other drug abuse are much higher in people with untreated bipolar disorder and depression. For motivated individuals, disulfiram (Antabuse) may particularly aid in maintaining sobriety from alcohol. Smoking tobacco while on the antidepressant buproprion (Zyban, Wellbutrin) is another aversive treatment, as the drug induces an undesirable taste when some smokers relapse. Agonist replacement medications assist with detoxification and/or offer a stable, safer maintenance therapy for those who repeatedly fail pure abstinence (e.g., methadone for opiate dependence, nicotine gum or patch for tobacco dependence). Many new medications are also in development including more opiate antagonists for the treatment of alcoholism and opiate dependence and NMDA antagonists such as acamprosate [Campral] for alcoholism (Tempesta et al., 2000). One day, perhaps there will even be a vaccine to confer natural immunity against cocaine (Schabacker et al., 2000). As Krystal et al. (2001) reported regarding the efficacy of naltrexone (ReVia), an opioid antagonist, in the treatment of alcoholism, sometimes medications do not prove to be as effective as promised. Evidence still suggests, however, that naltrexone may be quite effective if taken intermittently on the days that the individual feels at greater risk for relapse, rather than ingesting it every day (Boening et al., 2001).

    Whether addiction is a disease or merely a choice, the utility of the medical model is needed to address resultant risks to public and individual health. A careful review of this growing body of scientific literature should offer hope that real solutions are possible. All other models for addressing drug dependence have, to date, proven to be costly failures, and doctors are not going to ignore viable treatment options for healing those suffering with drug dependence. Defining addiction as a choice only abdicates our responsibility for seeking health and true healing for our patients and, instead, leaves crushed lives dehumanized by a chronic relapsing condition with no hope for cure. As every doctor knows, "Remember to do some good" should quickly follow the first rule to "do no harm."

    Dr. Halpern is an instructor in psychiatry at Harvard Medical School and on staff at McLean Hospital and Brigham & Women's Hospital. He is the recipient of a Career Development Award (K23) from the National Institute on Drug Abuse for ongoing research at McLean Hospital's Alcohol and Drug Abuse Research Center.


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  • BrigidBrigid Veteran
    edited January 2007
    Those articles are pretty old, BF. The brain sciences have made huge advances in the last three years alone and these were written before the advance in the understanding of the brain's role in addiction that's outlined in the New York Times article with which I started this thread.

    But I'm not going to debate with you whether addiction is a choice or not. The point I'm trying to make is that being judgmental about those who have addictions, casting blame, fault, shame, fear or any number of other negative things upon them is detrimental to their ability to get out from under their addiction.

    By the way, this was harsh:
    You'll either make it on your own - or possibly at the end of a breather. Or when you have emphisema(I'm too lazy to check the spelling of that word), when you your life is cut short and you don't get to see your children or grandchildren get any older. Or maybe when you're stuck in the hospital watching your life and lungs rot away - coughing up shit all the time - never able to catch your breath - just sitting across the room from Death - waiting for your gab to gasp it's last breath... Then the time for a decision will come - whether YOU are actually making the decision (or your doctor is) or not. You won't be smoking in a hospital on an oxygen tank - and then you might even wonder if those little fuckers were worth all the pain, loss and suffering you'll be experiencing in that moment.
    I don't find this particularly compassionate. You think I don't torture myself with these thoughts already? I told you how much I agonize over this addiction. Didn't you believe me? I don't need this kind of shock therapy, BF. It doesn't help. It sets me back. I'm already sick with fear and adding to it makes it worse. Whether you believe that addiction is a choice or not is irrelevant. What I'm telling you is that making me more afraid, being harsh, being hard assed about it disempowers me and pushes me further away from being able to deal with this addiction. And I don't think I'm the only addicted person in the world who feels this way.

    Perhaps you're addiction to cigarettes was a choice, BF, and you were able to quit by using sheer willpower alone. Everyone else is not like you and many, many people can't do it with sheer willpower alone. To say that all addictions can be conquered this way is nonsense and the scientific and medical communities have known this for years.

    The reason I posted this article in the first place is because it gives many people hope that there may be new ways in the future to deal with addiction more effectively now that there is proof of the brain's involvement and more understanding about how addiction works. It was not to debate an outmoded and unhelpful attitude towards addiction.
  • JasonJason God Emperor Arrakis Moderator
    edited January 2007

    I do not know anything about the science behind addictions or their effects on the brain, but I do know something about addictions themselves. I have been mentally and physically addicted to many things in my short life. I am intimately aware of what it is like to have something that was once done for the simple pleasure of doing it become an all-consuming habit that eats away at one’s physical and mental health; and that even if one were able to stop such a destructive habit, how the craving and desire to indulge in those old comforts are always present in the background. I think that while the superficial aspects and objects of each individual's addictions are as different and complex as the stars in the sky, the mechanisms underlying those addictions are basically the same.

