Pleasure on the brain

head with 3D rendering of brain in orange

In the mid-1600s, not long after Shakespeare’s time, there was a drug that captured headlines just as ice does today

It wove its dark web through Western society. So damaging was it claimed to be that in 1674 female campaigners produced a pamphlet begging for its prohibition. They argued that ‘the continual flipping of this pitiful drink … renders them that use it as Lean as Famine, as Rivvel’d as Envy, or an old meager Hag over- ridden by an Incubus’. This terrifying drug was rapidly turning men into sexless zombies.

By the early 1800s even heroin’s close relative, laudanum, was thought safer by most. It was considered totally acceptable to give children opium to keep them quiet … while this other drug was regarded as so addictive that doctors argued it ‘tore the lymph glands, dried the kidneys out and led to enervation, effeminacy, paralysis, impotence and terrible tautness’.

In 1915, close to 300 years after this drug had arrived in the West, ad campaigns claimed that shockingly small amounts were fatal to a cat and the public were consuming much more. One damning advertisement read: ‘It weakens the heart and digestion, has powerful untoward effects on the higher nerve centres, and is the cause of insomnia, high blood pressure and various nervous diseases.’

It had taken until 1820 for scientists to discover the alkaloid within the substance that was changing people’s behaviour and causing the cravings. It was named trimethyldioxypurin, and it appears under the microscope as ‘white needle-shaped crystals’.

So what was this drug turning men into zombies?
 They called it coffee.
 How could we go from demonising a drug like coffee to using it so ubiquitously today?
 How could our understanding of addiction have become so skewed?

Addiction and the Brain

When we begin to ask why human beings become addicted to specific things, it’s easy to notice recurring patterns. But despite everything most of us assume about addiction, it’s not a single syndrome with clearly defined causes. It’s not a disease. It is not due to a lack of morals. It is neither evil nor good.

Indeed, herein lies the problem with addiction as a concept, over all. It’s that it is not clearly defined. We do not share a common appreciation of what it actually means.

Research on the causes of addiction is vast. But it’s important to take a broad and holistic view. We can’t say with any certainty that addiction is driven by either nature or nurture. We need to take into account a wide range of factors including genetics, environment, family history, and past experiences.

One thing we do know is that a key role is played by the brain.

Enjoying your favourite sweet food … a big win at the races … having sex … getting high on drugs – your brain categorises all these situations under a common umbrella: pleasure. Your brain registers all pleasurable activities in the same way: by releasing a neurotransmitter (chemical ‘messenger’) called dopamine into a small part of our brain called the nucleus accumbens, a cluster of nerve cells that lives beneath the cerebral cortex (a thin layer of the brain that plays a key role in consciousness).

Nothing has more potential to provoke this pleasure response than psychoactive (brain-changing) substances. These substances often mimic different neurotransmitters. For example, heroin mimics endorphins, alcohol mimics glutamate and gamma- aminobutyric acid (GABA), and amphetamines like ice powerfully mimic dopamine itself.

But regardless of the substance or activity involved, the sensation of reward and pleasure is experienced in the same way, with this release of dopamine into the nucleus accumbens. Dopamine produces a pleasurable response; large amounts of dopamine produce a euphoric response, encouraging you to repeat the behaviour that caused this feeling to begin with. For those who go on to develop addictions, this is often the starting point.

Other parts of your brain such as the hippocampus and amygdala play a role in how pleasure can lead to addiction as well. Your hippocampus is responsible for establishing new memories of these pleasurable events (including how intense they are), and your amygdala creates a continued, or conditioned, response to certain stimuli (like the sight of alcohol, or the smell of cannabis).

As well as stimulating the brain’s pleasure response, pleasurable behaviours and substances have an effect on processes like motivation and memory. Dopamine interacts with other neurotransmitters, like glutamate, to influence the way your brain learns in relation to rewards. Your brain begins to associate enjoyment with desire, and you start to seek out the action that gave you the pleasurable feeling. In this way actions associated with the reward, such as walking to the bottle shop, begin to offer rewards of their own, and we seek out these feelings.

The brain is designed to experience rewards after some effort has been put towards them. However, addictive substances and behaviours provide these rewards ‘free of charge’, and very reliably. Over time, your brain adjusts. It learns that there are abnormally high amounts of dopamine being released by these behaviours and substances, and it stops producing dopamine after other, ‘normal’ pleasurable events (food, sex etc). The receptors responsible for receiving all of these dopamine signals become exhausted as well, making them less sensitive to receiving dopamine in the future.

This then leads you to feel less pleasurable impact from daily life, and an increased desire to return to the behaviour that provided the dopamine ‘burst’. Over time, you’ll need to engage in more and more of the behaviour to get the same effect. This is known as developing tolerance.

‘Do I Have a Problem?’

‘Am I an alcoholic?’

‘Are you an addict? Take this test to find out.’

‘Is someone you know an “almost alcoholic”?’

‘Ten places users hide their meth …’

The internet can be a wondrous place. A vast online universe where anything and everything can exist in some form or another. For many, it has become the standard medium for information sharing and gathering.

