Selected excerpts from the book The addiction Counselor’s Desk Reference, by Robert Holman Coombs and William A. Howatt.

THE BRAIN AND PSYCHOACTIVE DRUGS

The brain’s normal circuits include a system—the brain reward system—that induces pleasurable feelings when stimulated.

To regain these rewarding feelings, this circuit encourages a repeat of the behaviors that stimulate pleasurable feelings.

For more information on how the brain reward system operates, visit Bardo (1998), Neuropharmacological Mechanisms of Drug Reward: Beyond Dopamine in the Nucleus Accumbens.

Available from www.biopsychiatry.com/reward.htm.

All addictive drugs disrupt normal neurotransmission in the brain. “Addictive drugs change the brain’s communication system by interfering with synaptic transmission,” state Friedman and Rusche (1999, p. 48).

“Some drugs mimic certain neurotransmitters and convey false messages,” note Friedman and Rusche (p. 40). “Other drugs block neurotransmitters and prevent real messages from getting through.”

Still other drugs have different kinds of effects that modify the flow of information among neurons. But all addictive drugs interfere with the way neurons communicate.

“They change the way the brain works, and that changes how people perceive the world, how they feel about themselves and their world, and how they behave” (p. 48).

False messengers, the term Friedman and Rusche (1999), give to psychoactive drugs, mimic the actions of natural brain chemicals, the real messengers, some of which make people feel pleasure by activating their brain’s reward system.

With a speed and intensity that greatly exceeds normality, these extremely pleasurable feelings lead some to seek them at any risk. As this use continues, changes occur in the brain to perpetuate continued use until it becomes compulsive, beyond control, and problematic.

Drugs of abuse negatively impact regions of the brain by sending false messages, or by weakening or intensifying real messages. Drug users describe the intensified pleasure produced by drugs as being “high.”

In fact, drugs turn on the brain’s reward system with a potency that natural rewards can rarely match. Because of this, “drugs actually teach people to use more drugs” (Friedman & Rusche, 1999, p. 2).

Psychoactive drugs masquerade as neurotransmitters and interact with receptors and other components of the brain’s synapses. “As such they interfere with normal synaptic transmission by introducing false messages or by changing the strength of real ones” (Friedman & Rusche, 1999, p. 51).

Repeated drug use also results in tolerance, meaning that after continued use, one needs more and more of the drug (or addictive behavior) to feel the same pleasurable effects. Not surprisingly, as drug tolerance develops, users tend to escalate their use to achieve their desired state.

This increases the risk for physical and perhaps psychological dependency. “The long-term abuse of drugs causes profound changes in the brain,” notes Friedman and Rusche.

“The behavior of addicts is strongly influenced by the maladaptive learning that takes place as addiction develops. As a result, recovering from drug addiction does not mean returning to a condition like the one that existed before drug abuse began. Instead, addicts must grow into a new level of personal awareness, with new patterns of behavior. That is one reason why the treatment of addiction is so difficult” (Friedman & Rusche, 1999, p. 63).

THE BRAIN AND ADDICTIVE BEHAVIORS

Until recently, researchers and clinicians limited the term addiction to chemical (alcohol and other drugs) dependence. But neuroadaptation, the technical term for the biological processes of tolerance and withdrawal, also occur when substance-free individuals become addicted to pathological gambling, pornography, forms of sexual excess, eating excesses, overwork, compulsive buying, and other compulsive excesses (Coombs, 2004).

New studies of the brain’s reward system, using PET brain scan technology, dramatically show that drugs of addiction and behaviors that stimulate pleasure and elation (e.g., compulsive gambling) affect brain functions (Coombs, 2004).

The human brain processes all positive rewards similarly, whether the reward comes from a chemical or a behavior such as gambling, shopping, sex, or work. Hence, those who become addicted do not necessarily crave a specific drug per se, but the rush of dopamine these drugs produce.

Remarkably, the term addiction was not included in the latest diagnostic manual of the American Psychiatric Association—the Diagnostic and Statistical Manual of Mental Disorders, text revision (DSM-IV-TR, 2000).