    The body is nothing but a lifeless shell without the mind, and even though addictions can be physical in the sense that the body can become trained to need certain substances present in its system in order for it to function as it did before we became addicted, the mind is where all of our choices and decisions are made. When seen in this way, it is easy to see that the mind plays an important role no matter what the addiction. For someone to physically pick up an alcoholic beverage and drink it, the mind must have already had the intention to do so. For one to physically light up a cigarette and smoke it, the mind must have already had the intention to do so. For someone to physically do almost anything, the mind must have already had the intention to do so. With my own addictions, whether or not my body was dependent upon the object of my addiction, there still was a choice in my mind to give in to those cravings and desires.

    For the most part, addictions are really nothing more than a means for the temporary relief of our daily suffering, pain, and unhappiness in that they either ease the mental and/or physical symptoms of our suffering, or they serve to take our attention away from those symptoms. Addictions can also become near and dear to us when they induce pleasant mental states and bodily sensations, or act as a security blanket for our fears and social anxieties. Addictions can do all these things and much, much more; nevertheless, the only thing that they cannot do is actually remove the causes for our suffering. All too often, we do not see that the short term suffering of denying our unskillful cravings their objects of desire is preferable to the long term suffering of being a willing slave to those unskillful cravings. The difficult part is that even if we know that this is indeed the case, we are still unable to deny those unskillful cravings for very long.

    The Buddha often talked about clinging, but the word for clinging is sometimes translated as addiction—what we cling to, what our mind takes as its sustenance, is also seen as what we are addicted to. The four types of clinging that the Buddha mentioned were clinging to sensual passion for sights, sounds, smells, tastes, and tactile sensations, to views about the world and the narratives of our lives, to precepts and practices, and to doctrines of the self. What this means is that suffering comes down to the feeding habits of the mind. One reason that we are unable to simply let go of these addictions when we realize that they are bad for us is that the mind is not strong enough to stop feeding on them, and even if we manage to pry it from one source of nourishment, it just keeps finding new (and usually unskillful) ways to feed and cling—in other words we relentlessly feed our addictions, or we substitute one unskillful addiction for another.

    In my experience, the answer to freeing ourselves from our unskillful addictions lies in replacing them with more and more skillful addictions and training the mind. When we become addicted to more skillful things such as being generous, practicing mindfulness, et cetera, we slowly change the types of food that our minds feed upon. We rewire ourselves to find pleasure and happiness in more and more skillful ways, which will eventually help us to abandon all forms of addiction once and for all. When we train our minds, when we develop their powers of mindfulness and cultivate more and more refined states of concentration, we help to make them strong enough to overcome our addictions. A strong mind can ignore the voices of craving, and eventually silence those voices forever.


  • buddhafootbuddhafoot Veteran
    edited January 2007

    It was harsh.

    I don't know what you torture yourself with.

    I really hope that the medical community comes up with a pill, program or procedure for the brain that allows people to remove addictions from their lives.

  • NirvanaNirvana aka BUBBA   `     `   South Carolina, USA Veteran
    edited January 2007
    Brigid and Buddhafoot:

    I think I just heard a choir of angels rejoice over this last post. But it could be the Beethoven. I'm kinda addicted. The Piano Sonatas, Missa Solemnis, his one opera, Fidelio...
  • BrigidBrigid Veteran
    edited January 2007
    In my experience, the answer to freeing ourselves from our unskillful addictions lies in replacing them with more and more skillful addictions and training the mind. When we become addicted to more skillful things such as being generous, practicing mindfulness, et cetera, we slowly change the types of food that our minds feed upon. We rewire ourselves to find pleasure and happiness in more and more skillful ways, which will eventually help us to abandon all forms of addiction once and for all. When we train our minds, when we develop their powers of mindfulness and cultivate more and more refined states of concentration, we help to make them strong enough to overcome our addictions. A strong mind can ignore the voices of craving, and eventually silence those voices forever.


    Once again you're wisdom and ability to clarify the issue just astounds me. Amazing post and I particularly loved this last paragraph above.

    With the advent of new brain scanning technologies and advances in the brain sciences we're learning more and more about how our brains actually work and this I feel is very important because I am convinced beyond any doubt, and through personal experience, that when we understand our brain functions we're able to literally change the way they work through more skillful means. Just as you are saying, Jason. And as the Buddha taught, of course.

    The example from my own experience is my panic attacks. After years of bewilderment and confusion about how to deal with this disorder I finally did some hard research into how fear is processed in the brain and how this process can become...corrupted, for lack of a better term, by environmental, genetic and other factors. When the fear center of the brain, the Amygdala, is activated our brain automatically releases a host of chemicals (like adrenaline, for example) in order to prepare us for whatever danger we are about to face. However when this process is not working correctly the Amygdala can be activated when there is no actual clear and present danger. It can become hypersensitive and become activated by frightening thoughts alone.