So what happens if you’re worried you have an addiction problem? You may speak to a loved one, you may approach a counsellor or mentor, you may even enlist the help of a support group. What is more likely, however, especially in the early stages, is that you’ll keep the problem under wraps and search for information privately.

Surely the best place to start would be Google, right?

The tricky part is that, as we’ve suggested, addiction is neither black nor white. People don’t simply enjoy a glass of wine with dinner one day and crave a needle full of heroin the next. There is no clear-cut boundary or limit that defines when usage has become addiction. And that boundary differs from one individual to another. Two drinks after work may be entirely manageable for some, but a doorway to a serious drinking problem for others.

So what happens if your primary source of quick information doesn’t lead you to solutions, but only leaves you more confused and overwhelmed?

A simple Google search under ‘Do I have an alcohol problem?’ returns a whopping 149 million results. A search under ‘Do I have a drug problem?’ returns around 200 million results. If you looked at each page on alcohol problems for one minute, and did this for eight hours every day, it would take over 850 years to look at them all. If we did this for drug problems, it would take us over 1140 years! Heaven help those poor people with drug and alcohol problems!

There is a wealth of accurate, well-researched and balanced information about addiction out there on the net for people to access. The difficulty is often finding that information among the many millions of pages on the subject.

One way of assessing potential issues with drug or alcohol use is the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by many psychiatrists and psychologists to diagnose a range of mental disorders. The first edition was published in 1952 and the current fifth edition (DSM 5) has been in use since 2013.

DSM 5 categorises drug and alcohol problems under the broad heading of ‘Substance Use Disorders’, then breaks down the disorders into specific categories: Alcohol Use Disorder, Opioid Use Disorder etc. (As we’ll see later, the DSM looks at gambling in a similar way.)

The presence of a substance use disorder will include eleven possible symptoms. A doctor will be able to assess the severity of your disorder based on how many symptoms have been present during the past twelve months.

The eleven criteria are:

  1. taking the substance in larger amounts or for longer periods of time than you originally intended 

  2. worry about stopping, or repeated efforts to control use with no success 

  3. spending large amounts of time either using the substance, or doing things necessary to obtain the substance 

  4. failure to fulfil major obligations (e.g. at home, work or school) as a result of using the substance 

  5. craving, or experiencing a strong desire to use the substance 

  6. continuing to use the substance despite physical or mental health problems likely caused by or worsened by use of the substance (e.g. anxiety, sleep problems or blackouts) 

  7. continuing to use the substance despite negative effects on relationships with others (e.g. use leading to fights, or people constantly objecting to the use) 

  8. repeated use of the substance in dangerous situations (e.g. operating machinery, driving a car) 

  9. giving up or reducing regular activities because of substance use (e.g. hobbies, sport) 

  10. building up a tolerance to the substance – needing
to use larger amounts to obtain the same effects, or noticing decreasing effects from the same amount of the substance over time 

  11. experiencing withdrawal symptoms after stopping use (e.g. anxiety, irritability, vomiting, and seizures in the case of alcohol) 

It’s important to note that this list should not be used as a tool to ‘diagnose’ yourself or a friend or family member as a ‘drug addict’ or ‘alcoholic’. This list is here simply to give you an idea of the symptoms doctors would look for. Many other factors come into play when interviewing and diagnosing patients.

Should you read these criteria and be able to relate to some of them, the best course of action is to talk to someone you trust. There are parts of this book that discuss ways to cut down substance use or control your usage patterns better, as well as ways to prevent relapse for people looking to cut down or quit.

If it does nothing else, at least this list will possibly save you 1140 years of Google searching!

Myth 1: ‘You May Have an Addictive Personality’

You may be surprised to discover that for all of the tabloid stories that tout the significant role the addictive personality plays in our life, there is very little to support this assertion.

In the recesses of your mind you’ve probably always wondered, ‘Am I an addictive personality?’ However, the closer we look at addiction, it turns out that the notion of an addictive personality is a complete myth.

While genetic research surrounding addiction is ongoing, there is some concern as to the racial profiling that can be carried along with it.

When we begin to uncover the reasons behind why we become addicted to specific things – drugs, sex, video games, apps, smart- phones, the internet – it’s easy to notice recurring patterns. But despite everything we’ve assumed about it, addiction, it turns out, is not a single syndrome. It is not a disease. It is not an absence of morals. It is neither evil nor good. Addiction is multifaceted. Addiction is natural. And it will happen to most of us at some stage in our life in varying ways. But more on that later; suffice to say the notion of an addictive personality is, frankly, rubbish.

Myth 2: ‘All People Who Use Drugs Are the Same’

The progression from experimentation, to regular usage, to dependence is a journey that differs for every person. This journey almost never takes a direct path, but winds endlessly through the fun, carefree times as well as the stressful, frightening and heartbreaking.

It’s partially because of the unpredictable and ever-changeable nature of this journey that no two substance-dependent people are the same. The drugs differ, the behaviours differ, the thoughts and emotions differ.

Yet the traditional notions that drug use inevitably leads to addiction, and that all people who use drugs are the same, live on. The idea that you try a drug once and you’re hooked makes as much sense as the notion of having sex once and becoming a sex addict. And the idea that all users are dangerous, drug-crazed criminals is just as ludicrous.