Instead, DSM-IV-TR lists three forms of chemical abuse:

1. Substance abuse disorders: A maladaptive use of chemical substances leading to clinically significant outcomes or distress (recurrent legal problems and/or failure to perform at work, school, home, or physically hazardous behaviors, such as driving when impaired)

2. Substance dependency disorders: Loss of control over how much a substance is used once begun, manifested by seven symptoms: tolerance; withdrawal; using more than was intended; unsuccessful efforts to control use; a great deal of time spent obtaining and using the substance; important life activities given up or reduced in order to use the substance; and continued use despite knowing that it causes problems

3. Substance induced disorders: Manifesting the same symptoms as depression and/or other mental health disorder, which symptoms, the direct result of using the substance, will cease shortly after discontinuing the substance

Compulsive gambling, an addictive disorder that affects the pleasure center of the brain the same way as alcohol and other psychoactive drugs, is listed in DSM-IV-TR as an “impulse control disorder” and groups it with pyromania (fire setting), kleptomania (impulsion to steal), intermittent explosive disorder (failure to control aggression) and trichotillomania (constant pulling out of one’s hair; DSM-IV-TR, 2000).

Yet, research on the brain’s reward system indicates that, as far as the brain is concerned, “a reward is a reward, regardless of whether it comes from a chemical or an experience” (Holden, 2001, p. 980; Shaffer & Albanese, 2005, p. 6).

For this reason, “. . . more and more people have been thinking that, contrary to earlier views, there is a commonality between substance addictions and other compulsions” (Alan I. Leshner, cited by Holden, 2001, p. 980).

Contemporary research shows that the neurobiology of nonchemical addictions approximates that of addiction to alcohol and other drugs. Some chemicals or excessive experiences activate brain reward systems directly and dramatically, notes addictionologist William McCown (2005, pp. 459–481).

CONCEPTUAL TOOLS TABLE II.
Commonalities between Pharmacological Addictions and Gambling 
 
Symptoms or Behavior  | Alcohol and Other Drugs | Compulsive Gambling
Cravings                                       Yes                                             Yes
Denial of problem’s
  severity or existence               Yes                                           Yes
Disruption of families                 Yes                                           Yes
Effects on specific
   neurotransmitters                 Yes                                          Unknown
High relapse rate                        Yes                                         Yes
Loss of control                            Yes                                          Yes
Lying to support
    use or activity                         Yes                                          Yes
Preoccupation with
    use or activity                          Yes                                          Yes
Progressive disorder                 Yes                                         Yes
Tolerance developed                Yes                                          Yes
Used as a means of
   escaping problems                  Yes                                          Yes
Withdrawal symptoms
   common                                        Yes                                         --

Source: Best Possible Odds: Contemporary Treatment Strategies for Gambling Disorders (p. 17), by W. McCown and L. Chamberlain, 2000, New York: Wiley.

Essentially, substances and behaviors provide too much reward for an individual’s neurobiology to handle. Ingestion of certain chemicals is accompanied by massive mood elevations and other affective changes.

These may lead to a reduction in other activities previously considered rewarding. Similarly, the ability of excessive behaviors to activate brain reward mechanisms alters normal functioning.

This also results in a potentially addictive state (McCown, 2005). Some traditionalists may argue that nonchemical addictions are really obsessive- compulsive disorders (OCD). But, as McCown (2005) points out, “There are no rewards associated with OCD behaviors except for the overwhelming reduction in anxiety.

By contrast, addictions are initially extremely pleasant experiences. OCD, which plagues people with intrusive, unwanted thoughts or obsessions, is inherently distasteful” (McCown, 2005, pp. 468–469).

When comparing the characteristics of alcohol and other psychoactive drugs with compulsive gambling, Chamberlain (2004, p. 133) notes little difference (see Table II.1).

Addictions occur in constellations (Carnes, Murray, & Charpentier, 2004). That is, people addicted to one substance are often addicted to other substances and behaviors, as they note in these summaries of research studies:

• “For the contemporary drug addict, multiple drug use and addiction that includes alcohol, is the rule. The monodrug user and addict is a vanishing species in American culture” (N. S. Miller & Gold, 1990, p. 597).