    To make a long story short I learned that the problem with the panic disorder was that my frightening thoughts were bypassing the reasoning part of my brain and going straight to the Amygdala, causing panic with all its mental and physical symptoms. (Panic attacks can become so severe that the person suffering one can be going through the same mental and physiological terror as someone who is trapped in a burning building when there is actually no danger to them at all.) So the key is to either strengthen or create neural pathways from the frightening thought to the reasoning part of the brain and then, if necessary, to the Amygdala. And this can be done with practice. So when a frightening thought occurs we can literally force that thought to go to the reasoning part of the brain instead of directly to the Amygdala and that thought can be analyzed critically and calmly and understood for what it is; just a thought, not a real danger. The more we do this the stronger the neural pathways in the brain become and eventually the brain will do it automatically on its own. It's basically a rewiring of the brain.

    That's a very simplified explanation but I think you get my gist. So when I hear about advancements in the brain sciences I can't help but think to myself that science is catching up to what the Buddha taught in the first place. And if we learn more about addiction and the brain it gives me hope that we may learn how to more effectively and more skillfully deal with addiction. I will always rely on the Buddha's teachings about clinging, as Jason beautifully described them, but it's nice to have the science behind it to make it more visual for me until I get more advanced in my Buddhist practice.
  • not1not2not1not2 Veteran
    edited January 2007
    Just as an fyi, the effects of things such as mindfulness practice & cognative therapy is different than that of drugs. Drugs basically 'turn down the volume' of the stimuli which induce the problems. Cognative therapy & mindfulness-based practices have been shown in brain-scans to not supress, but rather respond differently. I personally favor the later approach when possible, but i have absolutely no problem with medications which take the edge off.

    Anyway, on the choice v. disease debate I can see both sides. Treating addiction as a disease seems to take away the power of one's own choice in affecting change. Considering that any addiction is simply a habitual series of similar choices, which are dependent on various conditions, I don't have a problem viewing addiction as a choice. However, pidgeon-holing (sp?) addiction to a simple matter of choice seems to sort of disregard the conditions that leads one to such choices.

    With smoking, for example, there are physical side effects which can disable one's ability to quit the habit. Also, regarding addiction as a simple matter of choice tends to imply the weakness, stupidity and/or insanity of the individual who is addicted. Even if those qualities can be established in the individual, making such implications often does not help the individual. In many cases, the individual already feels this way about themselves. So, such statements actually induce a state of mind which is a trigger for the addiction.

    Anyway, I really don't see anything wrong with what Buddhafoot said, as he was just relaying his own personal experience & approach to this very difficult matter. Perhaps he has found that giving himself any sympathy towards the 'addict' aspect of his personality would enable the addictive behavior. Not sure. But perhaps we should not take statements personally that were not intended as such.

  • XraymanXrayman Veteran
    edited January 2007
    from a Human Biological standpoint according to what i've learned, there is Physical, and mental dependence. sometimes both. I maintain that it is by choice if we take that firt drag on a cig, that first swig of booze that first pipe of crack-whatever.

    I (IMHO) believe that I made a choice in everything/addiction that Ive had-I have NO EXCUSE. This may or may not be the same for the rest of you.


    Thats all Im going to say about this matter.

    respect to you all
  • buddhafootbuddhafoot Veteran
    edited February 2007
    Well, it should also be noted that - however addiction occurs - once it has occured - there are a great many changes that can take place within the human body which now requires this addiction to be supported. We do change physically (not to mention psychologically) once a drug has been introduced and has become part of our systems - whether mental or physical.

  • SimonthepilgrimSimonthepilgrim Veteran
    edited February 2007
    buddhafoot wrote:
    Well, it should also be noted that - however addiction occurs - once it has occured - there are a great many changes that can take place within the human body which now requires this addiction to be supported. We do change physically (not to mention psychologically) once a drug has been introduced and has become part of our systems - whether mental or physical.


    Absolutely, BF: having experienced withdrawal from beta-blockers, I can assure youy that it is not only "bad" drugs that have these effects.

    It is interesting to note that morphine derivatives do not lead to dependency when used to control extreme pain.
  • becomethesignalbecomethesignal Explorer
    edited February 2007
    I just recently found this thread. I'm hopeful that you will be able to look at yourself in a more positive light. I certainly know what it means to be negative toward oneself and to have a lack of self-confidence. I don't know anything about addiction but I'm sure it is unimaginably difficult. A lot of my friends smoke. They want to live healthy lives and be healthy, but most of them started smoking quite young and so it is very difficult for them to stop. Again, I have no idea what it means to be addicted to nicotene, but my friends have set dates in the future surrounding something significant to them and that is when they plan to quit. In the mean time, I'm sure they don't feel good about it, but they don't continiously beat themselves up for it.
    You are a very special and unique individual who, no matter what you do, is essential to the universe. I really believe that. I have always enjoyed the posts that you have made and I sincerely hope that you will be able to look at yourself more positively and realize your value and significance (as, I think, everyone here does) and realize that people care about you and love you the way you are.
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