To treat addiction, people need help to develop psychosocial skills in addition to taking medication, says Kenneth E. Leonard.
We have known many of the fundamental aspects of addiction for some time. Individuals with addictions gradually give up other pleasures in favour of alcohol or other drugs; they experience cognitive difficulties and find it hard to stop thinking about their substance, and they often fail to control its intake or to cope without it. Remarkable progress has been made in identifying neurological factors and changes associated with these behaviours; this in turn has led to pharmaceutical treatments. However, although neurological aspects are crucial, they are not sufficient to explain, prevent or ameliorate addiction.
Addiction is more than a disease and involves more than the brain: it is a systemic behavioural disorder.
The development of an addiction is a continuous process, beginning with occasional substance use followed by habitual heavy use and culminating with seemingly incessant or episodically excessive use. Throughout this process, there are neurophysiological changes that occur. After a substantial period of frequent, heavy and patterned use, the term addiction is applied. The concept of disease, representing the underlying neurophysiological changes that occur, is commonly invoked to explain the addictive behaviours. But addressing substance use also requires that we recognize the social and psychological processes that underlie the development of addiction. These processes remain influential even as the circuitry of the brain adapts to the escalating use of a drug. In this sense, addiction is more than a disease and involves more than the brain: it is a systemic behavioural disorder arising from and maintained by psychological, social and biological processes operating both independently and in concert.
In most cases, the development of addiction emerges from an acquired pattern of substance use that serves some motivational function: enhanced positive feelings or states, and reduced unpleasant feelings or states. Individuals who expect that a substance can improve these moods are more inclined to use that substance. Whether someone progresses to addiction depends in part on how well that substance meets those expectations. Over time, sustained excessive substance use can increase negative emotions and reduce the impact of positive ones through the neurophysiological changes to the brain1, potentially magnifying the importance of the substance to the individual. But it is important to recognize that increased negative emotions and decreased positive emotions also arise through the impact of use on the individual's cognitive capabilities and the social environment. And that progression into addiction can be impeded by the availability of options other than drugs for enhancing positive states and for coping with negative states.
Furthermore, when it comes to quitting, changes in brain function that have been caused by an addiction do not always lead to cravings, loss of control or relapse. Individuals are able to adjust their intake of a substance or abstain altogether in response to environmental rewards. For example, studies have shown that providing prizes or vouchers for goods or services can increase abstinence from cocaine, tobacco, alcohol and opiates2. Moreover, relapse is influenced by intra-personal processes, including self-efficacy, expectancies about the effects of alcohol, negative emotions and coping abilities. These psychosocial problems remain, even if the underlying neurophysiology of the brain can be rectified.
A network of support
An essential element in addressing these issues for each addicted individual is to identify and improve their relationships with friends and family, because these connections directly and indirectly affect both the addictive process and recovery3. Addiction makes its mark on a person's social life: he or she may lose friends, alienate family and develop a new social network that supports their habits. The social environment has a significant effect on substance use. Research has demonstrated that marriage and a satisfying marital relationship reduce relapse among men with alcohol dependence and that incorporating relationship counselling into treatment for alcoholism leads to improved outcomes, such as abstinence4. Conversely, a critical partner, anger and psychological aggression are associated with poorer outcomes such as relapse5. The impact of interpersonal relationships also extends to adult peers and the broader social network, both in terms of general support as well as specific support for abstinence. A network of supportive friends and family are key elements to recovery6.
Relieving and perhaps reversing the neurophysiological aspects of addiction with medication is an important element of treatment. However, advances in medication for treatment will not, on their own, cure addiction. Individuals must also develop the skills and resources to cope with the inevitable negative and stressful experiences of everyday life and to experience meaning and pleasure in social and intimate relationships without the use of the addictive substance. Although these coping processes are represented in the brain, they are most effectively addressed through treatments such as cognitive therapy or training to improve coping skills that focus directly on the psychosocial aspects of addiction. The development and testing of psychosocial strategies to develop these skills and resources must remain an essential aim of research to help prevent and treat addiction.
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Leonard, K. Perspective: Beyond the neural circuits. Nature 522, S56 (2015). https://doi.org/10.1038/522S56a