As an addiction psychiatry fellow I work with a diverse cross-section of our community that suffers from substance abuse. Every day I see the personal damage caused by alcoholism and drug addiction and work with patients and their families to pick up the pieces and turn their lives in a better direction. When celebrities suffer from addictions and the tragic consequences play out on the public stage, it gives the average person a glimpse into how devastating addiction is to everyone in close proximity to the alcoholic/addict. Celebrity admissions to top-of-the-line rehab centers and overdose near-misses and deaths have become a recurrent catalyst for conversations and for reflection. However, we often seem to get more questions than answers.
Lamar Odom is just the latest in a long history of widely-reported celebrity overdoses reportedly due to drug abuse. If he does suffer from addiction, as his father was reported to, he is one of the almost 20 million Americans (more than 6 percent of the population) who suffer from drug addictions or excessive alcohol use.
Overdoses, and other complications of substance abuse, are likely more common than you realize in the U.S., with 44 overdose deaths per day from prescription pain medications and nearly 50,000 deaths per year related to alcohol and illicit drug use. Near misses are also exceedingly common and unfortunately in many cases substance abusers will later go on to die from a subsequent overdose.
Read more about Lamar Odom, PTSD and substance abuse here.
There must be something we can take from these public opportunities to reflect and question how someone who seems to have so much can spiral out of control from the effects of drugs and alcohol. It is a lot easier to start the conversation when it is about a public or celebrity figure like Lamar Odom than when it is about our loved one. However, the questions are the same. What causes someone to drink or use drugs when the substances cause so much pain and suffering in their lives and those around them? Why can they not stop drinking or using drugs?
A research paper from 2009 attempted to answer these questions, in part, by looking at the motivations that drive an addict to continue use despite the negative consequences. They differentiate "liking" from "wanting" and "learning."
"Liking," they describe, is the pleasure or reward a person gets when they initially use a drug or alcohol. This could be a "buzz" or "high" or the feeling of pleasure, confidence or disinhibition that you feel when you use. They go on to report that the opioid, endocannabinoid, and GABA are the neurotransmitter systems responsible for generating pleasurable reactions in the human brain. In the simplest terms, our brain is primed to experience pleasure and reward when engaged in certain behaviors that are essential for life (i.e., food, hydration, sex). Additionally, specific substances trigger specific neurotransmitter systems in our brain. Even non-addicts can experience pleasure and rewarding feelings when these systems are triggered by consumption of these substances.
"Wanting," they describe, is something we are motivated to do that promotes rewarding psychological and neurobiological features. They point out that we usually "want" things that we "like." However, in addicts this is not always the case. Many addicts find that they no longer "like" the substance they feel compelled to "want." This is an important distinction that people who have never suffered from addiction have trouble understanding. I am often asked by the family and friends of addicts "why don't they just stop." It is clear that addicts "want" the drug or alcohol as their behavior continues to be motivated by their efforts to obtain and use. However, when speaking with addicts I often find that they no longer "like" the drug or alcohol that they continue to consume and in many cases they say they "hate" it. While there can be some overlap in the systems related to "wanting" and "liking" in our brains, the authors point out that dopamine is the most important system which is primed for "wanting."
"Learning," they note, involves the initial paring of something that produces feelings of "liking" with feelings of "wanting." For example, when you drink alcohol the GABA system is activated and the brain "likes" the feeling. Additionally, the brain receives a rush of dopamine and is motivated by "wanting" to feel that rush again. We have "learned" we "like" how alcohol makes us feel and we "want" to feel that rush again and the "want" motivates our future behavior to drink again. One difference between an addict and someone who is not is that when a non-addict stops "liking" a substance they can stop "wanting it." On the other hand, an addict will continue to "want" their drug of choice despite openly expressing that they no longer "like" it. They are unable to "unlearn" the initial pairing of the substance with pleasure and reward and continue to return to the substance their brain "wants."
Read more about the most dangerous and addictive drugs in the U.S. here.
As I have previously discussed (here), one of the goals of motivational interviewing is to help addicts better understand and overcome their ambivalence about quitting ("not liking" and yet "wanting" their drug of choice). Their brain is telling them to "want" the substance and they must overcome this neurobiological drive. They also must learn, or relearn, skills and behavior that can lead to activation of the "want"/dopamine/reward pathway without using their drug of choice. This is really difficult. Our brains are powerful and the motivation to active the "want" pathway is strong. Most addicts (40-60 percent) relapse over the course of recovery, in many cases, several times.
Relapse and the repeated action to use drugs and alcohol despite the negative consequences is a hard concept to understand unless you have experienced addiction first hand. A fantastic five minute video-illustration helps to explain the concept of how our brain begins by "liking" a substance and then goes on to "want" it, even when we stop "liking" it. The character in this video portrays how a person will initially feel a rush and reward from a drug. By the end the character is no longer getting any reward/high ("like") but continues to use ("want") just the same.
This video can also be accessed here.
The "wanting" aka dopamine system is not only related to drugs and alcohol. I recently came across an article that summarized recent data showing that dopamine may be responsible for technology addictions including excessive texting, Facebooking and tweeting.
Whether the brain is searching for information, food, sex, drugs or alcohol, dopamine seems to play a role in creating motivation and goal directed behavior. Therefore, the next time someone tells you to stop texting and to pay attention or to put your cellphone down at the dinner table, you can have a little more understanding of how hard it is for an addict to shutoff the "want" drives in their brain. Ask yourself, do you really "like" checking your phone every time you hear a notification sound or do you "want" to do it? You may discover you can understand addiction better than you thought.
Read more about my thoughts on what fuels addiction here.
Dr. Goldenberg is an Addiction Psychiatry Fellow in Los Angeles and has written numerous articles about mental health and addiction topics. You can follow Dr. Goldenberg at docgoldenberg.com and on Twitter: @docgoldenberg
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Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.