Hijacked: The Neuroscience Behind SUD’s and Addiction

Euphoria—the most tweeted-about TV show of the decade in the U.S. [1]— has brought teenage drug use into the public spotlight. The show follows the troubled life of 17-year-old Rue, a drug addict fresh from rehab who has no plans to stay clean. Rue's battles with mental illness and addiction are not unusual, and her predisposition to self-medicate with dangerous drugs, particularly painkillers, is not at all out of the ordinary. This is a reality that many young addicts face today, and many people struggling with a substance use disorder can relate to Rue’s story [2]. The creator, Sam Levinson, utilizes Rue's character to raise awareness and empathy for difficult topics such as substance abuse and mental health. As someone with a past substance use disorder (SUD), he felt it was important to demonstrate the relief that drugs can bring to someone suffering from anxiety or depression - as well as the emotional turmoil that they can cause [2]. Euphoria depicts the pain that comes with drug abuse, as well as the constant need to continue using drugs despite the pain.

Addiction is noted as the most severe expression of SUD, with over 20 million Americans at its sufferance [3]. SUD is a chronic brain disorder shaped by powerful biosocial elements that have terrible implications for both individuals and society, such as homelessness, family instability, overdose, and economic burden [4]. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the criteria for a SUD fall into four major symptomatic clusters: impaired control (e.g. use of a substance more than intended), social impairment (e.g. substance use at the expense of personal relationships), risky behavior (e.g. substance use despite known adverse consequences), and pharmacological effects (e.g. withdrawal) [5]. The severity of an SUD is determined by how many of these criteria a person meets. As a result, while not every person diagnosed with an SUD will match all of the criteria, everyone will have some negative outcomes as a result of their usage. Addiction is a complex biosocial process and should be recognized as such, rather than as a choice.

Stigma and Addiction

Stigma, as stated by the American Addiction Center, is a major source of discrimination and exclusion, as well as a contributor to human rights violations [6]. Stigma is a set of negative views held by a group or society about a topic or a group of people. Some examples of stigmatizing behavior include media depictions of people with a SUD that are usually false, harmful stereotypes of people with SUDs, and treating addiction as if they are something people can just “overcome”. People who engage in culturally excluded behaviors, such as drug use, face prejudice, avoidance, rejection, and discrimination as a result of stigma. Because of this, many addicts may avoid attending treatment and access to healthcare [7]. A study by the Asian Journal of Pharmaceutical and Clinical Research about drug utilization in neonatal intensive care units concluded that most healthcare workers have negative attitudes toward those who use illicit drugs, which affects the quality of treatment they provide [8]. With adequate education, we can help destigmatize substance abuse. Reducing drug-related stigma can promote an environment where those suffering from SUD can seek help without shame or discrimination.

Many addicts say that they have been stigmatized by healthcare providers, family members, and the general public. In an article published in the The New England Journal of Medicine, the author, Dr. Nora Volkow, talks about her visit to Puerto Rico several years ago. She met a man who was injecting heroin in his leg at a makeshift injection site. According to the author, his leg was severely infected, and she advised him to go to the emergency room,  but he refused. He had been treated very poorly during previous visits and preferred the prospect of losing his life or amputation rather than repeating his shameful experience [9]. It is critical to lessen the stigma around addiction in order to encourage people to seek the road to recovery. To aid in destigmitization people can provide nonjudgmental, empathic assistance through educational programs and modeling of non-stigmatizing behavior. Some of these non-stigmatizing behaviors include avoiding hurtful labels, such as “crackhead” and “druggy”, listening while withholding judgment, and seeing a person for who they are, not their SUD. Because stigma is often founded on assumptions rather than facts, its detrimental effects can be mitigated by education [6]. 

Drugs and Alcohol: How they Affect the Brain

The brain is plastic, and can be fundamentally altered by chronic substance use; consumption of drugs and alcohol, especially at high levels, may disrupt healthy brain function such that restoration becomes difficult. While alcohol is legal, it is classified as a depressant, a drug that reduces neurotransmission, our brain's way of communicating through electrochemical signals. To do this, the brain utilizes neurotransmitters, chemical messengers that are produced by neurons, (fundamental unit of the nervous system) to send a signal from one neuron to the next [10]. When someone consumes a drug, whether illicit or recreational, it affects areas of the brain controlling cognitive and motor functions, causing these functions to speed up [11]. Alcohol consumption and illicit drug abuse can lead to depression, excessive blood pressure, organ dysfunction (in the heart, liver, pancreas), immune system dysfunction, overdoses, strokes, certain cancers, and unintentional death [12], [13]. 

