The Enigma of Addiction

Questions like “Why can’t that woman just stop drinking for her daughter’s wedding?” or “How can your father be an addict when he is so successful?” reflect a widespread lack of understanding about alcohol use disorder (or AUD) — of the physical disruptions in brain functioning of people with AUD that can sabotage efforts to control their consumption and can lead to denial and abusive behavior in otherwise kind, smart people.

Compared to addictive substances like heroin and activities like gambling, alcohol is a source of pleasure for many people. As a result, these people have trouble believing that addicted drinkers are not simply chasing a good time and lacking the will power to resist, that instead their altered brains are to blame.

Recent successes of GLP-1 drugs—prescribed for diabetes and weight loss—in countering addiction have sparked new research into the brain’s involvement in substance abuse. According to Penn Medicine addiction specialist Sarah Carstens, GLP-1 drugs “[were] associated^^ with a reduced risk of several substance use disorders (alcohol, cannabis, opioid and stimulant use)” in an observational study of nearly two million people in the U.S. Department of Veterans Affairs database.

Ongoing focus on the risks of ultra-processed food has also helped spread the word about what happens in the brain with addiction — officially defined as behavior that persists despite negative consequences, most often related to health and finances. For individuals who meet the Yale Food Addiction Scale’s criteria for substance use disorder in relation to foods high in sugar and fat, these “hyper-palatable” foods can override the brain’s natural signals of fullness or satiety.

And recent research on the brain’s adaptability and ever-changing condition has helped elucidate how addiction creates new pathways in the neural system similar to the way flowing water can carve new streams and reroute rivers. But this plasticity also offers hope for constructing healthier pathways and developing new treatments. The remarkably beneficial effects of psychedelic drugs for those with substance abuse offers additional support for theories about the brain’s role in addiction.

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Addiction changes the brain’s release of the neurotransmitter dopamine, with the addictive substance creating immediate sensations of pleasure, which in turn reinforces the addictive behavior. Over time, the dopamine system becomes desensitized and requires greater quantities of addictive substance to create pleasure — which simultaneously increases the negative experiences of withdrawal. Someone trying to diet might experience what’s commonly called “food noise.” People dependent on drugs and alcohol can feel physical pain, along with irritability and stress that interfere with daily life and trigger subsequent cravings.

Alcohol is a two-edged sword for those with AUD— called “dually reinforcing” by the NIAAA (National Institute of Alcohol Abuse and Alcoholism). Alcohol “can both activate the brain’s reward processing system, [but also] reduce the activity of the brain’s systems that mediate negative emotional states such as stress, anxiety, and emotional pain.” For those with AUD, drinking motivation shifts “from positive reinforcement to negative reinforcement [when] drinking is motivated by attempts to reduce the emotional discomfort of acute and protracted withdrawal.”

“Heavy drinking may also produce deficits in executive function,” according to NIAAA, “that contribute to behaviors and symptoms such as impulsivity, compulsivity, [and] impaired cognitive function and decision making.” As a result, an alcoholic who appears unable to resist the lure of alcohol’s pleasing effects may be having experiences of temptation, along with physical and emotional needs to reduce discomfort, that are unfamiliar to most people.

Recent research has also revealed regions of genetic variation, called SNPs, that are associated with addiction — with “the strongest gene signals… mapped to areas in the genome known to control regulation of dopamine signaling,” according to researchers at Washington University in St. Louis and elsewhere. Looking at genetic samples from more than one million individuals, they found one SNP linked to higher risk for general substance abuse and a different, substance-specific SNP for AUD. In children ages 9 and 10 “these genes correlated with parental substance use,” as well as mental illness.

The risk of AUD increases with age because “the amount of water in the body tends to decline… due to an increase in the proportion of body fat, [which] contributes to higher blood alcohol concentrations (BAC) and a greater degree of subjective intoxication,” writes NIH alcohol expert Aaron White. White also notes there are “higher levels of alcohol use and AUD in the Baby Boomer cohort than the preceding generation” for reasons that are not well-understood.

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In a study of 30 U.S. veterans, the psychedelic drug ibogaine relieved both alcohol addiction and clinically significant levels of PSTD following Traumatic Brain Injury. After these vets independently signed up to take ibogaine at a Mexican clinic, Stanford researchers performed extensive evaluations before and after their drug experiences, as documented in the recent film In Waves and War, available on streaming platforms.

“These men were incredibly intelligent, high-performing individuals who experienced life-altering functional disability from TBI during their time in combat,” said Stanford Psychiatrist Nolan Williams. “They were all willing to try most anything that they thought might help them get their lives back.” After the ibogaine sessions, the veterans showed an increase in brain waves called “theta rhythms,” which researchers believe encouraged neuroplasticity and led to the dramatic improvements shown in the film.

Individuals vary widely in both susceptibility to addiction and responsiveness to various treatments — another reason people have trouble grasping that those with AUD are true addicts. For example, some recovering alcoholics can drink in moderation, while others need total sobriety. It wasn’t until three of my immediate family members became alcoholics, one after the other, and I attended a rehab center family week, that I started to understand more about addiction—and about how a mother might be unable to stop drinking for her daughter’s wedding.

Because for most alcoholics, neither the positive or negative motivations ever go away.