Consider two groups of people who are using two different types of drugs.

A recent study of 1,000 ecstasy users showed that the median use of this drug was just twelve days in six months. Half the users had tertiary qualifications and only 2 per cent were in drug treatment.

On the other hand, in a similar study of 888 people who inject drugs, 83 per cent were unemployed, 55 per cent had a prison record and 47 per cent were in drug treatment. Based on employment, tertiary qualifications and lack of criminal record, it’s clear that one group is more ‘advantaged’ than the other.26

It is clear that people who use drugs are not homogeneous. Most people who use illicit drugs are middle-class and are not addicted. However, when we read about ice zombies in the media, those stories often focus on people living through trauma and/or poverty.

Governments and media are largely oblivious to this difference. This leads to blind spots in our drug policy too. If we can’t comprehend the realities of why different people become addicted to different drugs, we will continue to fail those who are desperate for support.

According to Professor Alison Ritter, a leading drug and alcohol researcher: ‘There’s a spectrum of drug use. There are people who use occasionally, and people who use regularly, and there’s not an inevitable association between using drugs and being harmed by that use. The proportion of people who develop a dependence from drug use has been well documented by James Anthony, a US researcher, and it’s like 20 per cent, 30 per cent, something like that. And so the vast majority of people who use a drug don’t develop a dependence. You can see that in the National Household Survey data.27 I mean, if all of the people who said they used cannabis were dependent, we’d be drowning. Society would grind to a halt.’

Professor Ritter explains that a fuller understanding of this spectrum of drug use will help us create a better community. ‘We’re still treating people who run into trouble with drugs as somehow different from us. And of course, regarded as a criminal under the law.

‘And all of those responses do absolutely nothing. They do nothing for the individual. They make it worse for the individual in terms of stigma and so on. And they make it worse for us as a society, as a community. One of my favourite sayings is “The strength of a society is the way in which it treats its weakest members.” If we look after our weakest members we become better.’

Myth 3: ‘Addiction Is a Moral Failing,
 Not a Health Problem’

Growing up, most of us are taught that we are special, that no one else in the world is quite like us. Ideally, this will remain a part of our everyday thinking, and we’ll keep reminding ourselves that people are individuals with a healthy dose of free will.

Sadly, this is rarely the case when it comes to people struggling with addiction. Society can adopt a blanket view of these people, effectively tarring all addicts with the same brush. The causes of addiction are generalised: living in a rough area, being of lower- than-average intelligence, being of low socio-economic status, belonging to a particular culture, even having a certain skin colour. The inner qualities of addicts are also overgeneralised: they have no self-control, no willpower, no ambition, or have simply given up on life.

The resulting judgments are usually harsh. After all, if we all have free will and responsibility for our own decisions, then these people only have themselves to blame for their situation, don’t they? Rarely, if ever, is substance dependence viewed as a health issue, an affliction of the mind and body, perpetuated by poor or risky health-related behaviour. Behaviour that continues despite readily available information about the dangers.

Dr Igor Koutsenok, a world-renowned addiction psychiatrist working for the United Nations, once gave a lecture in which he compared drug dependence with two common health problems: hypertension and type 2 diabetes. All three conditions usually result from lifestyle choices about what to introduce into the body, be it salt- and sugar-rich foods or a mind-altering chemical. All three can become chronic conditions that may flare up repeatedly if not managed properly. All three can have an impact on the individual’s physical and mental health and quality of life, as well as on those closest to them. Most importantly, given the right choices all three can often be entirely manageable: cut out the salt and sugar (or heroin), and the prognosis is usually fairly good.

Dr Koutsenok makes a great point: rarely would someone with a drug dependence be viewed in the same light as someone with type 2 diabetes or hypertension. Despite the similarities between the causal behaviours, drug addicts always seem to receive the rough end of the stick.

So why don’t we offer the same level of understanding, patience and compassion to people who use drugs as we do to those with type 2 diabetes or hypertension? The latter two are viewed as unfortunate medical conditions that could affect almost anyone, while drug use is seen as an illness of values, morals, judgment, faith. The latter two usually prompt an invitation to look on the bright side; the other is a dark path chosen only by weak-willed people.

‘Your diet may not have been the best and you now have type 2 diabetes, but it’s best to stay positive. I mean, it could be worse, you could be on heroin, right?’

Now, we are not in any way casting judgments on people with diabetes or hypertension, quite the opposite. 

Throughout this book we are encouraging understanding and compassion towards people with all medical conditions. Whether the affliction is due to illicit drugs or has another cause, we can safely assume that people rarely find the motivation to change while feeling alienated and judged by all.

One of the most powerful predictors of success in overcoming substance abuse that I have found in my experience is the knowledge that someone believes in you, especially when you’ve stopped believing in yourself. If our perception of addiction can change, and we can begin to replace harsh judgment with patient understanding, then the road to better health becomes far easier to navigate for so many people.

This is an edited extract from Addicted? by Matt Noffs & Kieran Palmer (Harper Collins $32.99)

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