The VTA sends dopamine projections to all parts of the forebrain and is involved in the regulation of reward, motivation, memory, and avoidance. Drug experience alters the dopamine neurons in the VTA, suggesting a critical role for VTA in mediating the effects of drugs [5]. The medial prefrontal cortex (mPFC), which is located in the front of the brain, has been implicated in addictive behaviors because it controls limbic reward regions, such as the hippocampus, amygdala and the hypothalamus. These limbic reward regions are involved in our behavioral and emotional responses, especially when it comes to behaviors we need for survival: feeding, reproduction and fight or flight responses [14]. 

All addictive drugs cause a pleasurable surge of the neurotransmitter dopamine in the nucleus accumbens, a brain region involved in processing reward. The nucleus accumbens regulates the reward pathway in our brain by communicating with other behavior-centers of the brain, such as the ventral tegmental area (VTA) and the medial prefrontal cortex (mPFC), which is located in the front of the brain [15]. There are many other brain regions involved in addiction, and each region communicates with each other to form the reward pathway. The basal ganglia is a structure located in the center of the brain; it is involved in the assimilation and control of voluntary behavior [13]. As drug use increases, dopamine levels increase beyond normal levels, causing decreased sensitivity. In order to achieve the same levels of reward, individuals must use more of the substance - a concept known as tolerance. This induces the person to consume more drugs in order to achieve the "high" associated with its use [13].

Treatments

In 2017, only about 19% of people that had an SUD received treatment [16]. Addiction differs from many medical disorders in that it cannot be traced back to a specific cause or abnormality. Understanding the mechanisms that drive substance use can lead to new treatment targets. Because addiction is a chronic disease, people cannot simply stop their usage for a few days. Not only is it extremely difficult to stop "cold-turkey" but many drugs require weaning off over the course of many weeks due to life-threatening withdrawal symptoms [17]. Most patients require long-term or repeated care to completely recover, and there is no single treatment that is appropriate for everyone. Some of the most common treatments to treat addiction and SUD are behavioral therapy treatments and medication treatments [18]. Behavioral therapy treatments modify addicts' attitudes and behaviors related to drug use and increase healthy life skills, while medication treatments help re-establish normal brain function and decrease cravings [18]. Medications are available for treatment of opioid (heroin, prescription pain relievers), tobacco (nicotine), and alcohol addiction. Scientists are developing other medications to treat stimulants (cocaine, methamphetamine) and cannabis (marijuana) addiction [18].

Treatment aims to return people to productive functioning in the family, workplace, and community, in addition to stopping drug abuse. According to many long-term researchers that follow people in treatment, most people who enter and stay in treatment stop using drugs, reduce their criminal activity, and improve their physical, moral, and psychological functioning [16]. Individual treatment outcomes, on the other hand, are determined by the extent and nature of the patient's problems, the appropriateness of the treatment and related services used to address those problems, and the quality of relationships between the patient and his or her treatment providers [16]. Unfortunately, many people consider relapse to be a failure of treatment. This is not true: addiction treatment typically necessitates ongoing evaluation and modification, similar to the approach used for other chronic diseases. For example, if a patient is receiving active treatment for hypertension and symptoms improve, treatment is considered successful, even if symptoms may reappear if treatment is discontinued [19]. Relapses to drug abuse do not indicate failure for the addicted person; rather, they indicate that treatment needs to be reinstated or adjusted, or that alternative treatment may be required.

Concluding Remarks

Alcohol and drug abuse are among the leading causes of preventable illnesses and premature death in the United States. Substance Use Disorder is a complex condition characterized by uncontrolled use of a substance in the face of potentially harmful consequences. People suffering from SUD have an intense focus on using a specific substance(s), such as alcohol, tobacco, or illicit drugs, to the point where their ability to function in daily life is impaired. People continue to use the substance even though they are aware that it is causing or will cause problems. Repeated substance use can modify how the brain functions, and these changes can last long after the immediate effects of the substance have worn off, or after the period of intoxication has passed. Addiction can lead to physical and psychological problems, as well as interpersonal issues with family and friends or at work. It is important to educate society about SUD and addiction in order for those that deal with SUD to be comfortable enough to seek treatment. Ultimately, an experienced behavioral health professional can put together a plan that is specifically tailored to the needs of a person struggling with addiction.