• “As many as 84% of cocaine addicts, 37% of cannabis addicts, 75% of amphetamine addicts, and 50% of opiate addicts were also alcoholic. Other studies have shown that 80% to 90% of cocaine addicts, 50% to 75% of opiate addicts, and 50% of benzodiazepine/sedative-hypnotic addicts were alcoholics” (N. S. Miller & Gold, 1993, p. 122). 
 
• “. . . clinical studies suggest a high comorbidity between eating and alcohol use disorders . . .” (Stewart, Angelopoulos, Baker, & Boland, 2000, p. 77).

• “. . . Lesieur and Blume (1993) noted that 47% to 52% of pathological gamblers also exhibit symptoms of abuse or dependency for alcohol or other drugs” (Winters, Bengston, Dorr, & Stinchfield, 1998, p. 186).

• “The alcoholic under the age of 30 is addicted to at least one other drug-most commonly cannabis, followed by cocaine, and then benzodiazepines” (Sweeting & Weinberg, 2000, p. 22).

• “Therapists working with individuals abusing alcohol, tobacco, and other drugs should be aware of the comorbidity of gambling in this population” (Sweeting & Weinberg, 2000, p. 46).

• “Similarly, in female alcoholics, comorbid eating disorder rates far exceed prevalence estimates for eating disorders in the general female population” (Stewart et al., 2000, p. 77).

• “The results of our co-twin control analyses indicated that early initiation of cannabis use was associated with significantly increased risks for other drug use and abuse/dependence and were consistent with early cannabis use having a causal role as a risk factor for other drug use and for any drug use or dependence” (Sweeting & Weinberg, 2000, p. 431).

• “. . . identification of multiple drug addiction is critical in the diagnosis and treatment of today’s alcoholics and drug addicts. Unless contemporary treatment methods are adapted to fit changing patient characteristics, attempts at rehabilitation may be futile” (N. S. Miller & Gold, 1990, p. 596).

ADDICTIVE INTERACTION DISORDER

Coining the diagnostic label, “Addictive Interaction Disorder,” Carnes et al. (2004) define 11 ways that types of addiction impact one another:

1. Cross tolerance: A simultaneous increase in addictive behavior in two or more addictions or a transfer of a high level of addictive activity to a new addiction with little or no developmental sequence;

2. Withdrawal mediation: One addiction moderates, provides relief from, or prevents physical withdrawal symptoms from another;

3. Replacement: One addiction replaces another with a majority of the emotional and behavioral features of the first;

4. Alternating addiction cycles: Addictions cycle back and forth in a patterned systemic way;

5. Masking: An addict uses one addiction to cover up for another, perhaps more problematic, addiction;

6. Ritualizing: Addictive rituals or behavior of one addiction serves as a ritual pattern to engage another addictive behavior;

7. Intensification: One addiction is used to accelerate, augment, or refine the effects of another addiction through simultaneous use;

8. Numbing: An addiction is used to medicate (soothe) shame or pain caused by another addiction or addictive bingeing;

9. Disinhibiting: One addiction is used frequently to chronically to lower inhibitions for other forms of addictive acting out;

10. Combining: Addictive behaviors are used to achieve certain effects that can only be achieved in combination; and

11. Inhibiting: One addiction is used to substitute or deter the use of another addiction that is thought to be more destructive or socially unacceptable.

Carnes et al. (2004) suggest that diagnostic codes should be reorganized to reflect this reality.

Additional Resources -- For a review of the most current research and thinking on various addictive disorders, see Coombs, R. H. (Ed.). (2004). Handbook on addictive disorders: A practical guide to diagnosis and treatment. Hoboken, NJ: Wiley.

For additional information on the Dopamine Reward System, see The brain’s drug reward system (1996, September/October). National Institute on Drug Abuse Notes. Addictions: Neurological/Biochemical aspects.

Available from www.aizan.net/families/npsy_substance_abuse.htm.

Also see The brain & the actions of cocaine, opiates, and marijuana at
www.udel.edu/skeen/BB/Hpages/Reward%20&%20Addiction2/actions.html.