If you or a loved one is struggling with substance abuse or addiction and are willing to seek help, you can call the Substance Abuse and Mental Health Services Administration (SAMHSA) hotline at 1-800-662-4357. 

References:

1. Spangler, T. (2022, February 25). ‘Euphoria’ is the most-tweeted tv show of the decade (So far), Twitter says. Variety. https://variety.com/2022/digital/news/euphoria-most-tweeted-tv-show-1235190599/

2. What euphoria gets right—And wrong—About teen drug use. (n.d.). Time. Retrieved March 9, 2022, from https://time.com/6152502/euphoria-hbo-teenage-drug-use/

3.  ​Volkow, N. D., Michaelides, M., & Baler, R. (2019). The neuroscience of drug reward and addiction. Physiological Reviews, 99(4), 2115–2140. https://doi.org/10.1152/physrev.00014.2018

4. Uhl, G. R., Koob, G. F., & Cable, J. (2019). The neurobiology of addiction. Annals of the New York Academy of Sciences, 1451(1), 5–28. https://doi.org/10.1111/nyas.13989

5. Oliva, Idaira, and Matthew J. Wanat. “Ventral Tegmental Area Afferents and Drug-Dependent Behaviors.” Frontiers in Psychiatry, vol. 7, Mar. 2016, p. 30. PubMed Central, https://doi.org/10.3389/fpsyt.2016.00030.

6. Villa, L., January 21, Mphl. updated on, & 2022. (n.d.). Stigma of addiction | reducing the stigma of substance abuse. DrugAbuse.Com. Retrieved February 25, 2022, from https://drugabuse.com/addiction/stigma/

7. March 10, E. S. U. & 2022. (n.d.). Barriers to addiction treatment: Why addicts don’t seek help. American Addiction Centers. Retrieved April 3, 2022, from https://americanaddictioncenters.org/rehab-guide/treatment-barriers

8. Choure, Mangal & Jadhav, Rakesh & Padwal, Sudhir. (2017). Drug utilization study in neonatal intensive care unit at rural tertiary care hospital. Asian Journal of Pharmaceutical and Clinical Research. 10. 102. https://www.researchgate.net/publication/315985054_Drug_utilization_study_in_neonatal_intensive_care_unit_at_rural_tertiary_care_hospital

9. Abuse, N. I. on D. (2020, April 22). Addressing the stigma that surrounds addiction. National Institute on Drug Abuse. 

   https://nida.nih.gov/about-nida/noras-blog/2020/04/addressing-stigma-surrounds-addiction

10. What Are Neurotransmitters? 9 Nov. 2017, https://qbi.uq.edu.au/brain/brain-physiology/what-are-neurotransmitters.

11. The serious effects of alcohol on the brain. (n.d.). WebMD. Retrieved April 3, 2022, from https://www.webmd.com/connect-to-care/addiction-treatment-recovery/alcohol/serious-effects-alcohol-on-brain

12. Drinking Too Much Alcohol Can Harm Your Health. Learn the Facts | CDC. 29 Dec. 2021, https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm.

13. Abuse, National Institute of Drug Abuse. “Addiction and Health.” National Institute on Drug Abuse, --, https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/addiction-health.

14. The limbic system. (2017, November 10). https://qbi.uq.edu.au/brain/brain-anatomy/limbic-system

15. Xu, Le, et al. “The Nucleus Accumbens: A Common Target in the Comorbidity of Depression and Addiction.” Frontiers in Neural Circuits, vol. 14, 2020. Frontiers, https://www.frontiersin.org/article/10.3389/fncir.2020.00037.

16. March 3, E. S. U. & 2022. (n.d.). Drug & substance abuse addiction statistics. American Addiction Centers. Retrieved March 10, 2022, from https://americanaddictioncenters.org/rehab-guide/addiction-statistics

17. August 23, E. S. U. & 2021. (n.d.). Can heroin, benzo or alcohol withdrawal cause death? American Addiction Centers. Retrieved March 11, 2022, from https://americanaddictioncenters.org/withdrawal-timelines-treatments/risk-of-death

18. Abuse, N. I. on D. (2019, January 17). Treatment approaches for drug addiction drugfacts. National Institute on Drug Abuse. https://nida.nih.gov/publications/drugfacts/treatment-approaches-drug-addiction

19. Abuse, N. I. on D. (--). How effective is drug addiction treatment? National Institute on Drug Abuse. https://nida.nih.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/how-effective-drug-addiction-treatment